us-co/policy/cms/chip-state-plan

(spa)(co-13-0015-mc1)(approval-package)Colorado CHIP SPA CO-13-0015-MC1: Approval Package (approved September 5, 2014, effective January 1, 2014)#

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_____________________________________________________________________________

Table of Contents

State/Territory Name: Colorado

State Plan Amendment (SPA) #: CO-13-0015

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (“CMs 7500 Security Boulevard, Mail Stop: S2-01-16 Cc M Ss

Baltimore, Maryland 21244-1850 ATER LOR MEDICAID & Chup senwie

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group SEP 0 5 2014

Ms. Suzanne Brennan

Director

Medical and CHP+ Program Administration Office Colorado Department of Health Care Policy and Financing 1570 Grant Street

Denver, CO 80203-1818

Dear Ms. Brennan:

- Jam pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number CO-13-0015 submitted on November 29, 2013, with additional information provided on August 25, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

In SPA number CO-13-0015, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups, using the approved MAGI conversion plan income thresholds. The state indicates on page CS7 that it will cover targeted low-income children, and indicates on page CS8 that it will cover targeted low-income pregnant women. The supporting document to CS8 clarifies the state’s claiming of title XXI funds for pregnant women. Page CS10 allows the state to cover children who have access to public employee coverage and updates the supporting documentation. Page CS11 allows the state to cover pregnant women who have access to public employee coverage and adds supporting documentation. And on page CS13 the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP. These pages are attached to this letter and should be incorporated into the current CHIP state plan according to the table below. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

New State Plan Page _ Impact on Current State Plan Section

CS15: MAGI-Based Income Methodologies Section 4.3: Add new subsection and supersede information on income eligibility and methods

CS7: Targeted Low-Income Children Sections 4.1.1, 4.1.2, and 4.1.3: Supersede information on children :

CS8: Targeted Low-Income Pregnant Women | Sections 4.1.1, 4.1.2, 4.1.3, and 4.1-PW: Supersede and add information on pregnant women

CS8: Supporting Document Section : Add new documentation

CS10: Children Who Have Access to Public Section 4.1.7 and 4.4.1: Supersede information on

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Page 2 — Ms. Suzanne Brennan

New State Plan Page | Impact on Current State Plan Section _

Employee Coverage dependents of employees of a state agency

CS10: Maintenance of Agency Contribution Appendix: Supersede current documentation

CS11: Pregnant Women Who Have Access to | Section 4.4.1: Add new information to section Public Employee Coverage

CS11: Maintenance of Agency Contribution _| Appendix: Add new documentation

CS13: Deemed Newborns Section 4.3: Add new subsection on deeming

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, Colorado 80202-4967

Congratulations on the approval. If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at (410) 786-0719. We look forward to continuing to work with you and your staff.

Sincerel Eliot Fishman Director Enclosures ce:

Mr. Richard Allen, ARA, CMS Region VIII, Denver

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logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility CO.0552.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Colorado State Funds: $ Federal Funds: $ Submitted By: Barbara Prehmus Last Revision Date: Aug 22, 2014 Submit Date: Nov 29, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. CO-13-0015 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Sections 2102(b)(1)(B)(v), 2110 (b), and 2112 of the SSA; 42 CFR 457.310, 315, and 320 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:207 out of 2000 Colorado CHIP MAGI-Based Eligibility & Methods, including MAGI- equivalent FPL % designation. Includes coverage of otherwise eligible children and pregnant women who have access to plublic employee coverage. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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CHIP Eligibility

OMB Control Number: Expiration dat

0938-1148 0/31/2014

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

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

The CHIP Agency operates this covered group in accordance with the following provisions: Age Must be under age 19. Income Standards

Income standards are applied statewide. | Yes

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

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

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

+ lio 19 142 260 4

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

N/A

Special Program for Children with Disabilities

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

PRA Disclosure Statement

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CMS. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. [f you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

V.20130709

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CHIP Eligibility

CNP AAETRENER & HATES RENEE

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

Section 2112 of the SSA

ry Targeted Low-Income Pregnant Women - Uninsured pregnant women who do not have access to public employee coverage and whose household income is within standards established by the state.

[¥] The CHIP Agency operates this covered group in accordance with the following provisions: Age Standards for Pregnant Women

* The state provides coverage to pregnant women:

Select an age range:

C From age 19, up to the following age:

@ With no age restriction. Another age range:

If there is no age restriction or if the age range overlaps with the qualifying ages for children, describe how the determination is made as to whether the applicant will be provided coverage as a child or as a pregnant woman.

Pregnant women under the age of 19 years old, which overlaps with the qualifying ages for children, will be enrolled as targeted low income children in Colorado's separate CHIP program. Such enrollment of pregnant women under the age of 19 as targeted low income children will be reflected on all reports, including financial reports.

[Must be pregnant or post-partum

Income Standards

Pregnant women coverage may only be provided if children's qualifying income standard under the plan is at least up to 200% of FPL for all age ranges.

Income standard is applied statewide

Are there any exceptions. e.g. populations in a county which may qualify under either a statewide income standard or a 0 county income standard?

Statewide Income Standard

CHIP coverage for pregnant women may only be provided if the qualifying income standard under Medicaid for pregnant women is at least up to 185%.

The highest income level for pregnant women cannot be higher than the highest income level for children.

Above 195] % FPL up to and including 260| % FPL SPA# CO-13-0015 Approval pae_ SEP 05 2014

Effective Date: January 1, 2014

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CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

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Targeted Low-Income Pregnant Women; CHIP Match Rate Authorization

TRANSMITTAL NUMBER:

CHIP 13-0015

STATE:

Colorado

Pursuant to Colorado’s approved title XXI section 1115 demonstration project No. 21-W-00014/8, the state is authorized to receive title XXI funds for uninsured pregnant women with income above 141 percent of the FPL through 195 percent of the FPL, who will be covered under the Medicaid state plan until July 31, 2015.

SPA# CO-13-0015

Approval Date:

SEP 0 5 2014

Effective Date: January 1, 2014

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

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

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

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

@ All children who have access to public employee coverage

C Certain children who have access to public employee coverage:

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

An attachment is submitted.

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

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

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

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CHIP ELIGIBILITY SPA

Separate Child Health Insurance Program

Eligibility —- Children Who Have Access to Public Employee Coverage csi0

ATTACHMENT 1: METHODOLOGY THE STATE HAS USED To CALCULATE MMIAINTENANCE OF AGENCY CONTRIBUTION |

Children of state employees will be enrolled into CHP+ if they meet all other technical eligibility requirements including income limits and lack of health insurance. Per section 10203(b)(2)(D) of the Affordable Care Act, States are permitted to extend CHIP eligibility to children of State employees who are otherwise eligible under the Title XXI (CHIP) State Plan to the extent that one of two conditions is met. These conditions are described in a new section 2110(b)(6) of the Social Security Act (added by the Affordable Care Act and amended by Public Law 111-309) and are referred to as the hardship and the maintenance of agency contribution conditions.

Colorado is electing to cover children of state employees under the maintenance of agency contribution condition authorized in Section 2110(b)(6)(B) of the Social Security Act. Specifically, this section grants an exception to the exclusion of children of state employees if the State determines that public agency expenditures for health coverage for employees that have dependent coverage is not less than the amount of such expenditures in the 1997 State fiscal year, increased by the percentage increase of the medical care expenditure category of the Consumer Price Index for All- Urban Consumers (all items: U.S. City Average).

SPA# CO-13-0015 Approval Date: SEP 0 5 2014 Effective Date: January 1, 2014

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GB AAG

Approval Date:

SPA# CO-13-0015

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Cems CHIP Eligibility

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

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

a Pregnant Women Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income‘pregnant women * who have access to public employee coverage on the basis of their, or a family member's employment.

[YZ] The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: .@ Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. C_ Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act.

Coverage under this option is extended to pregnant women whose household income is:

Select one of the options for the income standard when compared to Targeted Low-Income Pregnant Women

@ The same as the standards for Targeted Low-Income Pregnant Women.

Indicate whether coverage under this option is extended to all pregnant women who have access to public employee coverage. or only certain pregnant women:

(@ All pregnant women who have access to public employee coverage. C Certain pregnant women who have access to public employee coverage:

[@) Attach methodology the state has used to calculate maintenance of agency contribution.

‘An attachment is submitted.

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

fH] Age Standard

Select an age standard:

(@ Same as the age criteria used for Targeted Low-Income Pregnant Women.

C Different than the age criteria used for Targeted Low-Income Pregnant Women. [B] Must be pregnant or in a post-partum period.

iw Pregnant women considered to have access to public employee coverage. and therefore not excluded from CHIP through this option. otherwise meet the definition of targeted low-income pregnant woman in accordance with section 2112(d)(2) of the SSA.

PRA Disclosure Statement

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Cems CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V 20130017

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CHIP ELIGIBILITY SPA

Separate Child Health Insurance Program

Eligibility —- Pregnant Women Who Have Access to Public Employee Coverage csi

ATTACHMENT 1: METHODOLOGY THE STATE HAS USED To CALCULATE MAINTENANCE OF AGENCY CONTRIBUTION

Pregnant women who have access to public employee coverage will be enrolled into CHP+ if they meet all other technical eligibility requirements including income limits and lack of health insurance. Per section 10203(b)(2)(D) of the Affordable Care Act, States are permitted to extend CHIP eligibility to dependents of, or pregnant, State employees who are otherwise eligible under the Title XXI (CHIP) State Plan to the extent that one of two conditions is met. These conditions are described in anew section 21 10(b)(6) of the Social Security Act (added by the Affordable Care Act and amended by Public Law 111-309) and are referred to as the hardship and the maintenance of agency contribution conditions.

Colorado is electing to cover pregnant women who have access to public employee coverage under the maintenance of agency contribution condition authorized in Section 2110(b)(6)(B) of the Social Security Act. Specifically, this section grants an exception to the exclusion of dependents of state employees if the State determines that public agency expenditures for health coverage for employees that have dependent coverage is not less than the amount of such expenditures in the 1997 State fiscal year, increased by the percentage increase of the medical care expenditure category of the Consumer Price Index for All-Urban Consumers (all items: U.S. City Average).

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Effective Date: January 1, 2014

SEP 6 5 2014

Approval Date:

SPA# CO-13-0015

(spa)(co-13-0015-mc1)(approval-package)(page-18)Page 18#

Cems CHIP Eligibility

OMB Control Number: 0938-1148

Section 2112(e) of the SSA and 42 CFR 457.360

@ Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CHIP or Medicaid until the child turns one. ‘

The state operates this covered group in accordance with the following provisions: [i] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

lal The child is deemed to have applied for and been found eligible for CHIP or Medicaid. as appropriate, as of the date of the child’s birth, and remains eligible without regard to changes in circumstances until the child's first birthday.

The state elects the following option(s):

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

oO The state elects to recognize a child's deemed newborn status from another state and provides benefits in accordance with the “I requirements of section 2112(e) of the SSA.

ial The state elects to cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the authority of the state’s section 1115 demonstration on the date of the newborn’s birth.

SEP 0 5 2014

SPA# CO-13-0015 Approval Date: Effective Date: January 1, 2014

Page | of I

(spa)(co-13-0015-mc1)(approval-package)(page-19)Page 19#

cems CHIP Eligibility

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

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

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

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later,

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: © The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. @ The pregnant woman is counted as herself. plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income. the state will use reasonable methods to: [EJ Include a prorated portion of the reasonably predictable increase in future income and/or family size. ([] Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

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

by the person claiming an individual described at §435.603(f(2)(i) as a tax dependent. 8s

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

An attachment is submitted.

PRA Disclosure Statement

SPA# CO-13-0015 Approval Date: SEP 0 5 2014 Effective Date: January 1, 2014

Page | of 2

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cms CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. [f 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.

SEP 05 2014

SPA# CO-13-0015 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

(spa)(co-13-0016-mc2)(approval-package)Colorado CHIP SPA CO-13-0016-MC2: Approval Package (approved November 1, 2013, effective January 1, 2014)#

(spa)(co-13-0016-mc2)(approval-package)(page-1)Page 1#

_____________________________________________________________________________

Table of Contents

State/Territory Name: Colorado

State Plan Amendment (SPA) #: CO-13-0016

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services M Ss

7500 Security Boulevard, Mail Stop: $2-26-12 Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Program Group

William Heller NOV 0 4 2013

Director

Child Health Plan Plus

Colorado Department of Health Care Policy and Financing 1570 Grant Street

Denver, CO 80203-1818

Dear Mr. Heller:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) CO-13-0016 submitted on September 6, 2013 and related to the Modified Adjusted Gross Income (MAGI) Eligiblity has been approved with an effective date of January 1, 2014.

XXI Medicaid Expansion:

SPA number CO-13-0016 converts the state’s existing income eligibility standard to a modified adjusted gross income (MAGI)-equivalent standard, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into Colorado’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section 4.0 of the current CHIP state plan.

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information _ is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

If you have questions or wish to discuss this determination further, please contact Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

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Page 2 — Mr. William Heller

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, Colorado 80202-4967

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

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

Enclosure cc: Richard Allen, ARA, CMS Region VIII, Denver

(spa)(co-13-0016-mc2)(approval-package)(page-4)Page 4#

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility CO.0283.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Colorado State Funds: $ Federal Funds: $ Submitted By: Barbara Prehmus Last Revision Date: Sep 6, 2013 Submit Date: Sep 6, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. CO-13-0016 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:173 out of 2000 CO CHIP XXI Medicaid Expansion; previously approved through CO CHIP SPA #12. Includes MAGI-equivalent federal poverty levels as converted from the original CO CHIP SPA #12. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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is CHIP Eligibility

9ST ML TREN ha RE ITSO

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

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

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

19 108 142

NOV 0 1 2013

SPA # CO-13-0016 Approval Date: Effective Date: January 1, 2014

Page | of I

(spa)(co-13-0018-mc4)(approval-package)Colorado CHIP SPA CO-13-0018-MC4: Approval Package (approved November 23, 2013, effective October 1, 2013)#

(spa)(co-13-0018-mc4)(approval-package)(page-1)Page 1#

_____________________________________________________________________________

Table of Contents

State/Territory Name: Colorado

State Plan Amendment (SPA) #: CO-13-0018

This file contains the following documents in the order listed:

1) Approval Letter 2) Companion Letter 3) SPA Summary Form 4) Approved SPA Pages 5) Additional Attachments that are Part of the State Plan

(spa)(co-13-0018-mc4)(approval-package)(page-2)Page 2#

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

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

Children and Adults Health Program Group

Mr. William Heller NOV 26 2013 Director, Child Health Plan Plus

Colorado Department of Health Care Policy and Financing

1570 Grant Street

Denver, CO 80203-1818

Dear Mr. Heller:

I am pleased to inform you that Colorado’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), CO-13-0018, submitted on August 30, 2013, has been approved. This SPA incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Colorado’s CHIP State Plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA CO-13-0018 includes full approval of your state’s alternative single streamlined application used to apply for multiple human service programs. Until April 30, 2014, the state is using an interim alternative single streamlined paper application. Until October 1, 2014, the state is using an interim alternative single streamlined online application. The state will implement revised applications that will 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 Colorado’s approved CHIP state plan:

o C824

o Attachment 1- Statement of use with respect to the alternative single streamlined online application

o Attachment 2- Statement of use with respect to the alternative single streamlined paper application

o Attachment 3- Multibenefit Application

This approval and the attachments supercede the following sections of the current CHIP State Plan:

® Section 4.3: Single, Streamlined Application Screen and Enroll Process

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Page 2 — Mr. William Heller

e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Mr. Richard Allen

Denver Regional Office Colorado State Bank Building 1600 Broadway, Suite# 700 Denver, Colorado 80202-4967

If you have additional questions, please contact Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

ec: Mr. Richard Allen, ARA, CMS Region VII, Denver

(spa)(co-13-0018-mc4)(approval-package)(page-4)Page 4#

DEPARTMENT OF HEALTH & HUMAN SERVICES a

Centers for Medicare & Medicaid Services a CM 4 7500 Security Boulevard, Mail Stop: $2-26-12 ( Baltimore, Maryland 21244-1850 Caen Om AIEDICaiD h cHttP SERVIC

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Program Group

Mr. William Heller

Director, Child Health Plan Plus NOV 2 3 2013 Colorado Department of Health Care Policy and Financing

1570 Grant Street

Denver, CO 80203-1818

Dear Mr. Heller:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Colorado’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), CO-13-0018, submitted on August 30, 2013. Our review of this submission included a review of both the paper and online alternative single streamlined applications and the application used to apply for multiple human service programs developed by the state. Since the state’s application materials are the same for both Medicaid and CHIP, this letter is identical to the Medicaid companion letter.

Until April 30, 2014, the state is using an interim alternative single streamlined paper application. In addition, until October 1, 2014, the state is using an interim alternative single streamlined online application. The interim applications must be revised to reflect the following changes.

Date by which changes

hi: 3 Necessary changes will be completed:

Paper application: Co-branded Application for Health Coverage and Help Paying Costs:

Question #7—Removal of the question of individual shared responsibility exemption. April 30, 2014

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Page 2 — Mr. William Heller

Online application:

If the applicant has not indicated that he or she is aged or blind or disabled, the following questions will not appear on applications for health coverage only.

® Questions regarding bills, such as child care and child support

® Questions related to non-MAGI income types, such as in- kind income, veterans benefits and SSI

February 28, 2014

The following question will not appear for household members not seeking any benefits. e The non-MAGI screening questions related to disability,

blindness and long term care need. This function will be made dynamic.

April 30, 2014

The following questions will not appear for household members not seeking any benefits.

e Residency information

e Allcitizenship and immigration questions

February 28, 2014

Applicants will have the opportunity to identify themselves as American Indians and Alaska Natives for purposes of cost-sharing protections, and identify American Indian and Alaska Native income not countable for Medicaid and CHIP income determinations.

June 30, 2014

School attendance questions will only appear when necessary for

February 28, 2014

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Page 3 — Mr. William Heller

Medicaid eligibility determinations.

The state will integrate questions for Medicaid, CHIP and APTC into a single application. October 1, 2014

Please submit the revised alternative single streamlined paper application to CMS for review no later than April 1, 2014 to ensure approval by April 30, 2014. Also, please submit a revised alternative single streamlined online application to CMS for review no later than September 1, 2014, to ensure approval by October 1, 2014. We continue to be available to provide technical assistance. Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

We look forward to continuing to work with you and your staff.

Linda Nablo Director, Division of State Coverage Programs

ec: Mr. Richard Allen, ARA, CMS Region VIII, Denver

Enclosures

(spa)(co-13-0018-mc4)(approval-package)(page-7)Page 7#

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility CO.0267.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Colorado State Funds: $ Federal Funds: $ Submitted By: Barbara Prehmus Last Revision Date: Jan 16, 2014 Submit Date: Aug 30, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. CO-13-0018 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA; 42 CFR 457 Subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:331 out of 2000 Defines Colorado's CHIP eligibility processes, including request for Secretary approval of alternative single, streamlined application (both paper and online), an alternative multi-benefit application, and a supplemental form to gather tax-filer information for individuals who recently completed a pre-MAGI i li ti Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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CHIP Eligibility

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

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

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 developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

i An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

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.

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 CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means. [1 Other electronic means:

Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial

application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low- rd income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

wl Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and

a Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

Stee 3m

reVeY er ¥ SPA # CO-13-0018 Approval DaMWV 2 0 CUlS October 1, 2013

Page 1 of 2

(spa)(co-13-0018-mc4)(approval-package)(page-10)Page 10#

CHIP Eligibility

zl Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced IN premium tax credits in accordance with section 1943(b)(2) of the SSA. °

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 457.343:

[2] Once every 12 months.

wl 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

[B] information to complete the redeterm ination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering x insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 —' CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for

CHIP.

Check all types of agencies that apply:

(1) The Exchange

Medicaid

(2) Other agency administering insurance affordability programs

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the v requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

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

V.20130709

NOV 2 6 2018

SPA # CO-13-0018 Approval Date: October 1, 2013

Page 2 of 2

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USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

0 Paper Application ] Online Application

TRANSMITTAL NUMBER: STATE:

CO-13-0018 Colorado

Through October 1, 2014, the state is using an interim online alternative single streamlined application. After October 1, 2014, the state will use a revised online alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

(spa)(co-13-0018-mc4)(approval-package)(page-12)Page 12#

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

[xlPaper Application OOnline Application

TRANSMITTAL NUMBER: STATE:

CO-13-0018 Colorado

Through April 30, 2014, the state is using an interim paper alternative single streamlined application. After April 30, 2014, the state will use a revised paper alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

(spa)(co-13-0018-mc4)(approval-package)(page-13)Page 13#

Application for Public Assistance

State of Colorado Departments of Health Care Policy and Financing and Human Services

Please check the programs you want:

Food Assistance — Helps you buy food. You have the right to file your application today. You can complete 3 your name, address, and signature and turn this form into the county office where you live. An interview is & required. Benefits begin from the date the office receives your signed application. A decision will be made as

quickly as possible, but no later than 30 days from the date the office receives your signed application. If expedited assistance is denied, you may ask for an informal hearing.

Colorado Works — For households with a child or a pregnant mother. Provides a cash benefit to families in need. With a few exceptions, parents must participate in work activities. You will be required to work with or receive Child

Support Services.

Aid to the Needy Disabled Colorado Supplement to SSI (AND-CS) — Colorado Supplement provides an additional cash supplement to those persons not receiving the full SSI grant.

Aid to the Needy Disabled and Aid to the Blind (AND-SO) — For persons ages 18-59 who are totally disabled for at least six months or persons under age 59 who meet the definition of blindness. Provides a cash benefit.

medical assistance.

Old Age Pension (OAP) — For low income persons age 60 or over. Provides a cash benefit and may include

Cash Programs

assessment is required.

Home Care Allowance (HCA) — For persons who need help on a regular basis with some or all of their daily self- care (such as bathing, dressing, eating, getting around, and using the bathroom) or who need 24 hour supervision in a non-medical facility. Provides a cash benefit that must be used to pay the provider for services. A functional

month for personal needs.

Personal Needs Allowance (PNA) — For persons residing in a nursing home who have income less than $50 per

Medical

- Free or low-cost insurance from Medicaid or the Child Health Plan Plus Program (CHP+). - Affordable private health insurance plans that offer comprehensive coverage to help you stay well. - _Anewtax credit that can immediately help pay your premiums for health coverage.

O jo; O jo;oO;oO; a

Your Legal FIRST Name | Middle Initial | Legal LAST Name

MAIDEN Name _ | Social Security Number | Date of Birth

| Home Address (Number, Street)

City

| State | ZIP Phone Number Leave blank if you do not have one

| Mailing Address (If Different from Home Address)

City

State | ZIP Other Phone Number

Do You Speak and Read English?

QYes NoQ \f No, What Language(s) Do You Speak?

Are You Homeless? | Are You a Resident of Colorado? Yes NoQ QYes NoQ

Under penalties of perjury, | state that | have examined this application, and to the best of my knowledge and belief my answers are true, including household composition, citizenship and non-citizenship information, and | have listed all amounts and sources of income and property I receive/own. If 1am declaring an Authorized Representative, by signing below, | allow this person to sign my application, get official information about this application, and act for me on all future matters with this |agency. | read, understand, and agree to “What | Should Know.”

Your Signature | Date ] Spouse’s/ Co-Applicant Signature, if Applying (Not Required for Date __ Food Assistance) Authorized Representative, Conservator, Guardian Printed Date Authorized Representative, Conservator, Guardian Printed Name Date | Name | Authorized Representative Signature Date Authorized Representative Signature Date Person Who Helped Complete Application _ Address/Phone Date Application Page 1

(spa)(co-13-0018-mc4)(approval-package)(page-14)Page 14#

We can send links that aliow you to view electronic notices about your case. You may choose more than one option, but if you do not choose, you will receive paper notices by standard mail. Would you prefer? ;

QO Paper notices

> An e-mail with a link to view my notices sent to:

instructions: List EVERYONE LIVING IN YOUR HOME, Even if You Are Not Applying for Them. Use More Paper if Necessary.

If you are a non-citizen who has a SPONSOR, list the Sponsor's information as here, including their SSN.

*marriea, (OPtional for People Not Applying. This is voluntary for Birth Date Single. * food assistance. Race information is optional, will not affect Relation (MM/DD/YY) *Male! | Does This Dive ced ligibility, and is to ensure that benefits are provided regardless| to You Legal Name (First, Middle, Last) and Birth _ | Female Person Want Separated, lof race/color/national origin. i State (WF) | Benefits? | widowed | Social Security Number cities, (SSN)** Race itizen or US National Self My Birth Date ay e i is on Page 1 es My Name is on Page 1 (Yes ONO ‘i State: My SSN is on Page 1 No Person 2| / ! ay es Yes QNo + Fy State: “s KINo Person 3 / ! (Yes ClYes CINo - - ‘State: No. Person 4 / ! a es Yes QNo « - rState: | (QNo Person 5 / f (Yes (Yes CINo : f ‘State: No *Optional for Food Assistance “For programs other than Food Assistance, you must give your SSN if you are applying. You don't have to give it if you are not applying but if you do, it may 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 an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. Do Any of the Children Living in the Dyes If Yes, Have You Tried to Get Medical Support from the OYes Home Have a Parent Living Outside the CINo Child’s Parent Living Outside the Home? QNo Home?

Name of Parent

Address

Phone For Which Child

Other Information You Can Provide

Including Yourself, How Many People in Do You Pay Any Heating or Cooling Did You Receive LEAP Last Year at Your Home Do You Buy and Prepare Costs? Your Current Address?

Food for? Oves $ fmonth QNo Q Yes QNo

Total Money My Household Expects to $ Do You Pay for Electricity? Do You Pay for Phone Service?

Get This Month (Before Deductions). Yes $ /month (INo QyYes $ /month GNo

If You Are Supposed to Pay Rent or $ Do You Pay for Water? Do You Pay for Sewer?

Mortgage, Write the Amount. OYes $. /month _TINo OyYes $. /month _OINo Total Cash on Hand and Money in Your $ Do You Pay for Garbage Service? Other Utility Expenses.

| Checking/Savings Accounts. Yes $ /month No Type: Amount: $. /month Woke in the Home a Migrant or Seasonal Farm Yes Nol | Home Insurance/Property Taxes/HOA Fees $

Did Anyone in the Home Get Benefits in Another State in the Last 30 Days?

OyYes Noo

You may receive food assistance within 7 days if anyone in the home is a migrant or seasonal Yarm worker and the household has less than $100 in cash on hand and in the bank; OR the household has less than $100 in assets and less than $150 income per month; OR if your monthly shelter costs are more than your monthly income plus any cash on hand and in the bank.

Application

Page 2

(spa)(co-13-0018-mc4)(approval-package)(page-15)Page 15#

Is Anyone in the Home Pregnant?

| GYes No

If yes, please complete below.

Who is Pregnant?

| What is the Due Date?

How Many Babies Are Expected? |

List the Name of the Father.

Does Anyone in Your Home Have a

If Yes, Does This Person Need Help with Self-Care Activities?

Disability? /f Yes, Please List the Name Below. OYes No (Such as Bathing, Dressing, Eating, Using the Bathroom) Who? OYes Noo Who? OYes NoQ Do anyone have a medical or developmental condition that has lasted, or is OVYes Nol} expected to last, more than 12 months? If yes, who? Have You or Anyone in the Home Applied for Supplemental - . . . . QYes Nol) | /fyes, please complete below. Security Income (SSI) or Other Social Security Benefits? 8s yes, P P Who What Ossi Date of I I Application OPending Approved O program? | O Application Status ODenied Appealed 0 Who What Ossi Date of I ! Application OPending Approved program? | Q Application Status QDenied Appealed ( If No, has anyone who is disabled ever received SSI or SSDI? | GlYes NoO If yes, when did SSI or SSDI end? / /

If yes, please include a copy of the front and back of your U.S. Citizenship and

en Home a ayes Immigration Services card and complete below. ' Hf you have a sponsor, please provide that information.

Name of Non- Citizen Sponsor(s) SSN, Name, Alien Number Address, Phone Number Does the Non-Citizen Live with His or Her Sponsor? (Yes No Gi | Does the Non-Citizen Receive Free Room and Board? | OYes NoQ Document Type, ls their spouse or parent a veteran or an active-duty member of the US military? QYes NoQ

Document ‘ ar .

ID number Has this person lived in the US since 1996? | QYes NoQ Name of Non- Citizen Sponsor(s)’ SSN, Name, Alien Number Address, Phone Number Does the Non-Citizen Live with His or Her Sponsor? | Yes No | Does the Non-Citizen Receive Free Room and Board? QYes NoQ Document Type, Is their spouse or parent a veteran or an active-duty member of the US military? QYes NoQ

Document ID number Has this person lived in the US since 1996? | QYes NoQ

Is Anyone in the Home currently in Foster Care or Has Ever Been in

Foster care? OyYes No | /f yes, please complete below. Who? Age? When? Who? Age? When? Have You or Anyone in the Home Applied for Supplemental . : . - OYes Noll | /fyes, pl plete below. Security Income (SSI) or Other Social Security Benefits? ese yes, please comp ow Who What Ossi Date of of Application QPending Approved program? | Application Status ODenied Appealed ( Who What Q ssl Date of I of Application OPending Approved 0 program? | Q Application Status Denied Appealed Q Application Page 3

(spa)(co-13-0018-mc4)(approval-package)(page-16)Page 16#

INCOME use More Paper if There is Not Enough Room for Your Answers on This Application.

If yes, please include one full month of income (before taxes and deductions) or proof of Is Anyone Working? OYes employment. If you did not provide your Social Security number, please include proof of your

QNo employment. INCLUDE Sponsor's income even if the Sponsor lives out of the home. Complete this box if: CURRENT JOB 1: Name of Person Who is Working: e Anyone has a Home Business; or Employer Name and Phone number e Anyone sells things online on websites a such as eBay or craigslist; or Monthly Wages/Tips (Before Taxes): Average Hours Worked Each Week e Anyone is Self-Employed; or if anyone How Often is This Person Paid? ~ earns money by babysitting, donating Hourly ClWeekly GEvery2 weeks OTwiceamonth Monthly OvYearly plasma, or selling goods such as a , ~ — | make-up or kitchenware. ls This Job Considered Temporary and Expected to Last Less than 3 | Qes No Who is Self- Employed? CURRENT JOB 2: Name of Person Who is Working: Name of Business Employer Name and Phone number ls Business a Corporation or OYesa LLC? No Last Month’s Gross Income $ ly Wages/Tips (Before Taxes): Average Hours Worked Each Week | Utilities Paid for Business $ ften is This Person Paid? GiHourly Weekly Every 2 weeks Twice amonth OMonthly OYearly Business Taxes Paid $ Is This Job Considered Temporary and Expected to Last Less than 3 Months? | QYes NoO Interest Paid on Business Loans | $ CURRENT JOB 3: Name of Person Who is Working: . Gross Business Labor Costs $ Employer Name and Phone number ; Cost of Merchandise for Business | $ Monthly Wages/Tips (Before Taxes): Average Hours Worked Each Week | Other Business Costs. List: $ How Often is This Person Paid? $ QHourly CiWeekly GEvery2 weeks OTwiceamonth OMonthly OvYearly $ ls This Job Considered Temporary and Expected to Last Less than 3 Months? | OYes No $ $ peer IE EE Complete if Anyone in the Home Is Starting a New Job: "| Name of Person who is going to receive Total Income (Net Income) $ income: | Employer Name and Phone number Signature of Person Who Has This Income. Date this person will start new job: oe oo a : J Monthly wages/tips (before taxes): | For Any Other Income, Use More Paper

How often will this person be paid? if There is Not Enough Room for Your ClHourly ClWeekly OlEvery2 weeks CiTwicea month CiMonthly Yearly [| | Answers on This Application.

Is This Job Considered Temporary and Expected to Last Less than 3 Months? | OiYes NoQ

Has Anyone in the Home Quit or Lost a Job in the Past 30 days? | QYes Not) | /f yes, please complete below. Name of Person Who Quit or Lost a Job: Employer Name and Phone number:

Start and End Date of Job:

| Monthly Wages/Tips (Before Taxes): Date and Amount of Your Last Paycheck: How Often Was This Person Paid? | QHourly QWeekly OlEvery 2 weeks OTwice a month QMonthly OVYearly

Does Anyone Have Other Income? | GYes Not | if yes, check all that apply and complete below

Unemployment Benefits © SSI "1 Veteran Widow (] Worker's Compensation © Railroad Retirement

Child Support ©) Survivor Benefits © Dividends/Interest “= Disability Benefits " Rental Income Retirement/Pension SSDI (3 Alimony ©] Financial Aid “| In-Kind Income (working for rent) Social Security Benefits ~ Veterans Benefits “= Loans/Gifts © Public Assistance “| Other Cash Received Monthly

Application Page 4

(spa)(co-13-0018-mc4)(approval-package)(page-17)Page 17#

Person Getting Money Money From Monthly Person Getting Money Money From Amount Amount $ $ ' $ $ $ i Has Anyone Who is Applying Received a Lump Sum Payment? (Lawsuit or ifyes, please Insurance Settlement, Social Security, SSI, SSDI, Veterans, Inheritance, Surrender of Annuity, or Life QYes NoQ comp plete below. Insurance, Other) Who When Received Type of Lump Sum Amount $ Who When Received Type of Lump Sum Amount $ Does Anyone Pay Child or Adult Daycare, Student Loan Interest, Child Support, Alimony | jy¢, pioese (Alimony Does Not Apply to Food Assistance Eligibility), or Medical Expenses (such as Insurance Premiums, CINo {complete Prescription Medicines, or Copays)? below. Expense Who Pays Expense Who it is for Their Date of birth Month | Amount Paid

Does Anyone in the Home Attend High School, Vocational, Trade School, or QiYes | ifyes, please

College? CINo complete below. Last Grade Expected Date of

Name of Person Name of School Completed Graduation Enrollment Status

QHalf Time Full Time 2

OHalf Time Full Time 2

Are There Any Household Members Temporarily out of the Home in a

If yes, please

Medical Facility (such as a Nursing Home, Hospital, a Mental Health Institution, or a Group OYes Not | omplete below. Home)? Name of Person Date Entered Name of Facility Phone.

Are You Applying for Food Assistance or Colorado Works?

OYes Nol) | /f yes, please complete below

4. Have You or Any Member of Your Home Been Convicted of Fraudulently Receiving Duplicate Food Assistance Benefits in Any State After 9/22/1996? OYes No

2. Are You or Any Member of Your Home Hiding or Running from the Law to Avoid Prosecution, Being Taken into Custody, Going to Jail for a Felony Crime or Attempted Felony Crime, or Violating a Condition of Parole or Probation? QYes NoQ

3. Have You or Any Member of Your Home Been Convicted of a Felony Under Federal or State Law for Possession, Use, or Distribution of a Controlled Drug Substance (Felony Drug Conviction) or for a Crime While Under the Influence of a Controlled Drug Substance after 8/22/1996? QYes NoQ

4. Have You or Any Member of Your Home Been Convicted of Buying or Selling Food Assistance Benefits for More than $500 After 9/22/1996? OYes NoQ

5. Have You or Any Member of Your Home Been Convicted of Trading Food Assistance Benefits for Guns, Ammunitions, Explosives, or Drugs After 9/22/1996? OlYes NoQ

6. Have You or Any Member of Your Home Been Convicted of a Felony? (Only Required for Colorado Works) OYes Nol)

7. Have You or Any Member of Your Household Applying for Assistance Been Disqualified for an Intentional Program Violation or Been Convicted of Welfare Fraud in a Criminal Case? QiYes NoO

Has Anyone in the Home Been in the Military?

OYes NoQ

If Yes, Who?

Prefer:

If You Need Help to Pay Your Burial/Funeral Costs, Would You

Cremation Burial No Preference

Application

Page 5

(spa)(co-13-0018-mc4)(approval-package)(page-18)Page 18#

Affidavit of Lawful Presence

If You Are Applying for Colorado Works Everyone in Your House Over 18 Needs to Complete and Sign. If You Are Applying for Aid to the Needy Disabled, (AND-CS or AND-SO), Old Age Pension, or Home Care Allowance You Need to Complete and Sign.

Are You a Citizen of the United States Yes Not] If No, Are You a Legal Permanent Resident of the United States? OYes Not]

1 Am Lawfully Present in the United States Pursuant to Federal Law_OYes NoQ

| understand this sworn statement is required by law because | have applied for a public benefit. | understand that state law requires me to provide proof that | am lawfully present in the United States prior to receipt of this public benefit. | further admit that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8- 503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

Signature Date

Affidavit of Lawful Presence

If You Are Applying for Colorado Works Everyone in Your House Over 18 Needs to Complete and Sign. If You Are Applying for Aid to the Needy Disabled (AND-CS or AND-SO), Old Age Pension, or Home Care Allowance You Need to Complete and Sign.

Are You a Citizen of the United States QYes Nol If No, Are You a Legal Permanent Resident of the United States? Yes Nol

| understand this swom statement is required by law because | have applied for a public benefit. | understand that state law requires me to provide proof that | am lawfully present in the United States prior to receipt of this public benefit. | further admit that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8- 503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

Signature Date

Does Anyone Have Any of the QYesNoQ | List everything below.

Following: e Cash e Mutual Funds e Retirement Accounts |e Education Accounts * Checking and Saving Accounts |e Inheritance e Stocks ° Property (Land, Homes) * Certificates of Deposits (CD) e PASS Accounts « Bonds 2 401K »® Annuities e Individual Development |¢ Trusts e Proceeds from Sale of Home(s) « College Funds Accounts ¢ Promissory Notes « _ Other resources Person Who Has It | What Do They Have Amount Person Who Has It What Do They Have Amount $ $ $ $ 8 $ $ $ Does Anyone Own a Car, Truck, Van, Boat, Motorcycle, RV, or QYes NoQ List them below. Trailer? Person Who Owns It _| Make/Model and Year Value Person Who Owns It _| Make/Model and Year Value $ $ $ $ Has Anyone Given Away Anything of Value or Sold Anything QYes No List what was sold or given for Less than Fair Market Value in the Last Five Years? away below. Person Who What was Given Away or Sold and Person Who Gave It What was Given Away or Sold and Gave It Away or =| When Value Away or Sold It When Value Sold It $ 8

Application Page 6

(spa)(co-13-0018-mc4)(approval-package)(page-19)Page 19#

Is Anyone Buying or Does Anyone Own Land, Property, House, Rental Property, OiYes | List them

Timeshare, Cabin, or Lot? QINo | below. Person Who is Address or Property Description Value Person Who is Address or Property Description Value Buying/Owns Buying/Owns

$ $

Does Anyone Have Life Insurance Policies? QYes No Q | List policies below.

Who _| Company and Policy Number ORevocable Value Olrrevocable $

Who Company and Policy Number CiRevocable Value Cilrrevocable $

Does Anyone Have Burial Insurance Policies? | QYes No Q | List policies below.

Who __| Company and Policy Number QRevocable Value Olrrevocable 8

Who Company and Policy Number CiRevocable Value

| Cirrevocable $

Is Anyone enrolled in health coverage now from the following?

(Yes. If yes, complete the following section. CINo. If no, skip this section.

C] Medicaid Name: (1 Child Health Plan Plus . (CHP+) Name:

Name: Medicare claim number: ( Medicare

Check for: (Part A (Part B [Part D

Please include a copy of the front and back of the Medicare card if itis available. ( TRICARE (Do not check if you have direct care of Name: Policy Number: Line of Duty) 0 VA Health Care . . . Programs Name: Policy Number: (1 Peace Corps Name:

Name: Policy number:

Start date of coverage (mm/dd/yyyy):

Is this COBRA coverage? CYes Not] Is this a retiree health plan? DyYes No If eligible for Medicaid, do any members of this home have access to group health insurance and want help paying the monthly premium? Yes Nofl

Name: Policy Number: Other Name of health plan: Start date of coverage (mm/dd/yyyy): Does Anyone want help paying for medical bills from the last 3 months? OYes NoQ Do you live with at least one child under the age of 19, and are you the main person c1Yes Not! taking care of this child? es No Application Page 7

(spa)(co-13-0018-mc4)(approval-package)(page-20)Page 20#

instructions: Please complete for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you file one. If you don't file a tax return, remember to still add family members who live with you.

(Use More Paper if Necessary)

Do You Plan to File a Federal Income Tax Return NEXT YEAR?

OYes. If yes, answer questions 1-3 CINo. If no, answer question 3

You can still apply for Medicaid, CHP+, or health insurance even if you do not file a federal income tax retum.

1. Will you file jointly with a spouse? | Yes No © If yes, please list full legal name of spouse 2. Will you claim any dependents on | QYes No O If yes, list full legal name of dependents your tax return? - ~ If yes, list full legal name of the tax filer 3. Will you be claimed as a QYes No Q dependent on someone's tax return? How are you related to the tax filer?

Does Anyone Else in the Home Plan to File a Federal Income Tax Return NEXT YEAR?

QYes. If yes, answer questions 1-3 QINo. If no, answer question 3

You can still apply for Medicaid, CHP+, or health insurance even if you do not file a federal income tax return.

Name 1. Will they file jointly with a spouse? |ClYesNoQ | ifyes, please list full legal name of spouse 2. Will they claim any dependents on | QYes No If yes, list full legal name of dependents their tax return?

If yes, list full legal name of the tax filer 3. Will they be claimed as a QYes NoQ y dependent on someone's tax return?

How are they related to the tax filer?

Does Anyone Else in the Home

Return NEXT YEAR?

Plan to File a Federal Income Tax

OYes. If yes, answer questions 1-3 QINo. If no, answer question 3

You can still apply for Medicaid, CHP+, or health insurance even if you do not file a federal income tax retum.

Name soe a |

1. Will they file jointly with a spouse? |QYesNoQ | if yes, please list full legal name of spouse 2. Will they claim any dependents on | QYes No & If yes, list full legal name of dependents their tax return?

an 7 If yes, list full legal name of the tax filer 3. Will they be claimed as a QYes NoQ dependent on someone's tax return?

How are they related to the tax filer?

Application

Page 8

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What | Should Know

PLEASE KEEP THIS FOR YOUR INFORMATION

By completing and signing the State of Colorado Application for Public Assistance and other documents required to determine whether I’m eligible for public assistance benefits AND by accepting benefits that | am eligible to receive, | understand the following information and agree to the following requirements:

| must tell the truth; it is a crime to lie on this application.

I may have to give papers that show what I’ve told you is true. i may have to tell you of any changes to the information | gave you on my application. if [think you made a mistake, | can ask for an appeal or fair hearing.

The department will not discriminate.

The department will confirm citizenship and immigration status for everyone applying for benefits.

The department will tell you if your benefits change.

The department will take back any benefits you should not have received.

1. The Department of Health Care Policy and Financing (HCPF) is the state agency responsible for Medical Assistance Programs in Colorado. The Department of Human Services is the state agency responsible for the other public assistance programs. The County Departments of Human/Social Services and Medical Assistance Sites are the agencies that receive and process applications for all public assistance programs. In this statement, the term “department” is used to refer to all agencies.

2. | must give the department all needed proof and documents before qualifying for benefits.

3. The information | give on the application and in the application interview is confidential. But, the department can use or share the information with other program(s) that any of my family members are getting or are applying for. The information can only be used for purposes of treatment, payment, determining eligibility, and other program and administrative operations, or other purposes permitted by law for my family members or me.

4, Itis a crime to lie on the application or to take benefits that | know that my family and | are not eligible to receive and | may be subject to criminal prosecution for knowingly providing false information. Giving false information may be punished by a fine of up to $250,000 or a jail term of up to 20 years, or both.

5. Aperson found to have intentionally given false information cannot get food assistance and/or Colorado Works/TANF for 12 months for the first offense, 24 months for the second offense, and permanently for the third offense. A court can also stop a person from getting food assistance for another eighteen months. This crime is subject to prosecution under other state and federal laws. Receiving duplicate benefits of food assistance by lying about identity or residence will result in a 10 — year disqualification for the first and second offense and a permanent disqualification for the third offense.

6. The department will notify me in writing of how and when to tell the department of any changes.

7. If | do not tell the truth on my application or if information is left off of the application, or if | do not report changes to the department, as required, | may lose my assistance, and | may have to pay the department for the assistance received when | was not eligible. If | have to pay back money to the department, | understand that state or federal salaries, rebates, or tax refunds that would be received by me or another person on this application may be taken.

8. The law says the department must check the immigration status and citizenship for anyone who is applying. They will not check immigration status of family members who are not applying for benefits. | may be requested to give proof of non-citizen registration documentation received from the United States Citizen and Immigration Service (USCIS) for every non-citizen member in my house who is applying for benefits. The department will confirm information with USCIS and any information received from USCIS may affect my eligibility and benefits. Federal law (Public Law 97-98) requires me to give the department the Social Security number and/or alien registration number of all persons who are applying for public assistance. | must also provide the Social Security number and/or alien registration number for all sponsors. For adult financial programs, sponsor

Application

information will be confirmed with USCIS and the information received from USCIS may affect sponsor repayment for my eligibility and benefits. My sponsor and | may be responsible for reimbursing the state for benefits that | receive. 9. | do not have to be a U.S. citizen to apply for assistance. Please do not let the fear about immigration status stop you from seeking benefits for your family. 10. if |am a resident of an institution and jointly applying for SSI and food assistance prior to leaving the institution, the filing date of the application is my date of release from the institution. Processing time will begin from the date the application is received in the food assistance office. 11. Privacy Act Information: The department is authorized to collect information on the application, including Social Security numbers and will confirm information that may affect initial or ongoing eligibility and payments for all persons listed on my application. | am allowing the department to use Social Security numbers and other information from my application to request and receive information or records to confirm the information in my application. Food assistance will be denied to individuals that do not provide a Social Security number, and Social Security numbers will be used and disclosed in the same manner for both eligible and ineligible members. | release the department from all liability for sharing this information with other agencies for this purpose. For example, the department may get and share information with any of the following agencies: Social Security Administration; Internal Revenue Service; United States Customs and Immigration Services; Colorado Department of Labor and Employment; Financial institutions (banks, savings and loans, credit unions, insurance companies, landlords, leasing agents, etc.); child support enforcement agencies; employers; courts; and other federal or state agencies; and for food assistance, law enforcement officials for the purposes of apprehending persons fleeing to avoid the law. {fa food assistance over-payment occurs against my household, the information on this application, including all Social Security numbers, may be referred to Federal and State agencies, as well as private claims collection agencies for claims collection action. 12. The EBT (or Quest) card is used to pay me most of my public assistance benefits. | cannot trade or sell EBT cards. | cannot use or have in my possession EBT cards that are not mine. Unless | have an authorized representative, | cannot let someone else use my EBT card. | can only let my authorized representative use my EBT card. 13. For food assistance, | can name someone to be my representative. | must do this in writing. The person | designate to be my authorized representative may help me apply for assistance, get my benefits, and use my benefits to buy food for me. I may name one person to help me with each separate task or | may name one person to help me with all of these tasks. 14. If | think the department made a mistake, | can ask for a Fair Hearing. The department will tell me in writing how to make an appeal. | can ask for a Fair Hearing either verbally or in writing. My case may be presented by a member of my household or my representative, such as legal counsel, friend, or relative. | may request an appeal for any action on any program except for the CHP+ program.

Page 9

(spa)(co-13-0018-mc4)(approval-package)(page-22)Page 22#

15. If | think the CHP+ program made a mistake, | can ask for an appeal. CHP+ tells me about how to make an appeal in writing.

16. Colorado Works is Colorado’s TANF (Temporary Assistance for Needy Families) program. It is not an entitlement program and benefits are not guaranteed. Each county has the authority to determine eligibility requirements and benefit levels. To remain eligible, | may be required to complete an assessment and develop a plan. Unless exempted, | will be required to participate in work readiness activities.

17. As an applicant for Colorado Works, | am required to assign all rights to child support that may be received on my behalf or for those in my household that | am applying for. This assignment starts when | am determined eligible and will continue until my Colorado Works benefits end. If | do not do this or refuse to cooperate with Child Support Enforcement at the time | apply or while receiving cash assistance through Colorado Works, without good cause, | will not receive assistance or a basic cash assistance grant for my family.

18. If 1am an adult between the ages of 18 and 49, with no children under the age of 18 in my food assistance house, | will only be able to get food assistance benefits for three months during the next three years unless: | work in a job 80 hours each month and report that information to Employment First; or | work my assigned hours at my Employment First office, including Workfare or the Employment First work program; or | am determined to be physically or mentally unable to work; or the food assistance office tells me that | am exempt. As long as 1 do one of these activities each month, | will be able to receive food assistance benefits if | am otherwise eligible.

19. | understand and agree that to receive food assistance, certain members of the household need to register for work. This means that certain members of the household must: A) Report to the Employment First (work program) when the food assistance office schedules you for an appointment. B) Comply with the instructions the Employment First (work program) gives you including reporting for all scheduled appointments and following through on the written agreements you sign. C) Provide information to the food assistance office or the Employment First (work program) about any jobs you get while you are on food assistance. D) Tell the food assistance office or the Employment First (work program) if you are not able to work — you will be asked to provide verification; work any workfare hours you are assigned; go to job interviews arranged for you. Anyone who does not follow the work requirements may be disqualified from receiving food assistance. 20. | must cooperate fully with state and federal staff if my case is reviewed. My information on this application may be reviewed and confirmed by the department, or its representatives. My house will not be eligible for food assistance if | refuse to cooperate with any review of my case, including a quality control review.

21. | cannot use food assistance benefits to buy nonfood items, such as alcohol or cigarettes. | can be disqualified for using food assistance to pay for items purchased on credit. A person found guilty of using food assistance benefits to illegally purchase or receive controlled substances shall be disqualified for two years for a first offense and permanently for a second offense. Individuals found by a Federal, State, or local court to have used or received benefits in a transaction involving the sale of firearms, ammunition, or explosives shall be permanently ineligible to receive food assistance upon the first occasion of such violation.

22. Trafficking food assistance means knowingly transferring benefits to another person who does not use or does not intend to use them for the benefit of the household to whom the benefits were issued. The buying, selling, or transferring of food assistance benefits or Electronic Benefit Transfer Card for cash or consideration other than eligible food shall be considered trafficking. A person who traffics in food assistance benefits shall include any person who knowingly acquires, accepts, uses, or transfers to another for consideration, food assistance benefits not issued to him or her or toa household of which he or she is a member or for which he or she is an authorized representative. An individual convicted by a Federal, State, or local court of having trafficked benefits for an aggregate amount of $500 or more

shall be permanently ineligible to receive food assistance upon the first occasion of such violation.

23. If | do not report and provide proof of rent, mortgage, housing fees, property insurance, property taxes, court ordered child support payments, child or adult care, and medical expenses paid by people in my household who are elderly or who have a disability, | am stating that | do not want that specific deduction used to determine my food assistance benefit amount.

24. | can ask for food assistance apart from asking for benefits from other programs. My eligibility for food assistance will be determined apart from any other programs. The food assistance office shall process all food assistance applications in accordance with food assistance timeliness, noticing, and fair hearing requirements, even if | am applying for other programs.

25. Colorado residents who have a qualifying disability, such as persons receiving SSI or SSDI benefits, or residents who are at least 65 years of age (or a surviving spouse age 58 or older) might also qualify for a Property Tax/Rent/Heat Rebate from the Department of Revenue. Visit www.TaxColorado.com and click on the PTC button at the top of the page or call 303-238-7378 for details.

Domestic violence information and services are available to me. If | ever feel 1am in immediate danger | should call 911. If | would like to receive information regarding safety and services in Colorado, | will call the Colorado Coalition Against Domestic Violence at 303-831-9632 or toll free at 1-888-778-7091. | may also find the location of services near me by going to www.colorado.gov/cdhs/dvp. The National Domestic Violence Hotline at 1-800-799-SAFE (7233) or TTY 1-800-787-3224 or ndvh.org can also provide information. If 1am a survivor of domestic violence, sexual assault, or stalking the Address Confidentiality Program (ACP) can provide me with a legal substitute address to use instead of my real address for use with state and local government agencies. | can find out more about ACP at acp.colorado.gov. If | need or receive either of these services, | should tell my department worker because it will allow him or her to provide better service and assistance to me.

Our non-discrimination policy. This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion and political beliefs. The U.S Department of Agriculture also prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination with USDA, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800)221-5689, which is also in Spanish or call the State Information/Hotline Numbers; found online at http://www.fns.usda.gov/snap/contact_info/hotlines.htm. To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (ITY). USDA and HHS are equal opportunity providers and employers.

Application

Page 10

(spa)(co-16-0025)(approval-package)Colorado CHIP SPA CO-16-0025: Approval Package (approved September 6, 2017, effective January 1, 2016)#

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_____________________________________________________________________________ Table of Contents State/Territory Name: Colorado State Plan Amendments (SPA) #: CO-16-0025 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are Part of the State Plan The complete title XXI state plan for Colorado consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-16 Baltimore, MD 21244-1850 ctvts CtNltRS fOR MfDICÀRE & MEDIC/rlD St¡vlctS CENTER FOR MEDICAID & CHIP SERVIC¡S Childten and Health Prosrams sEP 0 6 2017 Gretchen Hammer Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan (CHP+) 1570 Grant Street Denver, CO 80203-1818 Dear Ms. Hammer: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), CO-16-0025, submitted on June 21, 2016, with additional information provided on August 29,2017, has been approved. This SPA has a retroactive effective date of January 1,2016. This SPA amends Colorado's eligibility application materials in response to stakeholder input recommending changes to improve readability of materials, streamline application questions to pertain only to eligibility determinations, and ensure that members of a federally recognized tribes have the opportunity to obtain all the benefits to which they are entitled. In addition to the approval of this SPA, the online application will need to be revised to meet the required changes as identified in the companion letter issued with this approval. On August 3, 2017, the state received approval for the same type of amendment under Medicaid SPA, CO-16- 0001. The Medicaid SPA has an efïective date of January l, 2016. Enclosed is a copy of the fbllowing state plan pages and attachments to be incorporated within a separate section at the end of Colorado's approved state plan: o CS24 . Attachment I - Alternative single, streamlined paper application This approval and the enclosures supercede the following sections of the current CHIP state plan: o Section 4.3: Single Streamlined Application Screen and Enroll Process o Section 4.4: Renewals, Screening by Other Insurance Aflbrdability Programs Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Jordan's contact information is as follows:

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Page 2 - Ms. Gretchen Hammer Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413 Facsimile: (410) 786-5882 E-mail: Joyce.Jordan@cms.hhs.eov Offrcial communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen's address is: Centers for Medicare & Medicaid Services 1961 Stout Street Room 08-148 Denver, Colorado 80294 If you have additional questions, please contact A my Lutzky, Director, Division of State Coverage Programs at (410) 786-0721. We look forward to continuing to work with you and your staff. &ô Anne Marie Costello Director cc: Richard Allen, ARA, CMS Region VIII, Denver / Anne Marie Costello /

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Children's Health Insurance

Program Eligibility

Control Panel _ ome 3 rane seas Children's Health Insurance Program Eligibility:

Summary Page

General Information State/Territory Colorado File Management name: Transmittal Number: Tribal Input YY-0000 where ST= the state abbreviation, YY = the last two

digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |CO-16-0025

Summary

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group “ Eligibility Processing Non-Financial Eligibility

Proposed Effective Date

(nm/aa/ yyy)

Federal Statute/ Regulation Citation

[2104 (b)(3) and 2107 (e)(1)(O) of the SSA; 42 CFR 457 Subpart C

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: ¢

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count: 669 out of 2000 inf revised alternative single streamlined application (both paper and online versions) and an alternative multi-program A application. This 5PA amends the Colorado eligibility application materials in response to stakeholder input to a address issues of readability (plain language, font size, and

Signature of State Agency Official

Submitted By: Amanda Forsythe

Last Revision Aug 31, 2017 Date: Submit Date: Jun 21, 2016

BACK CONTINUE )

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-0'l-"16 Baltinrore, MD 2'1244--1850 ctvts ctNtfRs toR MtDtc{ÎE & MtDtCAtD SilVtCÉS CENTER TOR MEDICAID & C}IIP SERVICES Children and Health Proerams GrouD sEP 0 6 2017 Gretchen Hammer Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan (CHP+) 1570 Grant Street Denver, CO 80203-1818 Dear Ms. Hammer: This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Colorado's title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), CO-I6-0025, which was subrnitted on June 2l ,2016. Our review of this submission included a review of the paper and online alternative single streamlined applications and the state's alternative paper application used to apply for multiple human service programs. 'l'he approval ot'CHIP SPA, CO-16-0025, includes full approval of the state's revised alternative single streamlined paper application and paper application for multiple service programs only. Until no later than December 31,2020, the state is using an interim single, streamlined online application. The online application will need to be revised to reflect the following changes. These changes are identical to those that were requested in the companion letter to Medicaid SPA CO-I6-0001. The respective changes will be completed by the dates noted in the table below. Necessary changes: Date by which changes will be comfileted: I Remove "Social Security Income" as a drop down option for "other income" for applicants not seeking coverage on a basis other than modified adjusted gross income (MAGI). March 2018 2 Remove detailed questions used to connect beneficiaries to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services in the Health Communities Program. These questions may be asked post-eligibility, for individuals determined eligible for Medicaid. March 2018 aJ Include the following questions for purposes of advance premium tax credits (APTC) eligibility: ¡ Are you entitled to receive Medicare Part A? o Are you enrolled in Medicare Part A? r ls your Medicare Part A? Additional Medicare questions should only appear if the applicant March 2018

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Page 2 - Ms. Gretchen Hammer Remove from the questions about information on applicants' employers Necessary changes Date by which changes will be chooses to fill out the Non-MAGI application. 4. Remove questions payments to providers for or adult for for health March 2018 5. Remove questions about where are applying. December 2019 6. Remove questions about assistance given care to individuals for health December 2019 Revise logic to only display the about whether applicants have an eligible immigration status to applicants who indicate that are not U.S citizens. December 2019 8. Update "Privacy" and "What I Should Know Language" to reduce duplication, a¡d miruor the paper application. December 2019 9. Include a separate question to provide applicants with a¡ opportunity to identify themselves America¡r Indians and Alaska Natives to for pulposes of cost-sharing protections, and identify America¡ Indian and Alaska Native income not countable for Medicaid and CHIP income determinations. December 2019 10. Remove the requirement for authorized representatives to sign the application prior to submission. December 2019 l1 Update the section on immigration document types to clarify that no documcnt expiration date is required for individuals with immigration documents that do not have expiration dates. December 2019 t2. Remove options for income and deductions that are not relevant for MAGI eligibility. December 2019 13 Clarify that applicants screened as potentially eligible on a non- MAGI basis may submit their application and obtain a determination based on MAGI, prior to completing additional detailed questions needed only to complete the determination on a non-MAGI basis. December 2019 14. Remove the question asking whether or not the applicant's employer sponsored plan is considered affordable. December 2020 15. Remove the reference to coverage year when asking "Did this person pass away" December 2020 16. Remove Railroad Retirement as an option for other health coverage in the section on other coverage. December 2020 17 Replace the term "Actual Annual" with "Expected Annual" throughout the application when seeking information from the applicant on total expected income during the coverase vear. December 2020 18. Remove all questions and associated help text related to applicants' receipt of or eligibility for a shared exemption. December 2020 19. December 2020 Retiree a¡d Veterans' Insurance

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Page 3 - Ms. Gretchen Hammer Please submit the revised altemative single streamline online application to CMS as for review no later than December 1, 2020, to ensure approval by December 31,2020. cMS will monitor the state's progress toward completion ofthe individual milestones listed above. We continue to be available to provide technical assistance. If you have any additional questions or require any further assistance, please contact your cHIp project officer, Joyce Jordan at Joyce..Iordan@çms.hh¡.sqy or (4 1 0) 7 86-3 4 13. Sincerely,ry¿*U Amy Lutzky Director Division of State Coverage Programs cc: Richard Allen, ARA, CMS Region VIII, Denver / Amy Lutzky /

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Colorado Transmittal Number: Co - 16 - 0025 CHIP Eligibility OMB Control Number': 0938 114E Expirarion date: l0 13 I /20 14 Effective Dater January 1, 2016 Page I of3 State Name: 2102(b)(3) &.2107(eX l)(O) ofthe SSA and 42 CFR 457, subpart C r-, The CHIP Agency meets all ofthe requirements of42 CFR 457, subpart C for application processing, eligibility screening and Ú enrollment. Application Processing tndicate which application the agency uses for individuals applying fol coverage who may be eligible based on the applicable modified adjusted gross income standard: ,-- The single, streamlined application developed by tbe Secretary in accordance with section l4l3(bXlXA) ofthe Affordable ! Care Act. An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with section l4l3(bXl)(B) ofthe Affordable Care Act. An alternative application used to apply for multiple human seruice programs approved by the Secretary, provided that the fi agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs, The agency's procedures permit an individual, or authorized person acting on behalfof the individual, to submit an applicat¡on v¡a the internet website described in CFR 45'7.340(a), by lelephone, via mail, in person and other commonly available electron¡c means. The agency accepts applications in the following other electronic means. I Other electronic means: Screen and Enroll Proc€ss The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, per.iodic red€terminations, and follow-up eligibility determinations. The procedures ensure that only targeted low- income children are plovided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs. Procedures include: - Screenins ofapÞlication to idertiô' all individuals eligible or potentially eligible for CHIP or other insurance affordability trt - programs; and sPA# CO-16-0025 npp,ouur o"t", SEP 0 6 2017

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ffi*" CHIP Etigibitity Effective Dater January 1, 2016 Page 2 of 3 - Income efisibilitv test. with calculation of household income consistent with 42 CFF. 457.315 for individuals identified as E potentially"eligibie fo. trled ¡caid or othe¡ insurance affordability programs based on household income; and =., Screening process for individuals who may qualiff for Medicaid on a basis other than having household income at or below the E applicable MAGI standard. based on information in the single streamlined application. The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced premium tax credits in accordance with section 1943(bX2) ofthe SSA. R€determination Processing No - Redeterminations ofel¡g¡bility for individuals whose financial eligibilrty is based on the applicable modified adjusted gross Ú incoure standard are performed as follows, consistent with 42 CFR 457.343: I Once every l2 months. - Without reouirins information from the individual ifable to do so based on reliable information contained in the individual's E account or åther iore current informalion available to the agency. lfthe agency cannot determine eligibility solely on the basis ofthe information ava¡lable to ¡t, or otherw¡se needs add¡tional E information to complete the redetermination, it prov¡des the individual with a pre-populated renewal form Çontaining the information already available. Screening by Other Insurrnce Affordability Programs The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of42 CFR 457.348(b) and to determine eligibility in accordance with 42 CFF. 457 .340 in the same manner as ifthe application had been submitted directly to, and processed by the state. x The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of42 CFR 457.340 to the same extent and in the same manner as ifthe applicant had been detemined by the state to be €ligible for CHIP. Check all Insu¡ance Affordability Progrums that apply: n The Exchange I Medicaid I other lnsurance Affordability Program - The CHIP Agency has entered ¡nto an agreement rryith agencies adm¡nistering other insurance affordability programs to fulfill the lll requirements of457.348(b)and will provide this agreement to the Secretary upon request sPA# CO-16-0025 ¡,pp.o""r o"tu, SEP B 6 2017

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CHIP Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no percons are required to respond to a collection of information unless it displays a valid OMB control number. Thevalid OMB control number for this ¡nformation collection is0938-1148. Thetime required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Ifyou 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 Repofis Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 v.20r404r5 Effeclive Dater January 1,2016 Page 3 of3 sPA# CO-16-0025 ooo,oun o",", SËP 0 6 20t7

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M See inside Things to Know Application Pr¡vacy State me nt ........,.........,........ Worksheets Where to mail your application ....... Glossary Having health insurance can help give you peace of mind and stay healthy. With insurance, you will know you and your family can get health care when you need it. Fill out this application to see if you qualify for: . Free or low-cost public health insurance from Health First Colorado (Colorado's Medicaid Program) or the Child Health Plan P/us (CHP+) program administered by the Colorado Department of Health Care Policy and FinancingQ, . Affordable private health insurance plans that offer comprehensive coverage available through Connect for Health ColoradoO (the Marketplace), or . A tax credit that can help lower your premiums for hea lth coverage. You may qualify for free or low-cost health insurance if you earn as much as 5¿6,500 a year for an individual, or $95,000 a year for a family of 4. Filling out this application does not mean you have to buy health insurance. Who can use th¡s appl¡cat¡on? Anyone can use this application. Apply¡ng will not affect your immigration status or chances of becoming a permanent resident or citizen. Call us to get connected to free help in other languages lf someone is helping you fill out this applicqtion, you may need to complete Worksheet A / 1p"g"t 18 - 19). For a l¡st of languages we can assist ¡n, see Things to Know. lf you need help in a language other than English, call and tell the customer service representative the language you need. Llame a nuestro centro de servicio gratis para ayuda o para obtener una cop¡a de esta formulario en Español. Department of Health Care Poìicy & Financing's Member Contact Ce nter . Toll Free: t-8OO-22t-3943 | State Relay: 711 Connect for Health Colorado Customer Service Center . Toll Free: 7-855-752-67 49 | TTY: 1-855-346-3432 Symbols used ¡n th¡s appl¡cat¡on worksheets are marked with the symbol / in this application (starting on page 18). Terms marked with an @ in the application can be found in the Glossary (starting on page 41). ii-¡ii 1- 16 t7 18-34 36-40 4L-43 sEP 0 6 2017

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Call us to get connected to free help in other languages Espäñol - ATENCIÓN: si habla español, tiene a su disposìc¡ón servicios gratu¡tos de asistencia l¡ngüística, Llame al I-8OO-227-3943 (State Relay: 711). Tiêîg ViÇt - CHú i Néu ban nói Tiðng Viêt, có các dich vu hô trg ngôn ngú mién phídành cho b?n. Gqi sõ 1-800-22L-3943 (State Relayr 711). *lttl#,{ - )1,e.* : ftr+/fr{ÉH%åg+y' lÍÃD)fuHIÊ1+.ÃÈ=+ÊEhEVf*. ÈËff€ r-eoo-zzr-3e43 (state Relay: 7u). -d401 -+9: -È1=ol= ^l8õl^l= ã?, Èq IIA ^lHlr'.= +ËË 0lEõlä + 1,1åLltl. 1-800-221-3e43 (state Relayl 711) Ë oË Éõlõll +d^lc, Pycc1uü -Ec¡,n Bbt roBopt4re no-pyccxø, ean ¿ocrynnur 6ecn¡arHbre yc¡yrø nepeBoA.røKa.3BoHl4re 1-800-221-3943 {State relay: 777],. h'tt-.\: - cïàt azt |rd:¿C?t+ *?4 )id?cî hUPT f+Cr'.,ÀC,S,4 RcÞ4Tr nts rLS,lTP+ +flrn+f¿\: 03, øth+(\@ *TC &ßGrì. 1-800-221-3943 (øDòd?+ 1ì+/tç+@-r 711). 71.1:é! ¡,Jr .,t" ú) L-8OO-22I-3943 r'r J^nr 'öljr, r.! ;F ¡'-/Jr ;Jjúr er-J- rl¡ r-{Jr Ét J-r-J .-lr,! :.lrrl - ¡",11 Deutsch - ACHTUNG: Wenn S¡e Deutsch sprechen, stehen lhnen kostenlos sprâchl¡che H¡lfsdienstleistungen zur Verfügung, Rufnummer: 1-800-221-3943 (State Relay: 711). Français - ATTENTION : S¡ vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800- 221-3943 (ATS : 711). ffi-e¡qrr EE-ù'q: a-rçrà ffi ù{q-F-d6 årâ dvqs+l aft-af¡+m FõTTdr ÈmËd ant¡6ø 1vm rcõ-dtr cr I sì-a ãK{6ts L-soo-zzr-ss43 FÊÊ'rf; zrr). Tagâlog - PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa w¡ka nang walang bayad, Tumawag sa 1-800-221-3943 (State Relayr 711). EtäËE - ÈËFIF : EÄ;ÉäãÉèi'rãrãâ. ft++Ú)=EEËlËäifüÆrrËl¿[Jf.r. 7-800-221.-3s43 (state Reray: 711) * T, ¿5€ãÉl-<-refã ( liêut. Oroomiffa - XTYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaan¡¡, kanfalti¡dhaan ala, n¡ argama. Bilbilaa l--800-221- 3943 (State Relay: 711). -!-¡l ,r"t¡ li .!ili ,.,. Êll l.i ,Jt óÉ! '¿r-¿ .¡lij È):f, ,t"s o' f:;É o,t! at'¡ a Jt ',e¡ - u.tli 1-800-221-3943 (state relay: 711) Polski - UWAGA: Je¿eli mówisz po polsku, moiesz skorzystêé z bezplatnej pomocy jqzykowej. Zadzwori pod numer 1-800-221-3943 (State Relay: 711). What you may need to apply . Socìal Security Numbers (or document numbers for any legal immigrants) for everyone in your household who needs insurance . Employer and income information for everyone in your household . Current health insurance information, including policy number for each member of your household . lnformation about any job-related health insurance available to your household Th¡ngs to Know continued on next pase Ø

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Why do we ask for this information? We may ask about income and other information to find what health coverage you may qualify for and if you can get help paying for it. We keep all the information you provide us private and secure, as required by law. What happens next? . Send or drop off your completed, signed application to one of the addresses in Addendum A. . lf you do not have all the information we ask foç sign and submit your application anyway. We will contact you and tell you what you need to do next. . lf you do not hear from us, please contact the agency you sent your application to (a list of agencies can be found in Addendum A). . Please note: . lt may take up to 45 days - or up to 90 days if the application requires a disability determination - from the date your application was received for a case number to be assigned to you' . You can check your status and benefits online through Colorado PEAK.(O Get more information about your case number and where to find it at: https://www. hea lthfirstco lo rado.co m/hea lth-fi rst- co lo rado/slossa rvlcase-n u m be r-fi nd / Where can you find additional ¡nformat¡on or help with this application? Health First Colorado and CHP+ Connect for Health Colorado O Online: Colorado.eovlPEAK ConnectforHealthCo-com Phone: L-8OO-22I-3942 1-855-PLANS-4-YOU (1-855-752-6749) TTY/TDD: State Relay: 711 1-855-346-3432 ln Person: Find an Application Assistance Visit ConnecÚalHcalthlp.eam for a list of Site O in your area who can help Certified Health Coverage Guides, Appl¡cation at Colorado.eov/hcpfmap Counselors, and Agents/Brokers (S in your area. For additional information, please see the separate lnstruction Booklet available at Colotado.govl HCPF/Applv and Co n nectforH ealthCO.co m/resou rces/the-bas ics/custo me r-reso u rces/. Applícøtíon storts on next pdge Ø l

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Write each member of your household in the Household Relationship Table on the next page. Use the Household Relationship Table Example below as a guide. Your income and household size help us decide what programs you qualify for, DO include the following people on your application: . Yourself . Your spouse* . Your children under 19 who live with vou . Anyone on your federal income tax t"irtn S . This could include children over 19, even lf they do not live w¡th you . Your unmarried partner* who needs health coverage Q . Anyone else under 19 who you take care of and lives with you f Note: lf someone in your household has passed away this year, you should still include them on your appl¡cation. Th¡s will help us better determine what benefits you may qualify for. * You DO NOT have to include other unrelated roommates. *Find the defin¡tions of these words in the Glossary (staÈing on page 41). lf you are claimed as a dependentx on someone else's federal tax return, also in clu de: . The person(s) who claims you . All members of that federal tax filing household claimed as dependents . Any family member liv¡ng with you Household Relationship Table Example ln Step 1, we are asking how each person ìn your household ¡s related to each other Use the example table on the next paEe to fi8ure out who should be ¡ncluded in your household. When you're ready, list each person ¡n your household on the next page. > Person I ¡s the main contact person for this application. > Start with Person 1, and fill in the relationship that Person t has to each member of the household. > Repeat this step for each person listed in the household. > Only use the terms husband, wife, or spouse when describing people who are legally married ("legally married" includes common law and common law registered, but does not ¡nclude c¡v¡l un¡ons). Ja ne o o Th¡s household ¡s made up of Jane, John, and Betsy. Jane ¡s the person filling out this appl¡cation and is known as Person 1. o lane and John are married to each other. @ Betsy is Jane's daughter from a previous relationsh¡p. Person 3: John f;m ffi ,Ç,,;l .'-tG.ì. G, - Person 2: lohn Betsy Step 7 continued on next Pdge o Person 1: Jane Betsy L

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Sample Household Relatíonship Table:. is the is the is the Betsy t¡Etlt¡tÌft t ,.,,. TryI | ,onn n¿nr¡r:r¡ Wife Mother of Person 6 Husband Stepfather of Person 6 Da ughter Stepdäughter of Person 5 t¡tnlãE¡rift @ Erl*flrrilrlftrEtrEffij ãrr*E+:ltß Household Relationship Table ) Person I is the ma¡n contact person for th¡s appl¡cãtion. > Start with Person 1, and fill in the relationship that Person I has to each member of the household. > Repeat this step for each person listed in the household. > Only use the terms husband, wife, or spouse when describing people who are legally married ("legally marriedl' includes common law and common law registered, but does not include civil unions). Person 3:_ Person À. Person Person Person 2: Person 5: ¡s the is the is the is the ìs the 2 (You ) of Person 6 of Person 6 of Person 6 of Person 6 of Person 6 of Person 6 Errtl1l!Íf-JfEt1l:rifi Ís the

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Complete Step 2 for each person ¡n your hôusehold. Start with yourselt then add other adults and ch¡ldren in vour household. lf you have more than 2 people ¡n your household, you can fill out Worksheet I // lpages3t -34}and make copiesofthe pages ifneeded. You do not need to prov¡de immigration stâtus or Soc¡al Secur¡ty Number (SSN) for household members who are not apply¡nt for health coverage. We will use your personal information only to check ¡f you qualify for health coverage 1. Legal Name (First) (lM iddle) (Last) Suffix 2. Date of B¡rth (mm lddlvvvyl 3, sex: n Male ! Female 4. Home Address (leave blank if you do not have one) C¡ty 5. Mailing Address (if d¡fferent from Home Address) Apartment/Suite S County s zip Code State 6. ln Care Of (lf applicable): City 8. Pr¡mary Phone Phone Type: Phone Type: 10. Preferred Spoken Language: ff Spanish Other (Please Spec¡fy): 1L. Preferred Written Language: n English E Spanish Other Specify): 12. Are you tem of Colorado? County Home Work State Zip Code 13. lf you are temporar¡ly living outs¡de of Colorado, where will you be l¡ving in Colorado when you return? Step 2, Persôn 7 contínues on next poge @

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L4. Socìêl Secur¡ty Number (or Taxpayer lDl lf you are applying for Health F¡rst Colorado or Ch¡ld Health Plen Prus (CHP+), ãnd have a SSN, we need th¡s information. lf you are apply¡ng for help pay¡ng for health insurance costs through the Marketplace, prov¡d¡ng your SSN w¡ll help us to qu¡ckly process your appl¡cation We use SSNs to check ¡ncome and other ¡nformation to see what type of health coverage you may qual¡fy for lf you do not have a SSN, and you are applying for health coverage, tell us why you do not have a SSN. lf you are not eligible to rece¡ve a SSN, do you have a Taxpayer ldentification Number (TlN), such as an lnd¡vìdual Taxpayer ldentification Number (lTlN) or an Adoption Taxpayer ldentification Number (ATIN)? lf so, enter it above. lf you do not have a Soc¡al Secur¡ty Number, please visit httþ://www,ssa.eov/ssnunrber/ for ¡nformation on how to apply for a Social Securìty Number, or call the Soc¡al Security Administration at 1-800-772-1.213 (TTY 1-800-325-0778) for assistance Please answer the follow¡ng: E Have applied for a SSN* E only elig¡ble to receive a ssN for valìd non-work reason n Not el¡gible to rece¡ve a SSN n Refuses to obtain due to well establ¡shed religious objection 1.5. Doyou plan to file a federal ¡ncome tax return next year? [ Yes n No you can still apply for Health F¡rst Colorado, CHP+, or other health ¡nsurance even if you do not fi¡e a federal ¡ncome tax return. However, you must plãn to file federal taxes every year you receive Advance Premium Tax Credìts (APTC) or Cost Shar¡ng Reductions (CSR) through the Marketplace. lf you selected Yes, answer questions a - f. lf you selected No, skip to question e. a. what is your current federal income taxfil¡ngstatus? [ Single E Marr¡ed FilingJointly n Head of Household ! Marrìed Filing Separately n qual¡fying Widow(er)with Dependent Chil.d b. tf you selected "Head of Household" or "lVlarried F¡ling Separately", do exceptional circumstances $ apply to your case? n Yes ENo c, lf you âre "Marr¡ed Fil¡ng Jointly", please name your spouse: d. Will you claim dependents on your tax return? n Yes n No lf Yes, list the legal name(s) of your dependents: e. lf you are a tax dependent, l¡st who claims you as a dependent: ls th¡s person listed on the application? E Yes n No ls th¡s person a non-custodial parent? n Yes n No I Are you liv¡ng with both parents, but your parents do not expect to file a joint federal income tax return? E Yes ENo Step 2, Person 7 continues on next page

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16. *Areyou pregnant? ff Yes E No lf Yes, how many babies are expected? Due Date (mm/dd/yutt)? Do you coverage? fl Yes (lf Yes, answer all of the follow¡ng questions,) E No (lf No, sk¡p to question 31.) 18. Do you live with at least one child under the age of L9, and are you the main peÍson tak¡ng care of th¡s chìld? n Yes nNo 20. *Do Vou have a medical, physical, mental, or developmental cond¡tion that has lasted, or is expected to last, more than 12 months, ¡ncluding btinoness?@ [ Yes ENo your self-care activ¡ties (such as bathìng, dressing, eating, using the bathroom)? fl Yes E No 19. Are you a full-time student? E Yes f] No 22,*Doyou need to move to a nurs¡ng home, acute care, hospital, group home, mental health institution or long-term care facil¡ty with¡n the next 30 days, or do you need in-home health care to stay in your home? E Yes ENo lf you have answered "Yes" to either qu esliolt 20,27,22, ot ¡f you qual¡fy for Med¡câre, you hâve the option to complete Worksheet ¡ / (pages 20 - 24) to find out ¡f you qual¡fy for health coverage for ¡nd¡viduals who hâve a d¡sab¡l¡ty, are 65 and older, and/or who are blind. 23. Are you a U.S. c¡tizen or U.S. national? n Yes E No 24. lf you are not a U.S. c¡tizen or U,S. national, do you have an eligible imm¡gration status? E Yes lf Yes, fill out the following table: o n Yes nNo E Yes ENo For an extensive list of non-citizenshìp status and ¡mmigration documents, read the lnstruction Booklet available at eqL!¿Plgl]SV/ HCP t/AþÐ lv and Con nectfo rH ea lthCO.com/resou rces/the-basics/customer- reso Llrces/. Other Health Coverage 25. Do you want help paying for medical bills from the last 3 months? fl Yes E No lf Yes, list the months that you want help (mm/yyyy) 26. Are you be¡ng treated for an injury for whìch you have brought or may bring a legal claim? l' E Yes ENo 27. Do you qualify for or are you enrolled in any of the following types of health care coverage? lf Yes, fill out Worksheet C / (OeZs¡. f_] TRICARE n Peace Corps n Other State or Federal Health Benefit Program f] coBRA n vA Health Care Benefits ! Retiree Health Plan ! other; Step 2, Peßon 7 continues on next page (ì 5

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28. Doyou qualify for or are you enrolled ¡n Medicare? E Yes E No lf Yes, you have the option to complete worksheet B / (pages 20 - 24) to find out ¡f you qual¡fy for health coverage for indivlduals who have a disab¡l¡ty, âre 65 and older, and/or who are bl¡nd. 29. Doyou qualify for health insurance through a current employer? n Yes E No lf Yes, fill out WorksheetO / (page26). 30. Are you currently incarcerated? n Yes nNo lf Yes, a re you cu rrently wa¡ting for a decis¡on on charges? n Yes f] No 31. Race (opüonal- check allthat apply) ! Amerìcan lnd¡an orAlaska Native (fill out Worksheet E) ¡/ f] Asian lndian n Black or Afr¡ca n American n ch¡nese E Fil¡pino ! Guamanian or Chamorro ! Japanese I Korean E Hispanic/ Latino n Na$ve Hawai¡an n otherAsian n other Pac¡fic lslander I samoan ! Vietnamese n White or caucas¡an ! other: 32. Current Job & lncome lnformation (check all that apply) E I do not have a ¡ob. E lllavea¡ob. - Sk¡p to question 61. - lf you are currently employed, tell us about your income. Start with question 33. T- lam self-emoloved, " ¡ill out wortsheet P/ (page 28) and return to questìon 61. T-.] I have another income LJ (including rental ¡ncome). Fill out Worksheet G / (page 29) and return to question 61. Crrrrent lôb 1: 37. C¡ty 38. State 33. Employer Name 34. 36. Employer 39. Zip Code Pay Per¡od: n Da¡ly ! Weekly E Every 2 Weeks [ ]Monthlv ITwiceaMonth n Yearly 41. Average Hours Worked Each Week: 42. Tell us the total gross pay that you got or will get th¡s month as a one-time payment from this employer (th¡s could be a bonus or other extra pay you got). 43, Does your ¡ncome from this job change month to month? n Yes E No tf Yes, fill out the Current Wages/lips AND Expected Annual lncome for this job, lf No, only fill out the Current Wages/tips in number 42 above. You do not need to fill out the Expected Annual lncome 44. Expected Annual income S 45 a. ls this income from seasonal employment? lf yes, answer 46 n Yes LJ No from this job: 45 b, ts this ¡ncome from commission-based employment (including n Yes n No tip based employment)? lf yes, answer 46. 46. Will the expected annual ¡ncome from th¡s job be the same or n Yes n No lower ¡n the next calendar year? Current Job 2: (lf you onlv have one iob skip to question 61') 47. Employer Name 49, Apartment/Su¡te f 48. 5 Step 2, Person 7 continues on next poge

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s Pay Period ! Da¡ly n Monthly n Weekly ¡ Twice â Month 53. Zip ü Every 2 Weeks n Yearly E Yes n Yes fl Yes 55. Average Hours Worked Each Week: 56. Tell us the total gross pay that Vou got or w¡ll get th is month as a one-time payment from this employer (this could be bonus or other extra pay you got). 57. Does your income from this job change monthto month? E Yes n No lf Yes, fill out the Current Wages/T¡ps AND Expected Annual lncoJne for thìs job. lf No, only fill out the Current Wâges/Tips in number 42 above. You do not need to fill out the Annual lncome. 58. Expected Annual from th¡s job: 59 a, ls this income from seasonal employment? 59 b. ls this ¡ncome from commìssion-based employment (¡ncluding tip based employmentl? 60. W¡ll the expected annual ¡ncome from th¡s job be the same or lower in the next calendar year? !No lNo lNo 61. DEDUCTTONST ln Check all that apply, and give the amount and how often you pav it, Tellìng us about these deductions could make the cost of yoìiíhealth insurance lower. You should not ¡nclude a cost that you already considered in your answer to job income and net self-employment, 62. Do your deductions change month to month? n Yes E No lf Yes, for each deduction that changes, fill out the Current Amount AND the Expected Annual Amount columns. tf you are not poying the deduction ot th¡s tíme, but expect to cloim ¡t on your tqx return, fill out 50 Íor the Current Amount, and w te the omount you w¡ll include on your tãx return for the Expected Annuol Amount' lf No, only fill out the Current Amount column. You do not need to fill out the Expected Annual Amount column, E Weekly n N4onthly 2 Weeks f l Frequency One Time Only n Twice Weekly [] N4onthly 2 Weeks Frequency ü One Time fl Weekly ü Monthly 2 Weeks 63. Tell us the total amount of income you plan to report on your tax return that you have NOT yet ¡ncluded in this application and ¡ts Worksheets. lnclude incomes such as past employment/ or benefits that you received ¡n past months, Date the change occurred? 64, After you submit this application, we wìll ver¡fy your income. Please tell us if any of the follow¡ng have happened to you in the past two years to help us with this verification process. Check the box and enter the date this change occurred for all reasons that apply show¡ng why your income has changed. End of Step 2, eerson I @ n Stopped work¡ng at a job ! Hours changed at a job n Change in Employment ! Married, LegalSeparation, or Dìvorce 51. City 52. State n Otheí (mm/dd/yyyy) 7

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EM Complete Step 2 for your federal income tax return. See and children who live with you and/or anyone on 1 for more information about who to include. :: 1. Legal Name (F¡rst) (Middle) (Last) Suffix 2. Date of girth (mm/ddlyyyy) 3. sex: n Male ! Female 4. Home Address (Leave blank if you do not have one) C¡ty 5. lf Person 2 ¡s L8 years or lf yes, please fill out the mailing address below Apartment/Su¡te f County about their health coverage? Yes No own Zip Code State 6. Ma¡ling Address (lf different from Home Address) Apartment/Suite # 7. ln care of (lf applicable): City State Z¡p Code County 8. Email Address 9. Primary Phone Phone Typei ! Home ! Work Home Work 10. Secondary 11. Preferred Spoken Language: English span¡sh Specify): Wr¡tten Language: ! English ! Spanish other (Please Specifv); 13. ls Person 2 tem pora rily l¡ving outside of Colorado? n Yes n No 1-4. lf Person 2 ¡s temporarily l¡vìng outside of Colorado, where w¡ll they be l¡ving in Colorado when they return? Code I Step 2, Person 2 continues on next pose Ø

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15. Social Securitv Number (or Taxpayer lD) lf Person 2 ¡s epply¡ng for Health First Colorado or Ch¡ld Health Plan Prrrs (CHP+), ând has a 55N, Please answer the following: we need this information. lf they are a pplying for help paying for hea lth insura nce costs throl9l. Tl ¡l"u" rppl¡ed for a ssN* the Marketplace, providing the¡r SSN w¡ll help us to quickly process their applìcation. We use SSN5 LJ to check ¡ncome and other information to see what type of health coverage they may qualify for. f] Only el¡gible to receìve a lf Person 2 does not have a SSN, and they are apply¡ng for health coverage, tell us why they do SSN for valid non-work reason not have a SSN. lf they are not eligible to receive a SSN, do they have a Taxpayer ldentification Number (TtN), such as an lndividual Taxpayer ldentification Number (lTlN) or an Adoption n Not eligible to receive a SSN laxpayer ldentification Number (ATIN)? lf so, enter it above. *lf they do not have a Social Secur¡tY Number, please vis¡t htt0://wwwssa.Êov/ssnumber/ for ¡nformation on how to apply for a Social ! Refuses to obtain due to well Securìty Number, or call the Social Secur¡ty Administration at 1-800-772-121.3 (TTY 1-800-325- established relig¡ous objection 0778) for ass¡stênce. 1.6. Does Person 2 plan to file a federel income tax return next year? E Yes n No They can still apply for Health First Colorado, CHP+, or other health insurance even ¡f they do not file a federal income tax return. Howevec they must plan to file federal taxes every year you receive Advance Premium Tax Credits (APTC) or Cost SharinB Reductions (CSR) through the Marketplace. lf they selected Yes, answer questions a - I lf you selected No, sk¡p to question e. a.What¡s Person 2's current federal income tax filing status? [ Single E Married Fil¡ngJointly n HeadofHousehold ! N4arrìed Filing Separately E Qual¡fying Widow{er) w¡th Dependent Child b. tf Person 2 selected "Head of Household" or "Married F¡ling Separately", do exceptional circumstances Oapply to their case? E Yes nNo c. lf Person 2 is "Married Filing Joìntly", please name his or her spouse: d.Will Person 2 claim dependents on their tax retu rn? E Yes n No lf Yes, list the legal name(s) of their dependents: e. lf Person 2 ¡s a tax dependent, list who claìms them as a dependent: ls this person listed on the appl¡cation? E Yes n No ls this person a non-custodial parent? E Yes n No f. ls person 2 l¡ving with both parents, but their parents do not expect to file a joìnt federal income tax return? n Yes ENo 9 Step 2, Person 2 continues on next poge A

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1.7. *ls Person 2 pregnant? n Yes lf Yes, how many babies are expected? nNo Due Date (mm/dd/yyyy)? Does Person 2 need health coverage? E Yes (lfYes,answerall of thefollow¡ng questions.) ! No (lf No,skipto question 32 ) 19, Does Person 2 live with at least one child under the age of 19, and is Person 2 the ma¡n person taking care of this child? E Yes E No 20. ls Person 2 a full-time student? n Yes n No 21. *Does Person 2 have a mental, or developmental condition that has lasted, or ¡s expected to last, more than 12 months, ¡ncludi blindness? Yes No 22. *Does Person 2 have a or developmental condition that causes them to regularly need help with some or all oftheir self-care activities (such as bathing, dressing, eating, us¡nB the bathroom)? E Yes ENo 23. *Does Person 2 need to move to a nurs¡ng home, acute care, hospital, group home, mental health institution or long-term care facil¡ty w¡thìn the next 30 days, or do they need in-home health care to stay ¡n your home? fl Yes n No lf Person 2 answered "Yes" to either question 21, 22, 23, or qual¡fies for Med¡care, Person 2 has the option to complete Worksheet B / (pa1es2} - 241to find out if they qualify for health coverage for individuals who have a d¡sab¡l¡ty, are65 and older, end/or who are blind. 24. ls Person 2 a U.S. c¡tizen or U.S. national? ! Yes E No 25. lf Person 2 is not a U.S. citizen or U.S. national, do they have an el¡gible immigration status? E Yes lf Yes, fill out the follow¡ng table: For an extens¡ve list of non-citizensh¡p status and imm¡gration documents, see the separate lnstruction Booklet available at Colorado.eov/HCPF/Applv and ConnectforHealthCO,comlrcsources/the-basics/customer-resource5/, Other Health Coverage 26. Does Person 2 want help paying for medical bìlls from the last 3 months? fl Yes n No lf Yes, l¡st the months that they want help {mm/yyyy) 27. ls Person 2 be¡ng treated for an injury for which they have brought or will bring a legal claim? E Yes nNo n Yes ENo n Yes ENo ffi 28. Does Person 2 qual¡fy for or lf Yes, fill out Works heetc / are they enrolled in any of the following types of health care coverage? (page 25). f] TRICARE ! Peace Corps E other state or Federal Health Benefit Program f:l COBRA E vA Heêlth Care Benefits ! netìree Health Plan E Other: 10 Step 2, Peßon 2 continues on next page o

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29. Does Person 2 qual¡fy for or are you enrolled ¡n Med¡care? E Yes ENo tf Yes, Person 2 has the option to complete Worksheet B / (pages 20 - 24) to find out ifthey qualify for health coverage for ind¡viduals who have e d¡sab¡lity, are 65 and older, and/or who are blind. 30. Does Person 2 q ualify for health insurance through a current employer? n Yes nNo lf Yes, fill out Works neeto tr/ (page 26). 31. ls Person 2 currently incarcerated? E Yes E No lf Yes, are they curre ntly wa¡ting for a decision on cha rges? n Yes ENo '! 32. Race (optional - check allthat apply) E American tndian orAlaska Native (fill out Work sheetel / E Asian lnd¡an E Black o r African Americân ! Chinese E F¡lipino ! Gua ma n ian or Chamorro f] Japanese I Korean f] Hispanic/ Latino n Native Hawa¡ian E otherAsian n Other Pac¡ficlslander ! Samoan n V¡etnamese f] Wh¡te or caucas¡an ! other: 33. Current Job & lncome allthat apply) n Does not have a iob. Sk¡p to question 62. f-l Has a iob. - lf they are currently employed, tell us about the¡r income. Start with question 34. f-l ls self-employed. ^ " Fill out worksheet F / (page 28) and return to question 62. fl Hãs other income * (¡ncluding rental íncom€). Fill out Worksheet G/ (page 29) and return to Crrr"nt Job 1' q'"ttion 62' 34. Employer Name 35. s 37. Employer Phone 40. z¡p Code s Pay Per¡od: n Daily ! Monthly 42. Average Hours Worked Each Week: 43. Tell us the total gross pay that Person2 got or will get this month as a one-time payment from this employer (th¡s could be a bonus or other extra pay they got). 44. Does Person 2's income from this job change month to month? E Yes n No tf Yes, fill out the Current Wages/T¡ps AND Expected Annnual lncome for this job. lf No, only fill out the Current Wages/Tips in number 42 above. They do not need to fill out the Expected Annual lncome. 45. Expected Annual income S 46 a, ts th¡s income from seasonal employment? lf yes, answer 46. E Yes n No from this job: - 46 b, ls this ¡ncome from commission-based employment {including E Yes fJ No tip based employment)? lf yes, answer 46. 47. Will the expected annual income from this job be the same or n Yes I No lower in the next calendar year? Current Job 2: (lf Vou onlv have one iob sk¡p to question 62.) 48. Employer Name 49, Employer ! Weekly E Twice a Month n Every 2 Weeks n Yearly # øt ct 38. City 39. State Step 2, Person 2 continues on next poge 50. 11

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51. Employer Phone Pay Period; n Da¡ly n Monthly I Weekly I Twice a Month 54. zip Code E Every 2 Weeks n Yearly s 56. Average House Worked Each Week: 57. Tell us the total gross pay that Person 2 got or will get this month as a one-time payment from this employer (th¡s could be a bonus or other extra pay they got), 58. Does Person 2's income from this job change month to month? f] Yes n No lf Yes, fill out the Current Wages/T¡ps AND Expected Annnual lncome for this job. lf No, only fill out the Current Wages/Tips in number 42 above. They do not need to fill out the Expected Annual lncome. 59. Expected Annual incomeft 60 a. ls this income from seasonal employment? fl Yes ! No from th¡s job: 60 b. ls this income from commission-based employment (¡ncluding l l Yes n No tip based employment)? 61. Will the expected annual income from this job be the same or fl Yes E No 62. DEDUC eductions could make the cost-õf their health insurance lower. Person 2 should not ¡nclude a cost that they already considered in their answer to job income and net self-employment. 63. Do their deductions change month to month? E Yes n No lf Yes, for each deduction that changes, fill out the Current Amount AND the Expected Annual Amount columns. tÍ Petson 2 is not poy¡ng the deductíon ot th¡s tíme, but expects to clo¡m ¡t on theirtax retum, Ííll out 50 for the Current Amount, ond w te the amount Person 2 will include on the¡r tax rctum fot the Expected Annual Amount. lf No, only fill out the Current Amount column. Person 2 does not need to fill out the Expected Annual Amount column. me Only fl Twice E Weekly E Monthly 2 Weeks ! One Tìme On n Weeklv n Monthly 2 Weeks Type Deduction 63. Tell us the total amount of income Person 2 plans to report on your tax return that you have NOT yet ¡ncluded in th¡s application and its Worksheets. lnclude incomes such as past employment, or benefits that you received in past months. 64. After this verify Person application 2's ¡ncome. is submitted, we will Please tell us if any of the n Stopped work¡ng at a job ! Hours changed at a job following have happened to Person 2 in the past two ¡ Change in Employment years to help us w¡th th¡s verification process. Check the box and enter the date this change occurred for all reasons that apply showing why their income has E Married, Legal Separation, or Divorce changed. Í2 n One T¡me Only n Weekly fl Twice Monthly E Monthly Tl Yeêrlv 2 Weeks Date the change occurred? (mm/ddlyyyy) 53. State 52. C¡ty Amount Amount Amount Amount Amount fl Other: End of step 2 Percon 2 Ø

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!Ðæ 1, I know I or another applicant may be automatically provided enrollment into Health F¡rst Colorado (Colorado's Medica¡d Program) or Child Health Plan P/us (CHP+) ¡f we are el¡g¡ble. I can v¡s¡t the Health First Colorado webs¡te at Colorado.gov/ PEAK for more information. lwill immediately notify the State of any medical claim or lawsuit I have. I w¡ll cooperate w¡th the State in collecting the medical b¡lls the State has paid. The State may collect from any insurance company or court settlement for medical bills that the State has paid. lf I am on Health F¡rst Colorado and rece¡ve money for the same medical bills that the State has paìd, I will give the money to the State. I ass¡gn to the State all rights io payment for medical expenses and treatments. I also assign my right to appealO a denial of benefits by another party responsible for payment for benefits to the State. lf there ¡s an absent parent(s) from my home, and I am apply¡ng for Health First Colorado, I must seek medical support from the absent parent(s). I may contact Ch¡ld Support Enforcement for assistance. 2. Federal and Colorado state law requ¡re the Department of Health Care Policy and Financ¡ng to recover all med¡cal assistance benefits, includ¡ng cap¡tation payments, pa¡d on behalf of Health F¡rst Colorado clients from the estates of deceased Health First colorado cl¡ents who were permanently institutional¡zed. For Health First Colorado clients who were over the age of 55 when benefits were prov¡ded, the Department recovers payments for nurs¡ng facility services, home and community-based serv¡ces, and related hospital and prescr¡ption drug serv¡ces. There are certa¡n exemptions to estate recovery, For further information, please contact Vour county and request the "Med¡cal Ass¡stance Estate RecoverV Program" brochure, 3, lf I am eligible for Advance Premium Tax Credit ('APTC"), these payments will be made directly to my selected ¡nsuIance carrier(s), Acceptance of APTC may ¡mpact my annual tax liab¡lity. I will be given the option to apply all, some or none of the APTC amount I may be eligible for to my monthly premium. 4, lf I am receiving financial assistance, I know that I must tell the organization provid¡ng the assistance if information I l¡sted on th¡s application changes. I am awêre I have 10 calendar days to report any changes if I êm enrolled ¡n Health Fìrst Colorado Step g continues on next poge A or Ch¡ld Heêlth Plan P/us (CHP+). Changes are to be reported to my local county office for Health First Colorêdo or to CHP+. I am respons¡ble for paying fees, premiums and co-payments for myself and my family if they are required for Medical Assistance benefits, I know I have 30 calendar days to report any change to Connect for Health Colorado if I am rece¡v¡ng Advance Premium Tax Cred¡ts, Reduced Co-Pays or Deductibles, or lam enrolled in a Qualìfied Health Plan. lf my family is enrolled ¡n multiple insurance affordability programs$ I must report changes to each organizaüon ¡n the appropriate time frame, I understand that a change in information could affect my eligibility and eligibil¡ty for member(s) of my household. 5. I understand that my answers, toBether with any supplements or additional pages, are the bas¡s for the health insurance policy that is ¡ssued. I agree that no insurance of financ¡al ass¡stance program w¡ll be effective until the date specified by the insurance company or organ¡zation providinB the certificate, polìcy, or notice. I understand that I may request a copy of the Application. I agree that a photographic copy of this application shall be as valid as the original. A leg¡ble copy signature sha¡l have the same force and effectiveness as the orig¡nal. Th¡s document, or the information conta¡ned herein, will become a part of the contrêct when coverage is approved and ¡ssued. 6. To make ¡t easier to determ¡ne my el¡gibil¡ty for help paying for health coverage in future years, ìf lam enrolled in a Qual¡fied Health Plan, I agree to allow Connect for Health Colorado to use income data, ¡ncluding information from tax returns for the next coverage year. O Connect for Health Colorado w¡ll send me a notice, let me make changes, and I can opt out at any time. I can visit the Connect for Health Colorado website at ConnectforHealthCO.com for more ¡nformation. 7, I understand that if I am eligìble for the Advance Premium Tax Credit (APTC) and/or Reduced Co-pays and Deductibles these payments will be made directly to my selected ¡nsurance carrier(sl, Acceptance of APTC and/or Reduced Co-pays and Deductibles may impact my coverage yea(s) tax liab¡lity. lwill be g¡ven the option to apply all, some, or none of any APTC amount I may be el¡gible for to my monthly premium, 13

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WWw 8, The Department of Health Care Policy and Financ¡ng and Connect for Health Colorado do not discriminate on the basis of race, color, ethnic or national orig¡n, ancestry, age, sex, gender, sexual orientation, gender identity and expression, relig¡on, creed, political beliefs, disabilìty, or marital status in any of ¡ts programs, services and activities, For further information about the Department's policy, to request free disabil¡ty and/or language aids and services, or to file a d¡scrimination complâint, contact: 504/ADA Coordinatot 1570 Grant St, Denver, CO 80203, Phone: 303-866-6010, Fax: 303-866-2828, State Relay: 711, Email: hcofs04ada@state,co.us. For ¡nformation about Connect for Health Colorado's policy, aids and services or to file a discr¡mination complaint, contact: General Counsel, 3773 Chefty Creek N. Dr., Su¡te 1005, Phone: 303-590-9640, Fax: 303-322- 4217. Complaints can also be filed w¡th the U.S. Department of Health and Human Services Office for Civil Rights at http://www hhs.Êov/ocrlfi lins-with-ocr/index.html. 9, I know that ¡t is unlawful to rece¡ve APTC and CSR from two state lvlarketplaces at the same time. I have agreed to submit this appl¡cation for myself and/o¡'my fam¡ly. By sign¡ng this application, lcertify that lhave reviewed this application; that I understand and agree to the R¡Bhts, Responsib¡lities, and Penalties; and that under the penalty of perjury, I certify the information I have given is true ¡nclud¡ng the ¡nformation concern¡ng citizenship and alien status. This means I have provided true answers to all the questions on this form to the best of my knowledge. This certification extends to Producers or other persons filling out an application on behalf of an applicant. I know that ¡f I am not truthful, there may be a penalty. Penalties may ¡nclude imprisonment, fines, denial of insurance, and c¡v¡l damages, Any insurance carrier or agent of an ¡nsurance carrier who knowingly provìdes false, incomplete, or m¡slead¡ng facts or information to a policyholder or claimant for the purposes of defraud¡ng or attempting to defraud the policyholder or cla¡mant w¡th regard to a settlement or award payable from ¡nsurance proceeds shall be reported to the Colorado Div¡sion of I w¡th the Department of Regulatory Agencies. I have rece¡ved information on how to apply, what information is available, and what I may neèd to g¡ve the application site to help me w¡th getting benefits. My right to appeali 10, lf I think Health F¡rst Colorado/Child Health Plan P/us (CHP+) or connect for Health colorado has made a m¡stake, I T4 can appeal the decision, To appeal means to tell someone at Health First colorado/cHP+ or connect for Health Colorado that I think the action is wrong and ask for a fa¡r review of the action. I know that I can find out how to appeal by contacting Health First Colorado at 1-800-221-3943, or lcan contact the Marketplace at 1-855-PLANS-4-YOU or by v¡siting the¡r website at ConnectforHealthCO.com. I know that I can be represented ¡n the process by someone other than myself. My elig¡bil¡ty and other ¡mportant information will be explained to me. Additional lnformation Domestic violence information and services are available to me. lf I ever feel I am in ¡mmed¡ate danger I will call 9L1., lf I would like to rece¡ve information regard¡ng safety and serv¡ces ¡n Colorado, lwill call the Colorado Coal¡tion Aga¡nst Domestic V¡olence at 303-83L-9632 or toll free at 1-888-778-7091, I may also find the location of services near me by going to h[pi¿ wwwcolorado.qov/cdhs/dvo, The National Domestic V¡olence Hotline at 1-800-799-SAFE (7233) or TTY L-800-787-3224 or htto://wwwthehotline.orsl can also prov¡de ¡nformation. lf I am a survivor of domestic violence, sexual assault, or stalking, the Address Confidentiality Program (ACP) can provide me w¡th a legal substitute address to use instead of my real address for use with state and local goveinment agenc¡es. lcan find out more about ACP at acp.colorado.sov. lf I need or rece¡ve either.of these serv¡ces I will tell my department worker. By check¡nt th¡s box, I agree to allow my information to be used and collected from the data sources for this applicatjon, ¡nclud¡ng information from federal tax returns. I have consent from a¡l people I l¡st on the application allowing collection of information about them from data sources for this application. (See full Pr¡vacy Statement on page 17.) (check box belowl Step 3 continues on nert poøe @

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As part process, we are required to verìfy information you have provided us for th¡s appl¡cation. that Connect for Health Colorado does not have permission to verify income ¡nformation By checking the from tax returns. box below you ind¡cate By not allowing the use of this data, you understand that Connect for Health Colorado will send you a letter requesting that you provide proof of ìnformation for your household, lf you do not provide the requested proof of your ¡nclud¡ng your annual ¡ncome. household's ¡ncome tax return ¡nformation within 90 days of the request, you w¡ll be determined inel¡gible for Advance Premium Tax credits/cost shar¡ng Reductions (APTC/CSR). E I do not give Connect for Health Colorado permiss¡on to validate my income data against federal sources. Sign Here The next two (2) questions are used to figure out if you qualify for serv¡ces from the Healthy Commun¡ties Program through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) @ provisions of Heãlth F¡rst Colorado (Colorado's lvled¡caid Program). These questions are optìonal. 1. Special serv¡ces may be available to children and pregnant n Med¡cal Services ! Prescr¡ptions women. Please checkthe health services thatany pregnant E Mental or Behav¡oral n School orHealth women or chìldren in your household get or use: Health Services Services E Other (Descr¡be): 2. Has any child in your household been to the emergency room for treatment s¡nce his or her last visit to n Yes E No the doctor? Attention: You may not be done . Did you get help with this application? F¡ll out Worksheet a / þaees L8 - 1gl. . Does one of the following apply to anyone on the application? lf yes, fill out Worksheet B / ¡f you want to find out ¡f you qual¡fy for additional services. (pages 20 - 24). o A person on the application has a medical or developmental condition that has lasted, or is expected to last, more than 12 months, including blindness. . A person on the application needs help with some or all of his/her self-care activities (bathing, dressing, eating, or using the bathroom). . A person on the application is in, or has been in a medical facility (such as a nursing home, hosp¡tal, mental health institution, or a group home) within the last 90 days. " Qualify for or enrolled in Medicare. . Qualifies for or is enrolled in: Medicare, TRICARE, lÐ Peace Corp, Other State or Federal Health Benefit Program, VA Health Care Benefits, O or Other Coverage fill out Worksheet C / lpaee zSl. . Qualifies for or is enrolled in insurance from an employer: fill out Worksheet D / lpage 26]t, . American lndian/Alaska Native? Fill out Worksheet E , þaee 271. . Self-employed? Fill out WorksheelF / lpaee 28]|. . other income that ¡s not from a job or self-em ployment? Fill out worksheet G t/ lpaee zgl' . Apply¡ng outs¡de of Open Enrollment and had a life change event in the past 60 days? Fill out Worksheet H / (page 30). . More than two people in the household? Fill out Worksheet I / (pages 3L - 34) for each add¡tional person. Sign this application. The person who filled out STEP 1 should s¡gn this application. lf you are an authorized representative, you may sign here as long as you have provided the information required in Worksheet e 1/ (pages 18 - 19). Date Person I s¡gnature or Author¡zed Representative lf you are signing this application outslde of Open Enrollment make sure you review Workheet H Enrollment begins November L and ends January 31. (page 30). Open tndofstenz @ 15

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Your application can be processed at either your local County Department of Human and Social Services Office or by Connect for Health Colorado. 16 tnd of step t @

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connect for Health colorado (the Marketplace") and the Department of Health Care Pol¡cy and Financing will keep the information you provide pr¡vate, as required by law. However, if you chose to apply for ass¡stance, the Marketplace and Department of Health Care Policy and Financing can use or share your household information with other program(s). The ¡nformation can only be used for purposes of insurance coverage, treatment, payment, determining eligib¡lity, and other program and adminlstrative operations or other purposes permitted by law. Assistance programs will check your answers using information in our electronic dâtabases and the databases of partner agencies. lf the information does not match, we may ask you to send us proof. You will be asked to provide only the minimum information necessary to determine eligibility for assistance and relevant health plan options, as applicable. As part of the process, we w¡ll communicate wlth you or your authorized representative, and then provide the ¡nformation to the health plan you select so that they can enroll those who are eligible in a qualified health plan or an insurance affordability program. Demographic information on race and ethn¡c¡ty will be shared with health insurance carriers by the Marketplace only for the purpose of determ¡ning your el¡g¡bility for benefits that are âpplicable to certain ethnic groups. Health insurance carriers can no longer deny coverage based on your health status. lf you are seek¡ng ass¡stance, we may ask you screening questions about your medical history to help us determine which assistance programs you are eligible for. This information ¡s not used to determ¡ne your ¡nsurance rates. Household members who do not want insurance will not be asked questions about citizenship or immigration status. lmportant: The Marketplace and the Department of Health Care Policy and F¡nancing are authorized to collect information on the application, including Social Security numbers, and will confirm information that mây affect initial or ongo¡ng eligibility for all persons listed on your application. You are allowing the Marketplace and the Department of Health Care Policy and Financing to use SocialSecurity numbers and other information from your application to request and receive information or records to confirm the ¡nformation ¡n your application; if you apply for other public ass¡stance programs, the Department of Human Services may use this information as well. You release the Marketplace and the Department of Health Care Policy and F¡nancing from all liab¡lity for sharing this information with other agencies for th¡s Apptication continues on next page ß\ purpose. For example, the Marketplace and the Department of Health Care Policy and Financing may receive from and/or share your informatíon with any of the following agenc¡es: Social Security Admin¡stration; lnternal Revenue Serv¡ce; Un¡ted States customs and lmmigration Serv¡ces; Department of Homeland Security; Centers for Medicare and Medicaid services; Colorado Department of Lãbor and EmploymenU financlal institutions (banks, savings and loans, credit unions, insurance companies, etc.); chlld support enforcement agencies; employers; courts; and other federal or state agencies. We need this information to check your eligibility for health insurance or help paying for health insurance and to give you the best serv¡ce possible if you choose to apply. The Marketplace and the Department of Health Care Policy and F¡nancing will also use the information you provide as part of the ongoing operation of both agenc¡es, including activities such as reporting on and managing the insurance affordability programs (Ð for eligible individuals, performing overslght and quality control activities, combating fraud, and respondlng to any concerns about the secu rity or confidentiality of the information. we will use the information you provide for our ¡nternal business purposes only, and we will not sell or trade it. You have the r¡ght to see certain information we have about you. You may also have the right to have this information corrected if we have any incorrect information on file. Protection of your data: Connect for Health colorado and the Department of Health Care Policy and Financing have significant protections in place to ensure the privacy of your personal information. To rev¡ew the full privacy policy for Connect for Health Colorado please visit: http://connectforhealthco.com/ site-information,/privacv-policv/ To review the full privacy policy for the Department of Health Care Policy and Financing please v¡sit: https:// www.co lo rado. sov/oacìfic/h cpf/h ea lth - ins u ra nce- oortabil¡tv-aíìd-accou ntabilitv-act-hipaa-0 17

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ir¡?¡rilt{rulftÃ ¡ â Section A: Authorized Representat¡ve or Organization L. lsyourauthoflzed representaüve an: L l lnd¡vidual L__l OrganÌzation copies of your notices/communications? I J, StAte lu, ¿rp Looe ry AppIcanr 5 )tgnarure uate Imm/oo/yyyy, 18 worksheet A continues on next poge @

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By signing, I agree to fulfill all responsibilities with¡n the scope of the author¡zed representation that the ind¡vidual who I represent is requ¡red to fulfill. I agree to maintain the confidentiality of any information regarding the applicant or client provided by the agency or Connect for Health Colorado in compliance w¡th state, federal, and all other applicable laws. lf an Author¡zed Representative is an organization, the signature of an organ¡zational contact who is either a provider, staff member or volunteer of the organ¡zation ¡s requ¡red, As a providet staff member or volunteer of an organization whìch ¡s an Authorized Representative, I affirm that I will adhere to the regulations in 42 CFR $431, Subpart F and to 45 CFR S155.260(f), and 42 CFR $447.L0, as well as all other relevant state and federal laws concerning conflicts of interests and confidential¡ty of information. lf you have been given the legal authority to act as an Authorized Representative on the appl¡cant or client's behalf through some means other than assignment through this Worksheet, you w¡ll need to affirm that you have that authoriw and provide the appropriate documents verifying that you have that author¡ty. _ l, affirm that I have legal authority to act on behalf of the appl¡cant or client. (Please prov¡de a copy of the following documents with this application when ¡t is subm¡tted: a power of attorney, court order establishing legal guardianship, or other legal document expl¡citly stating that you may le€ially act on behalf of the appl¡cant or client.) Section B: For Certified Application Counselors, Health Coverage Guides, Agents, Brokers, Agency Representative, or Outreach Specialist only.O n Health Coverage Gu¡de Agent/Broker Agency Representative Outreach Spec¡alist or þ_ü I¡@E rlFræ,lram End of Worksheeto O 19

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Additional lncome 2. Tell us about Add¡tional lncome you or your spouse rece¡ved this month or last month. Do not repeat income that may have already been listed on earl¡er ¡ncome pages, I No Add¡tional lncome. 3. Tell us about Expenses you or your spouse have th¡s month or last month. Do not repeat expenses that may have already been l¡sted on earlier pages. n No Expenses. Type of expense Who oavs this expense? Who is ¡t for? Month Amount Type of ¡ncome Month received Who ¡t is for? Monthly amount before taxes ãnd deductions 20 worksheet B continues on next page lÀ

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4. Tell us about Resources you or your spouse rece¡ved this month or last month, even if you or your spouse are not requesting assistance. I No Resources, 5. Tell us about Property you or your spouse own or are buying, even if you or your spouse are not requesting assistance. n No Property. 6. Tell us about Veh¡cles you or your spouse own or are buying, even if you or your spouse are not requesting ass¡stance, fl No Vehìcles. Type of Resource Owners Name(s)? Account Number Amount Name of F¡nanc¡al lnstitution Jo¡ntly Owned? lYes nNo I Yes t] No f Yes !No f Yes fJNo owners Name(s)? Jointly Owned? Full Address of Property Type of Property Value Amount owed? üYes ENo nYes nNo IYes nNo Owners Name(s)? Jo¡ntly Owned Type of Vehicle Year Make/Model Value Amount Owed? ¡Yes !No EYes INo IYes ENo nYes nNo Worksheet B contínues on next page @ 2L

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7, Tell us about Life lnsurance Pol¡cles you or your spouse own, even ¡f you or your spouse are not requesting assistance. n No Life lnsurance Pol¡cies. Owner Namelsl Policy Number lnd¡v¡duâls Covered lnsurânce Company Face Value câsh Value 8. Tell us about Bur¡âl Policies you or your spouse own, even if you or your spouse are not requesting assistance. ¡ No Bur¡al Pol¡cies. Name ofAppl¡cent or Spouse Amount ls ¡t lrrevocable? Name of lnstitution or Person Holding the Money EYes nNo []Yes nNo T-l Yes fl No 9. Tell us if you, your spouse, or anyone actìng on you or your spouse's behalf has B¡ven away anyth¡ng of value w¡thin the last 5 years, even if you or your spouse are not requestjng assistance. ¡ Nothìng of value has been given away within the last 5 years. Person Who Geve ltem Away Item G¡ven Away Date Given Away Value of ltem Amount Owed :l ;: .ij rr:ll 22 worksheet B continues on next pøge @

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Disability Questions 10, Has anyone who is d¡sabled in the household applied for Supplemental Security lncome (ssl)? E Yes nNo yes, me person person or ü Yes nNo app Pend¡ng [:l Approved n Denied status lf no, has th¡s person ever rece¡ved Supplemental Security lncome/soc¡al Secur¡ty D¡sab¡l¡ty lnsurance? E Yes nNo 12. What is your Medicare Claìm Number? You can find th¡s number on the front ofyour Med¡care card; 14. ls your Medicare Part A premium free? nYes nNo 19. When did your Medicare Part B beg¡n (mm/yyyy)? MEDICARE PART A 13, Are you entitled to or receiving Medicare Part A? EYes nNo MEDICARE PART B 18. Are you to or receiv¡ng Medicare Part B? t-l Yes ll No MEDICARE PART C 22. Are you entitled to or receiv¡ng Med¡care Part C (Medicare Advantage)or will you be entitled or enrolled in the month in wh¡ch you would like to purchase pr¡vate health insurance? nYes !No 23. When d¡d your Medicare Part C begin (mm/yyyy)? n I don't know. MEDICARE PART D 24. Are you entitled to or receiving Medicare Part D? [] Yes [: No 25. When did your Med¡care Part D begin (mm/yyyy)? ! I don't know. 26. How much ¡s your Med¡care Part D premìum? E I don't know 27. Who pays for your Med¡care Part D premium? 15, Are you currently enrolled? nYes nNo 16. When d¡d your Medicare Part A beg¡n (mm/yyyy)? n I don't know. 17. Who pays for your Medicare Part A premium? n I don't know. 20. How much is your Med¡care Part B premium? n I don't know. 21. Who pays for your Med¡care Part B premium? Worksheet B continues on next nøøe @ 23

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Signature and Certification ry flitã @il lffir {Pr¡nt Name) F¡rst tvroo te Last sumx re Authorized Representative, Conservator, Guerd¡an, or other Contact: tv oore 5UmX lrf rfr r. r\rdfrc, rrfs L 24 End ofWorksheet" O

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Part 1 lf you or anyone in your household are currently enrolled in any of the following types of coverage, please fill out the table below. lf there are more than four individuals in your household that are enrolled ¡n this coverage, please make a copy of this Worksheet. Name of Person Enrolled Type of Coverege From L¡st Above lnsurance Compâny Nâme Pol¡cy Number Part 2 lf you or anyone in your household are currently enrolled in any of the follow¡ng types of coverage, please fill out the table below. lf there are more than four ind¡viduals ¡n your household thãt are enrolled in th¡s coverage, please make a copy of th¡s Worksheet. Name of Person Enrolled Type of Coverage From List Above Insurance Company Name Pol¡cy Number End of Workshee, C O 25

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WÐ tJtlti Hrsr ano Lasr Name oT Emptoyee urrereo Loverage uare oT örrrn tmm/qq/yyyy, Who else in your household has access to this coverage? lf there are more than four individuals in your household that have access to coverage, please make a copy of this Worksheet. Household Member's Name ls th¡s person el¡gible but not enrolled, or is this person enrolled? Check the box that applies, Date your ¡nsurance could have started lmm/wvv) n El¡g¡ble but not enrolled n Enrolled n El¡g¡ble but not enrolled I Enrolled E Eligible but not enrolled [f Enrolled n E¡ig¡ble but not enrolled I Enrolled Employer Name Employer Address m have access to an employee-only health plan that meets the m¡nimum value standard health plan? ! Yes ! No liyes, what ß the name of the lowest-cost plan offered only to the employee (do not include fêmily plans): n I don't know. How much would you pay in premiums for th¡s plan? How often do you pay this premium? n Weekly n Every 2 Weeks n Twice a Month ! Monthly E Yearly n I don't know n Other: Does your employer offer wellness programs to the employee (do not include family plans)? E Yes ¡ No lf yes, prov¡de the premìum that the employee would pay if he/she received the mêximum discount for any tobacco cessation programs, and didn't rece¡ve any other d¡scounts based on wellness programs: s What chênge, if any, will the employer make for the new plan year? n Employer won't offer health coverage [] Employer will start offering health coverage to employees or change the premium for the lowest-cost plan that meets the mìn¡mum value standard and ¡s available to the for that plan? Frequency: n Weekly n Every2Weeks E Monthly ll Yearly fl Tw¡ce a Month n ldon't know How much will the have to tn employee only. (Premium should reflect the Date of change (mm ldd/yyWl: f- --- -_] d¡scount for the wellness program). I End of worksheet o O 26

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Certa¡n money you receive may not count as income for determining if you qualify for Health First Colorado or CHP+. List any income (type, amount, and how often) reported on your applicatjon that includes money from these sources: . Per capìta payments from a Tribe that come from natural resources, usage r¡ghts, leases or royalties. . Payments from natural resources, farming, ranching, fish¡ng, leases, or royalties from land des¡gnated as lndian trust land by the Department of lnterior (including reservations and former reservations). . Money from sell¡ng things that have cultural sign¡ficance. Tr¡be?O n Yes nNo n Yes fl No fl Yes fl No fl Yes E No 1. Who ¡n the household has received a servìce from the lndian Health Serv¡ce, a Tr¡bal Health Program, n Person A n Person C or Urban lndian Health Program or through a referral from one of these programs? n Person B n Person D n Person A fl Person C I Person B t] Person D 27 2, lf none, who in the household is eligible to receive serv¡ces from the lnd¡an Health Service, a Tribal Health Program, or Urban lndian Health Program or through a referral from one of these programs? End ol Worksheer t O name:

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I ... l: :jj :l: . l: do you have? fl sale of Livestock/Poultry n other: n ame 5. Are you the only owner of the bus¡ness? n Yes E No lf no, please answer the questions at right. lf yes, please sk¡p to question 6. How many owners are there (including yourselfl? What percent of the business do vou own? 6, How much money does your self-employment bus¡ness make? Give us that amount the bus¡ness earns before any taxes, deductions, or expenses are taken out. lf your income changes from month to month, tell us your Current Gross Monthly Amount (6a) AND your Expected Annual Amount (6b) AND ¡f you expect your Expected Annual Amount w¡ll be the same or lower for the next calendar year (6c), lf your income is the same each month, then only tell us your Current Gross Monthly Amount (64). 6a. Current Gross Monthly Amount: 6b. Expected Annual Amountl 6c. Wi¡l the Expected Annual Amount from this self employment be the same or lower ¡n the next calendaryear? fl yes I No 7. Do you have any monthly self-employment expenses? fl Yes I No lf yes, list all of your self-employment expenses below. lf you need more space to report all of your expenses make a copy of this page. For a more extens¡ve Iist please see the separate lnstruction Booklet available at Colorado. qov/HCP F/Ap plv a nd con nectfo rH ealthCO.com/resou rces/the-b asics/custome r- resources/. lf your self-employment expenses change month to month, fill out both the Current Amount AND the Expected Annual Amount. lf your self-employment expenses do not change month to month, you only need to fill out the Current Amount. n One Tìme only n Twice Monthly n Weekly E Monthly ! Every 2 weeks E Monthly [] weekly n Monthly 2 Weeks fl n one Time only fl Tw¡ce ! Weekly [:] Monthly 2 Weeks n One T¡me only E Tw¡ce lvlonthly E Weeklv n Monthly n Every 2 Weeks n ! weekly only n Twice Monthly ¡ Monthly 2 Weeks n Yearly End oÍ Worksheet F

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z. uare or Þrnn fmm/oo/yyyy, Section A: Grants, Scholarships, or Work Study 2. Does this person have any income from Grants, Scholârships, or Work Study? n Yes ! No lfyes, answer questions 3 and 4 below. lf no, skip to Section B. 3. What is the âmount (S) of Grants, Scholarships, and/or Work Study this person used for living expenses this month? 4. What is the taxable amount (5) of Grants, Scholarships, and/or Work Study th¡s person received for the year? Section B: Other Income Please list all your other ¡ncome below. 5. Does your other income type change month-to-month? n Yes E No lfyes, fill out the Current Amount AND Ëxpected AnnualAmount columns for each type of other income that appl¡es to you. lf no, you do not need to fill out the Expected Annual Amount column. You do not need to report any money from the following types because they are not cons¡dered income: Su pplemental Security lncome (SSl), Veterans Benefits, Child Support Payments, Adoption Assistance Program, Workers Compensation, or Gifts. Time Only n Tw¡ce Monthly ! Weekly n Monthly 2 Weeks uency E One Time Only n Tw¡ce E Weekly fl Monthlv 2 Weeks uency [] One T¡me Only [] Twice Monthly [] Weekly f-] Monthly E Every 2 Weeks n One Time Only E Twice Monthly n Weekly n Monthly 2 Weeks Tl fl One Tìme E Weekly nt nt Amount End of worksheet u O 2 Weeks fl Monthly 29

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@¡r:rl¡t?¡fl r¡t¡m¡mfrt @ ru coverage 30 EndofWorksheett O

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llti ì.:i iÌl Name 2. Date of Birth (mm /ddlyVyyl 3. sex: E lvlale E Female 4, Home Address (leave blank if you do not have one) City Apartment/Suite # they l¡ke to rece¡ve the¡r own ma¡l about theìr fl yes County 5. th¡s person ¡s 18 years or health coverage? lf yes, please fill out ma¡l¡ng address below. No State zip Code 6, Mailing Address (¡f different from Home Address) Apartment/Suite # 7, ln Care Of (if applicable): C¡ty 9. Pr¡mary Phone 10. 11. Preferred Spoken Language: English Spanish Language: E Engl¡sh ! Spanish outside of Colorado? Yes County n Work Cell Home Work Other Please Specify): Other (Please Specify): ne Phone Type: ls person tem No zip Code 14. lf this person is temporarily lìving oLrtside of Colorado, where in Colorado will they be l¡ving when they return? C¡ty 15. Social Secur¡ty Number (SSN) Z¡p Code County Workheet I continues on next pdge Ø 31

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lf THIS PERSON does not have a sSN, and is apply¡ng for health coverage, tell us why THIS PERSON does not have a SSN. fl Has appl¡ed for a SSN* n Not el¡gible to receìve a SSN ! Only el¡g¡ble to rece¡ve ã SSN for val¡d non-work reason E Refuses to obta¡n due to well establìshed Rel¡gious objection *lf someone does not have a Social Security Number, they can vis¡t htto://wwwssa.eov/ssnumber/ for ¡nformation on how to apply for a Soc¡al Security Number. They can also call the Soc¡al Secur¡ty Admin¡stration aI7-8OO-772-7273 (TTY 1-800-325-0778). 16. Does THIS PERSON plan to file a federal income tax return next year? E Yes n No You can still apply for Health F¡rst Colorado, CHP+, or other health insurance even if you do not file a federal income tax return. However, you must plan to file federal taxes every year vou rece¡ve Advance Prem¡um Tax Cred¡ts (APTc) or cost Sharing Reductions (CSR) through the Marketplace. lf yes, answer questions A-F. lf no, sk¡p to question E. ng status? nsingle [] Married FilingJo¡ntly n Head of Household E Marr¡ed Fil¡ng Separately n Qualifying Widow(er) with Dependent Ch¡ld B, lf this person checked that they are "Head of Household" or "Married Fil¡nA -.. separately", do exceptional circumstanc"r ¡S "ppty to in"ir..tu? - ! Yes n No C. If THIS PERSON is fil¡ng jointly, please name his or her spouse. n Yes fl No D. W¡ll TH|S PERSON cla¡m any dependents on therr tax return / [f Yes f] No . lf yes, list the legal name(s) of dependents: E. lf THIS PERSON is a tax dependent, list who cla¡ms them as a dependent: . ls this person listed on the appl¡cation? EYes INo . ls th¡s person a non-custod¡al parent? []Yes DNo h ls TH|S PERSON lrvrng wrth þotn parents, out tnerr parents oo not exoect ' nYes nNo to file a joint federal ¡ncome tax return? [] Yes n No fl Yes. (Answer allthe following questions.) [f No. (sk¡p to question 32.] I EF imítEElitã l¡fuf.Turu ¡¡@ilE 19. Uoes I Hls PLR5oN lrve Wrtn at leasr one and is THIS PERSON the main person takìng child under the age ot L9, _ ., ."r" oiir'r¡t "¡'ilai n Yes nNo 20. ts TH|S PERSON a full-time student? n yes n No 21. *DoeíiHls PERSoN have a mèdical, phys¡cal, mental, or developmental condition that has lasted, or ¡s expected to last, more ihan 12 months, including blindness?(þ [] Yes !No 22. +Does THIS PERSON have a medical, physìcal, mental, or developmental cond¡tion that causes THIS PERSON to regularly need help with some or all of THIS PERSON's self-care activities (such as bath¡ng, dress¡ng, eating, using the bathroom)? fl Yes Ll No 32 Worksheet t continues on next pøgeØ

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E 23. +Does THIS PERSON need to move to a nurs¡ng home, acute care, hosp¡tal, group home/ mental health institutìon or long-term care fac¡l¡ty with¡n the next 30 days, or does THIS PERSON need in-home health care to stay in their home? fl Yes ! No lf THIS PERSON answered 'Yes' to e¡ther Question 21, 22, 23, or qualìfies for Medicare, THIS PERSON has the option to complete Worksheet B / (pales20-24llofindoutiftheyqualifyforhealthcoverageforindividualswhohaveadisabilitvare65and older, and/or who are blind. ¡Yes nNo ;.' .: 1ì' ::i' l.' rir 't-l '.:.. 25, lt THIS PERSON Ìs not a U.5. c¡trzen or U.5. nahonal, does Ttlls PERSoN have an elrgrble rmmrgrabon statusi [] Yes (Fill out the followin8 table.) ment type Document expiration untry [] Yes n No of nce ls THIS PERSON, their spouse or parent an honorable discharged veteran or an active-duty membef of the u.s. m¡litary? f] Yes f] No For an extens¡ve l¡st of non-citizenship status and ¡mmigration documents, please see the sêparate lnstructlon Booklet ava¡lable at Colorado.qov,/HCPF/Aoolv and ConnectforHealthCO.com/resources/the-bâsics/customer-resources/. 26, Does THIS PERSON want help pay¡ng for medical bills from the last 3 months? ü Yes |:]No lf yes, list the months thêt they want help (mm/yyyy) ,@uryforwhichtheyhavebroughtorw¡llbringalegalclaim?@ nYes ¡No 28. Does THIS PERSON qualify for or are they enrol¡ed in any of the following-types of health care coverage? lfyes, selectwhich appliesandfill out Worksheet c / (page25l. n TRICARE ll Peace Corps n Other State or Federal Health Benefit Program n VA Health Care Benefits [] coBRA fl Retiree Health Plan Ü other: 29. Does THIS PERSON qualify for or are they enrolled in Medicare? fl Yes n No lf yes, Person 2 has the option to complete Worksheet B / (pages 20 - 2al lo find out if they qual¡fy for health coverage for indiv¡duals who have disabil¡tìes, are age 65 or older, and/or who are blind. throuph a - .. (pag" ã6). ! t"t []No 31. ls THIS PERSON currently incarcerated? EYes []No lf yes, ¡s THIS PERSON currently wa¡ting for a dec¡sion on charges? n Yes n No 32, Race (optional - check all that apply) I American lnd¡an or Alaska Native (fill out Work sheetE) / E Asian lndian E Black or African American E chinese n F¡l¡pino I Guamanian or Chamorro I Japanese I Korean f] Hispanic/Latino E Native Hawai¡an n otherAsian E other Pac¡fic lslander ! samoan ! Vietnamese n wh¡te or caucasian ! other: Workheet I contínues on next Poge o 33

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33. Current lob & lncome lnformation (check all that apply) I Does not have a job E Has a lob Skip to question 62. lf they are currently employed, tell us about their income. Start with questions 34, 35. Employer Address 37. Employer Phone from this current Job 2: llf vou onlv have one iob, skip to question 62.) I ls self-employed F¡ll out Worksheet F / (page 28) and return to question 62. I Has other income (including rental income). Fill out Worksheet G ¡/ (page 29) and return to questjon 62. ''.' a,rr¡ôñ+ l^h 'l' 34. Employer Name: 42, Average Hours Worked Each Week: 44. Does THIS PERSON'5 income from this job change month to month? n Yes lf yes, fill out the Current Wages/T¡ps AND Expected Annual lncome for this job. lf no, only fill out the current wages/T¡ps ¡n number 42 above. They do not need to fill out the Expected Annual lncome. 45. Expected Annual ¡ncome o you not 36. Apartment/Su¡te # 40. Zip Code Pay Period: n One T¡me Only n Tw¡ce Monthly n weekly n Vlonthly fl Every2 Weeks n Yearly 43. Tell us the total gross pay @that THIS PERSON got or will get this month as a one-time payment from th¡s employer. (Th¡s could be a bonus or one time payment they got.) ENo 46 a. ls th¡s ¡ncome from seasonal emplovment? lf yes, answer 47. [--i Yes 46 b. ls this income from commission-based employment (ìncluding tip n Yes based employment)? 47. Will the expected annual income from this job be the same or lower n Yes ¡n the next calendar year? nNo fJ No nNo 38. City 39. State 52, City 53. State 48. Emplöyer Name: 49. 51. 56. Average Hours Worked Eêch Weekl if you do not have one) Pay Period: n One T¡me Only fl Twice Monthly E Weekly f] Monthly ¡ Every 2 Weeks E Yearly 57. Tell us the total gross pay that THIS PERSON 8ot or w¡ll get this month as a one-time payment from th¡s employer. (This could be a bonus or one time payment they got.) 50. s 54. Z¡p Code 34 worksheet t contÌnues on next poge ø

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59. Expected Annual income 1þ from this job; 58. Does THIS PERSON'5 income from this job change month to month? [Yes lf yes, fill out the Current Wages/T¡ps AND Expected Annual lncome for this job. lf no, only fill out the Current WagesÆips in number 42 above. They do not need to fill out the Expected Annual lncome. lNo 60 a. ls this income from seasonal employment? lf yes, answer 61. fl Yes 60b, ls th¡s income from com m¡ss¡on-based em ployment (¡nclud¡ng tip EYes based employment)? lf yes, answer 61. 61.Will the expected annual ¡ncome from th¡s job be the same or lower E Yes in the next calendar year? 62. DEDUCIIONS:(Ð Check all that apply, and give the amount and how often THIS PERSON pays ¡t. Telling us about these deductions could make the cost of health insurance lower. THIS PERSON should not include a cost that they already considered ¡n their answer to job income and net self-employment. 63. Does THIS PERSON's deductions change month to month? n Yes n No lf Yes, for each deduction that changes, fill out the Current Amount AND the Expected Annual Amount columns. lf THIS PERSON ¡s not payìng the deduction at th¡s time, but expects to claim it on their tax return, fill out S0 for the Current Amount, and write the amount they will include on their tax return for the Expected Annual Amount. lf No, only fill out the Current Amount column. They do not need to fill out the Expected Annual Amount column. Time Only E fwice Monthly n Weekly n Monthly 2 Weeks Tì Yearlv [] One Time Only fl n Weekly tl Monthly 2 Weeks n One Time Only tl Twice Monthly fl Weekly ll Monthly E Every 2 Weeks n Yearly 64, Tell us the total amount of income THIS PERSON plans to report on the¡r tax return that they have NOT yet included in this appl¡cation and its Worksheets. lnclude incomes such as past employment, or benefits that THIS PERSON rece¡ved in past months. 65. After you submit th¡s application, we will ver¡fy n Stopped working at a job your ìncome. Please tell us ¡f any of the following E Hours changed at ê job Date the occurred? have happened to you ¡n the past two years to us w¡th this verification process. Check the box help and E Change in Employment enter the date this change occurred for all reasons ü Marrìed, that apply show¡ng why your income has changed ll No üNo fJ No Amount Amount Amount rnd oÍworksheet t @ I Other: or Divorce 35

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Adams - Department of Humen Serv¡ces 7190 Colorado Boulevard Commerce CitV CO 80022 Phone: 303-227-280Oj Fax: 303-227 -2380 Arapahoe - Department of Human Serv¡ces 14980 East Alameda Drive Aurora, CO 80012 Phone: 303-636-1170; Fax: 303-636-1426 Beca - Department of Publ¡c Welfare 772 Colorado Street Springfield, CO 81073 Phonet 7 L9-523-4737: Faxi 7 !9-523-4820 Boulder - Department of Hous¡ng and Human serv¡ces PO. Box 471 Boulder, CO 80306 : Phone:303-441-1000; Fax:303-441-1523 Broomfield - Depârtment of Health and Human Serv¡ces #6 Garden Center Broomfield, CO 80020 Phone: 7 20-887 -2200; Fax: 303-469-2110 Cheyenne - Department of Human Services 560 West 6th North PO, Box 146 cheyenne wells, co 808L0 Phonei 7 I9-7 67 -5629; Faxi 7 !9-7 67 -5707 Conejos - Department of Soc¡âlServ¡ces PO. Box 68 Conejos, CO 8L129 Phone: 719-367-5455; Fa|i.l 7 !9 -37 6-2389 Crowley - Department of Human Services 631. Ma¡n Street, Suite 100 Ordway, CO 81063 Phonet 7 79-267 -3456; Fax]. 7 19-267 -5296 36

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Denver - Department of Humen Services 1200 Federal Boulevard Denver, CO 80204 Phonet 7 2O-944-3666t Faxi 720-944-3094 Douglas - Department of Human Services 4400 Castleton Court Castle Rock, CO 80109 Phone: 303-688-4825 ext. 534L; Fax: 877-285-8988 Elbert - Department of Human Serv¡ces P,O, Box 924 K¡owa, CO 80117 Phone: 303-621-3149: Faxt 303-62!-0!22 Fremont - Depertment of Human Serv¡ces 172 Justice Center Road Canon Cìty, CO 81212 Phonei 719-275-2318; taxi 7 f9 -27 5-5206 Garfield - Department of Human Serv¡ces 195 West 14th Street Rifle, CO 81650 Phone:970-625-5282 ext.3255; FaX]. 97 0-625-287 6 Grand - Department of Social Services P.O. Box 204 Hot Sulphur Springs, CO 80451 Phone: 970-725-3331; Fax: 970-725-3696 Huerfano - Department of Social Serv¡ces 121 West 6th Street Walsenburg, CO 8L089 Phonet 719-738-28!0 ext. 110; Fax: 779-738-2549 Jefferson - Department of Human Serv¡ces 900 Jefferson County Parkway Golden, CO 80401. Phone: 303-271.-1388; Fax: 303-271-4500 37

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Lake - Department of Human Services PO. Box 884 Leadv¡lle, CO 80461 Phoner 719-486-2088t ta¡| 7 L9-486-4L64 Larimer - Department of Human Serv¡ces L501 Blue Spruce Drive Fort Collins, CO 80524 Phone: 970-498-6300;Fax; 970-498-6304 ' L¡ncoln - Department of Human Services P.O. Box 37 103 3rd Avenue Hugo, CO 80821 Phonei 7 79-7 43-2404; tax]. 7 79-7 43-2879 Mesa - Department of Human Serv¡ces 57O 29% Road Grand Junction, CO 81502 Phoner 970-241-848O: FaXr 97 0-248-2849 M¡neral - Department of Social Serv¡ces P.O. Box 40 Del Norte, CO 8LL32 Phone: 7L9-657-338!j tax: 7L9-657 -2997 Montezuma - Department of Soc¡al Serv¡ces 109 West Main Street, Room 203 Cortez, CO 81.321. Phone: 970-565-3769; Fax; 970-565-8526 Morgan - Depertment of Human Serv¡ces 800 East Beaver Avenue Fort Morgan, CO 80701 Phone: 970-542-353Oj Fax: 970-542-3415 Ouray - Department of Soc¡al Serv¡ces P.o. Box 530 Ridgway, CO 81432 Pho nei 97 0-626 -2299 : Fax: 97 0-626 -997! 38

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TTffi Phillips - Department of Soc¡âl Services 127 East Denver Street, Suite A Holyoke, CO 80734 Phoner 970-854-228O; Faxi 97 0-854-3637 Prowers - Department of Humen S€rvices PO. Box 1L57 Lamar, CO 81052 Phone: 719'336-7486; Fax: 719-336-7198 R¡o Blanco - Department of Human Serv¡ces 345 Market Street : Meeker, CO 81641 : Phone: 970-878-9640; Faxr. 970-878-4893 Routt - Department of Human Services P.O. Box772790 Steamboat Springs, CO 80477 Phone: 970-870-553, Faxi 97 O-87 0'5260 Saguache - Department of Social Services P.O. Box 215 Saguache, CO 81149 Phone: 719-655-2537t Faxt 7 !9-655-0206 San Miguel- Department of Social Services P.O, Box 96 Telluride, CO 81435 P^oîet 970-728-4417ì Faxt 970-7 28-4412 Summit - Department of Social Services P.O. gox 869 Frisco, CO 80443 Phone: 970-668-916I; Fax: 970-668-4714 Wash¡ngton - Department of Human Selv¡ces P.O. Box 395 Akron, CO 80720 P h o n e | 97 O -3 45 -2238 t t ax: I 7 o -3 45 - 2237 I I I I I 39

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Agent An agent represents a health insurer and offers their policies to consumers. TheV are generâlly either employed directly by an insurer or contracted by them to market their plans. Agents êre fam¡liar w¡th the features of the plans the¡r company sells and can prov¡de expert and deta¡led answers to your questions about those polic¡es. Appeal A request for your health ¡nsurer or plan to review a decision or a grievance aga¡n, Author¡zed Representative An Authorized Representatìve ¡s either a person or an organization that you trust and let fill out your appl¡cation, talk about this applicatjon w¡th us, see your ¡nformatìon, get ¡nformation about your application, and sign your appl¡cation on your behalf An Authorized Representative also takes legal respons¡bility for the ¡nformation provided in this application. lf an Authorized Representative ¡s a person, they must be 18 or older. An Authorized Representative is NOI an Agent/Broker, Health Coverage Gu¡de, or a Certified Applicatìon Counselor, Broker A broker offers policies from several insurers that they are contracted to represent. Brokers can prov¡de ass¡stance ¡n comparing the rates and benefits of health plans from several companies. An exper¡enced broker can provide expert and detailed ¡nformation on plan spec¡fic features and limitations of various policies. ch¡ld Health Plan Prus (cHP+) CHP+ is public health insurance for ch¡ldren and pregnant women who earn too much to qualify for Health First Colorado, but cannot afford private health ¡nsurance. For more informatìon on CHP+ go to CHPPfus.orp. Also referred to as the Marketplace. Connect for Health Colorado'" offers ind¡vìduals, families and small businesses an onl¡ne marketplace for health insurance and exclusive access to up- front financ¡al ass¡stance, based on ¡ncome, to reduce costs. Customers can shop through a website and get expert help in person and over the phone from a network of customer serv¡ce professionals, including Customer Service Center Representatives, Health Coverage Guides and certified health insurance agents and brokers. The Marketplace ¡s a non-profit entity establ¡shed bv a 2011 state law. Connect for Health Colorado A deduction is an amountyou can take offofthe total amountyou earn (gross income). Common deductions include al¡mony and student loan ¡nterest. We do not need you to tell us about things like charitable contributions or home mortgage interest, For additional ìnformation, visit the IRS website at httÞ://www.irs.sov/taxtopics/tc450,html. Deductions 4t

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Dependent A ch¡ld or other ¡nd¡vidual for whom a parent, relative, or other person may claim a personal exemption têx deductìon. D¡v¡dend/lnterest The charge for the use of borrowed money. lnterest you get from a bank or div¡dends from a stock you own are examples of investment income, which you should tell us about if you apply for help pay¡ng for health coverage. The EPSDT benefit prov¡des treatment care services for comprehens¡ve and preventive health diagnostic and children (ages 0-20) who qual¡fy for Health First Colorado. Eerly and Period¡c Screen¡ng, D¡agnostic and Treatment (EPSDT) Exceptional C¡rcumstânces lf you have been a victim of domestic violence and are still marr¡ed to the perpetrator but will not be able to file a joint tax return, please enter how you plan to file as e¡ther Head of Household or as Married F¡lìng SeparatelY. Also mark the Exceptional C¡rcumstances check box ¡n the app¡ication, Federãl lncoñe Tãx Return lncome tax return ìs a document you file with the lnternal Revenue Service or the state tax board reporting your income, profits and losses of your business and other deductions as well as details about your tax refund or tax liabil¡ty. A 1040 form ¡s an example of a federal ¡ncome tax return, Gross pay/lncome Profits before taxes, deductions, or expenses are paid. Health Coverage Gu¡des Health Coverage Guides are certified by Connect for Health Colorado to assist customers wìth applying for health coverage and financial assistance programs that help reduce health ¡nsurance costs. They also help customers to understand coverage options and prov¡de unbiased assistance in shopping for and selecting health plans. A contrêct that requires your health ¡nsurer to pay some or all of your health care costs in exchange for a prem¡um. 42

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A demand for money to pay for damages you have suffered due to an ìnjury. Damages ¡s the sum of money the law ¡mposes to compensate the injured party for their loss or injury. lnsurance claims, court filings and cr¡m¡nal charges aga¡nst the ¡ndividual you believe caused the injury are examples of legal claìms. Legal Cla¡m M¡n¡mum Value Standard A health plan meets this standard if it is designed to pay at least 60% of the total cost of medical services for a standard population. Starting in 2014, ìndividuals offered employer-sponsored coverage that prov¡des minimum value and that is affordable w¡ll not be eligible for a prem¡um tax credit. ls an onl¡ne benefits portalwhere coloradans can apply and manage the¡r public benefits including food, cash and medical assistance. PEAK (colorado Program El¡g¡bility and Application Kitl Spouse A marr¡age partner such as a husband or w¡fe, A health care program for active-duty and retired uniformed services members and their famil¡es. Health care programs operated by the United States Department of Veterans Affa¡rs for elig¡ble veterans. Veterans Affa¡rs (VA) Health Care Benefits 43

(spa)(co-18-0027)(approval-package)Colorado CHIP SPA CO-18-0027: Approval Package (approved August 9, 2022, effective October 1, 2017)#

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_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Colorado CO-18-0027

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

August 9, 2022

Tracy Johnson Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan Plus (CHP+) 1570 Grant Street Denver, CO 80203-1818

Dear Ms. Johnson:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), CO- 18-0027 submitted on June 29, 2018, with additional information submitted on June 30, 2022, has been approved. Effective October 1, 2017, this SPA implements mental health parity requirements to ensure that financial requirements (FRs) and treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits.

Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that FRs and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of section 2705(a) of the Public Health Service Act, in the same manner that such requirements apply to a group health plan. Colorado demonstrated compliance by providing the necessary assurances and supporting documentation that the state’s application of FRs and non-quantitative treatment limitations to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act.

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

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

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Page 2 – Ms. Tracy Johnson

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Amy Lutzky

Deputy Director

/Signed by Amy Lutzky/

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SPA #27 Date Amendment # 27 Submitted: June 29, 2018 Date Amendment # 27 Approved: Date Amendment # 27 Effective: October 2, 2017 (Requested)

Effective October 2, 2017, Colorado amended its State Plan to document its compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) under Sections 6.2 and 8.4

SPA number: CO-18-0027 Proposed effective date: 10-02-2017 Proposed implementation date:

1.4-TC Tribal Consultation. (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

The State included consultation on this SPA in the tribal consultation log dated September 25, 2017. A copy of the relevant page of the consultation log is attached.

6.2.2.2-DC State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)Page - 11 – State Health Official

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

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to

children eligible for dental-only supplemental services. Children eligible for

this option must receive the same dental services as provided to otherwise

eligible CHIP children (Section 2103(a)(5). Please update Sections 1.1-DS, 4.1- DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

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In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. Previously 8.6

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: The State permits each Managed Care Entity (MCE) to use additional variables, such as the place of service, to assist in the classification of M/S and MH/SUD benefits, where appropriate. While these flexibilities are afforded to the MCEs, they do not replace the requirement to use the ICD and DSM criterions selected above.) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes

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No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those

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children only and Section 6.2.3- MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective

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treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

The minimum essential benefit package is the same for all CHP+ members enrolled in the CHP+ MCEs.

6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

The state classified services in the four categories based on the approach described in the CMS Parity Compliance Toolkit and guidance provide through the CMS/SAMHSA technical assistance process and the CMS parity academy. Recognizing that Federal parity regulations allow states some latitude in placement of benefits within each of these categories Colorado developed a preliminary definition list for use in classifying benefits in each category based on the current state plan benefit package. The state provided these definitions in a detailed parity compliance toolkit to MCOs to ensure that each plan properly assigned services within each category. After sending out the

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state's parity compliance toolkit, the state held numerous technical assistance meetings with each MCO to assist in the assignment of services to each category and proper completion of the full compliance toolkit. This helped ensure consistency among MCOs when answering questions about each benefit category and provided the state a standardized toolkit for each MCO's demonstration of compliance.

The state used the following definitions for each category: • Outpatient: Routine services that occur in an outpatient setting and are not included in the emergency category. • Inpatient: Any non-emergency service that involves the individual staying overnight at a facility. This includes inpatient MH and SUD treatment and crisis stabilization services occurring in a facility. • Emergency: Services or items delivered in an emergency department (ED) setting or emergency/crisis stabilization services, not requiring an overnight stay, which are not delivered in an inpatient setting. • Pharmacy: Covered medications, drugs and associated supplies requiring a prescription.

6.2.3.1.1 MHPAEA The State assures that:

The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub-

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classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

CHP+ Members are not subject to any aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit:)

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No Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

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Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5- MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits.

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Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

CHP+ Members are not subject to any QTLs for mental health or substance use disorder benefits.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non- quantitative treatment limitations.

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR

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457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i))

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Guidance: If there is no single level of a type of QTL that exceeds the one- half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

CHP+ Members are not subject to any additional NQTLs applied to mental health or substance use disorder benefits.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers?

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

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6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other

Guidance: If other is selected, please specify the entity.

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State Managed Care entities Both

Other

Guidance: If other is selected, please specify the entity.

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

6.3.1.  The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Describe: Previously 8.6

Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (457.1005 and 457.1010)

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

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8.4.3  No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: Covered services for MH/SUD are listed within 6.2 through 6.2.28 and Co-Payments for all program benefits are listed in 8.2.3 through 8.2.4. No Guidance: For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

Pregnant women are not charged any co-pays for services received.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits?

Yes

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No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results of the parity analysis as an attachment to the State child health plan.

8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

Each MCO completed the state’s MHPAEA Compliance Toolkit (Toolkit), submitting it to the state will supporting policies and an attestation of their compliance with the above regulation by an Officer of the organization. The state’s Toolkit was modeled from the CMS Parity Compliance Toolkit and contains a thorough analysis on the application of co-payments to M/S and MH/SUD benefits within each classification. All MCOs are required to complete numerous analyses within the Toolkit to analytically demonstrate their overall compliance, including compliance with the Two-Part Test. The analyses composed in the Toolkits allow the State to ensure state-wide compliance with 42 CFR 457.496.

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to

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medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

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

The 5% maximum allowable cost-sharing limit is calculated for each individual family. The annual amount is then recorded on the family’s enrollment card with instructions in the member packet of the “shoe box” method and the process to be followed when the limit is reached.

State planners estimate that few families will reach their 5% limit. An analysis of the State’s fee schedule suggests that cumulative cost sharing will rarely exceed 1% of the family’s adjusted gross income. However, CHP+ administrative personnel make families aware of the aggregate limit on cost sharing through a number of information and educational sources.

Through direct communication with families, the CHP+ marketing and outreach efforts often discuss the aggregate limit on cost sharing. The first direct written communication with CHP+ families instructs parents that the expenditures on their child(ren)s health care through CHP+ should not exceed 5% of family income. Through contracts with Managed Care Organizations, the CHP+ administration ensure that the plans make their

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enrollees aware of the aggregate limit on cost sharing by including information regarding the cost-sharing limit in their member handbooks.

(spa)(co-19-0029)(approval-package)Colorado CHIP SPA CO-19-0029: Approval Package (approved August 8, 2019, effective July 1, 2018)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Selices 7500 Security Boulevard, Mail Stop 32-0-l-16 Baltinrore, MD 21244-'1850 clvrs crNTrRs fot M[DtcÂ¡t & MtDtc^tD sEnvKrs CENTTR FON MED¡CAID & CHIP SERVICES Child¡en and Health Prosrams AUG 0 I 2019 Laurel Karabatsos Acting Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan Plus (CHP+; 1570 Grant Street Denver, CO 80203-1818 Dear Ms. Karabatsos: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIp) state plan amendment (SPA), CO-19-0029, has been approved. CO-19-0029 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L, for utilization of a managed care delivery system. This SPA has an effective date of July 1 , 20 I 8. Sections 2101(a),2103(Ð(3), 2107(b), and2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Colorado has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan as of July 1,2018. This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts fbr CHIP populations in effèct as of the state fiscal year beginning on or after July I , 2018 must comply with the CHIP managed care regulations and be submitted for CMS review. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Jordan's contact information is as fbllows: Centers for Medicare & Medicaid Servioes Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (41 0) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov

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Page 2 - Ms. Laurel Karabatsos Ofnicial communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Director, Division of Medicaid Field Operations West. Mr. Allen,s add¡ess is: Centers for Medicare & Medicaid Services 1961 Stout Street Room 08-148 Denver, Colorado 80294 Ifyou have additional questions, please contact Amy Lutzky, Director, Division ofState Coverage Programs at (410) 786-0721. 'We look forward to continuing to work with you and your staff. Marie Costello Director cc: M¡. Richard Allen, Director, Division of Medicaid Field Operations West /signed Anne Marie Costello/

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3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. At this time, prenatal woman over the age of 19 are not in Managed Care. Presumptive eligible individuals are not in Managed Care. Newly eligible individuals are not in Managed Care. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost- effective and efficient manner. (42 CFR 457.490(b))

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If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low- income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b)) The Colorado, CHIP populations that are not served through a Managed Care Organization (MCO) are in the Fee for Service, State Managed Care Network (SMCN). The SMCN is administered by an Administrative Services Organization (ASO), which is competitively procured, and contractually obligated and audited to ensure compliance with Section 2102(a)(4); 42 CFR 457.490(a) and Section 2102(a)(4); 42 CFR 457.490(b).

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

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. Children ages 0 – 3, that are determined eligible, may participate in the Early Intervention Program, which is a program administered by the Colorado Department of Human Services (CDHS). MCOs have financial responsibility, but services are provided by CDHS.

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3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment Each MCO has their own actuarially sound rate Describe population served: All populations except: prenatal woman over the age of 19, presumptively eligible, and newly eligible individuals.

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

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment: PAHP is only for Dental services. At this time, all populations except: prenatal woman over the age of 19, presumptively eligible, and newly eligible individuals. As of 10/1/2019, prenatal women over the age of 19 will be eligible for dental benefits. Other (please explain)

Describe population served:

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

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

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

3.1.2.2

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

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in

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

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)). In the state of Colorado, there is no procurement process for an MCOs to join the program. 3.2.2

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

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the

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Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

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

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

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

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

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1))

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No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

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

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

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

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3.4.1 Enrollment Process 3.4.1.1

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

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

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider- beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

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

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3.4.2.2

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

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross- referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction

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specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross- referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 457.1212 Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

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

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees

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and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

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

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

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

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the

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prevalent non-English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68;

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• The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

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

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

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services;

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• The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of- network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State- approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and • Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days

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before the intended effective date of the change. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross-referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to- door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or

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agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross- referencing to 42 CFR 438.206) 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross-referencing 42 CFR 438.68(e)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered

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care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of- network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross- referencing to 42 CFR 438.207)

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3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross- referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an

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amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)) 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross- referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross- referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; • Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; • Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs; • Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b))

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Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 457.1260) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1))

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Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross-referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the sub contractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify

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other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable sub regulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3). 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e))

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3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c))

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3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is: • At the enrollee's option and not required before or used as a deterrent to proceed to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the

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right to request a State review. • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals.

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The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c))

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3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)) 3.9.20

The State assures that it has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review: • The review is at the enrollee's option and is not required before or used as a deterrent to proceed to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal

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system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process; • The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414) 3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)) 3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

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Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual

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payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42

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CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)) 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the

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certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)). 3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to

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act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250. 3.12.1 Quality Strategy

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Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; • The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); • Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities;

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• Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS: • A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will: • Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1))

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3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1))

Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request.

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3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3). 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and

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performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3. 3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)) 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d))

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Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR- related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review). 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects,

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validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR- related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4).

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in

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performing the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)) 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished

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to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)) 3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)) 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10 The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d))

(spa)(co-19-0030)(approval-package)Colorado CHIP SPA CO-19-0030: Approval Package (approved January 23, 2020, effective October 1, 2019)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

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

Children and Adults Health Programs Group

JAN 2 3 2020

Tracy Johnson

Medicaid Director

Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan Plus (CHP+)

1570 Grant Street

Denver, CO 80203-1818

Dear Ms. Johnson:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), CO- 19-0030, has been approved. CO-19-0030 extends dental coverage to pregnant women enrolled in Children’s Health Plan Plus (CHP+). This SPA has an effective date of October 1, 2019.

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

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

If you have additional questions, please contact Amy Lutzky, Director, Division of State Coverage Programs at (410) 786-0721.

We look forward to continuing to work with you and your staff. Sincerely,

—

/signed Anne Marie Costello/

‘Anne Marie Costelld“ ~ ““~ Director

cc? Mr. Richard Allen, Director, Division of Medicaid Field Operations West

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SPA #27 Date Amendment # 27 Submitted: June 29, 2018 Date Amendment # 27 Approved:

Date Amendment # 27 Effective: October 2, 2017 (Requested)

Effective October 2, 2017, Colorado amended its State Plan to document its compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) under Sections 6.2 and 8.4.

SPA #28 Date Amendment #28 Submitted: June 29, 2018 Date Amendment #28 Approved: Aug 23, 2018 Date Amendment #28 Effective:

July 1, 2017

Effective July 1,2017, Colorado added the authority for direct certification through Supplemental Nutritional Assistance Program (SNAP) and the Temporary Assistance for Needy Families Program (TANF) to the Express Lane Eligibility option. Moreover, Colorado added the authority to waive an enrollment fee when a child is eligible for the Child Health Plan Plus program, when there is a pregnant mother in the household, enrolled in either the Medicaid or Child Health Plan Plus program.

SPA #29 Date Amendment #29 Submitted: June 25, 2019 Date Amendment #29 Approved:

Date Amendment #29 Effective:

July 1, 2018 (Requested)

Effective July 1, 2018, Colorado revised Section 3 of the plan to incorporate updates pursuant to the Medicaid Managed Care final rule as it relates to the Children’s Health Insurance Program.

SPA #30 Date Amendment #30 Submitted: November 20, 2019 Date Amendment #30 Approved: Date Amendment #30 Effective:

October 1, 2019

Effective October 1, 2019, Colorado revised Section 6.2 of the plan to add pregnant women to the dental coverage pursuant to C.R.S. § 25.5-8-107(1)(a)(II). The amendment also updated the well-baby codes in Section 8.4.2 to reflect the most current codes.

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6.2.21. Care coordination services (Section 2110(a)(21)) 6.2.22.  Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.  Hospice care (Section 2110(a)(23))

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25. Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.  Medical transportation (Section 2110(a)(26))

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.27. Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28.  Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

6.2-DC Dental Coverage The State will provide dental coverage to children, and, beginning October 1, 2019, to enrolled pregnant women of any age, through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children and enrolled pregnant women eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5); see also CHIPRA #7, SHO #09-012 issued October 7, 2009):

6.2.1-DC State Specific Dental Benefit Package. The State assures that the following categories of dental services, represented by the American Dental Association’s Current Dental Terminology (CDT) Code of Dental Procedures and Nomenclature, are covered in the dental benefit package: 1. Diagnostic (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (CDT codes: D2000-D2999) 4. Endodontic (CDT codes: D3000-D3999) 5. Periodontic (CDT codes: D4000-D4999) 53

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acceptable alternative to the one put forth by the State Legislature, which would have increased cost sharing over 1000%. After rule adoption, the rules are published in the Colorado Register and posted to the Secretary of State website.

The Department gives CHP+ members and applicants a chart that describes plan options, annual enrollment fees, and copayments based on income and family size.

Guidance: The State should be able to demonstrate upon request its rationale and justification regarding these assurances. This section also addresses limitations on payments for certain expenditures and requirements for maintenance of effort.

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

8.4.1.  Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.  No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

The following procedures will be considered well-baby and well-child care: CPT-4 codes: Preventive medicine codes: 99381-New patient under one year; 99382-New Patient age 1-4 years; 99383-New patient ages 5-11 years; 99384- New patient ages 12 through 17 years; 99385- New patient aged 18 years; 99391-Established patient under one year; 99392-Established patient ages 1-4 years; 99393-Established patient ages 5 through 11 years; 99394 – Established patient aged 12-17; 99395- Established patient aged 18 years; 99431- Newborn care (history and examination); 99432-Normal newborn care.

Evaluation and Management Codes: 99201-99205-New patient; 99211-99215- Established patient.

The following diagnoses will be considered well-baby and well-child care: ICD-10 codes: Z00.1- Z00.129—Encounter for routine child health and/or Health examination for newborn; Z00.2-Z00.6— Encounter for examination; Z00.70-Z00.71— Encounter for examination for a period of delayed growth; Z02.82 - Z02.89— Encounter for adoption services or other general examination.

All infants and children should be seen by a Primary Care Provider regularly for immunizations (shots) and check-ups. The CHP+ follows the well-child visits schedule recommended by the American Academy of Pediatrics (AAP) accepted Bright Future Schedule. The American Academy of Pediatrics recommends that children receive well- child visits at the following ages: 1 week, 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months 18 months, 2 years, 3 years, 4 years, 5 years 6 years, 8 years, 10 years, 11 years, 12 years, and 13 years.

(spa)(co-20-0032)(approval-package)Colorado CHIP SPA CO-20-0032: Approval Package (approved September 13, 2023, effective October 24, 2019)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850 Children and Adults Health Programs Group September 13, 2023 Adela Flores-Brennan Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan Plus (CHP+) 1570 Grant Street Denver, CO 80203-1818 Dear Adela Flores-Brennan: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number, CO-20-0032, received on June 24, 2020, with additional information submitted, September 11, 2023, has been approved. Through this SPA, Colorado has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, which requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. This SPA has an effective date of October 24, 2019. Additionally, Section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Colorado demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner. Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov

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Page 2 – Adela Flores-Brennan

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Sarah deLone Director /Signed by Sarah deLone/

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1.4

SPA #32 Date Amendment # 32 Submitted: 6/23/2020 Date Amendment # 32 Approved: Date Amendment # 32 Effective: 10/24/2019

Effective October 24, 2019, Colorado amended its State Plan to document Colorado’s compliance with Section 5022 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act).

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

The State included consultation on this SPA in the tribal consultation log dated 04/14/2020. A copy of the relevant page of the consultation log is attached.

6.2-BH Behavioral Health Coverage Section 2103(c)(6) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner.

Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related coverage, please describe the recommendations being followed for those services.

Attached to this document is the State’s periodicity scheduled.

6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any covered CHIP populations:

State-developed schedule American Academy of Pediatrics Other Nationally recognized periodicity schedule (please specify):

All Developmental and Behavioral Health recommendations outlined in the United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B.

Other (please describe: )

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to

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the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders, and if there are differences in benefits based on the population or type of condition being treated, please specify those differences.

If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral benefit.

Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1- BH.

6.3.1- BH Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

In addition to the Behavioral Health benefits covered within the CHIP benefit as outlined by the AAP Bright Futures periodicity schedule and the USPFTF recommendations graded A or B, the State allows for flexibility among CHIP MCO’s to go beyond services defined in the CHIP state plan to address the specific needs of individual patients and populations.

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

This is a contractual requirement for the Contractor to provide access to all required components of periodic health screens, as set forth by the American Academy of Pediatrics Bright Futures periodicity schedule. American Society of Addiction Medicine (ASAM) and InterQual provide guidelines for determination of the appropriate levels of care. CHP plans in Colorado utilizes these tools for acute and intermediate-level services which require a prior authorization.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age- appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools.

The State requires that CHIP MCO’s use age-appropriate, validated behavioral health screening tool(s) in primary care as well as behavioral health care settings. MCO’s are required to provide an individual needs assessment after enrollment, and at any other necessary time, that includes, but not limited to, the screening for behavioral health needs. Within these requirements, the State provides flexibility in the use of behavioral health screening tools to ensure practices are given

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the freedom to select screening tools that fit with their practice workflow and patient population, and the screening is appropriate for the needs of the individual patient.

In accordance with Colorado Revised Statute 10-16-139(5), and as specified in Colorado’s managed care contracts, MCO’s “shall include coverage and reimbursement for behavioral health screenings using a validated screening tool for behavioral health; coverage and reimbursement may be no less extensive than the coverage and reimbursement for the annual physical examination.” Managed care contracts also specify the requirement that MCO’s must implement mechanisms to provide an individual needs assessment after enrollment, and at any other time necessary, which includes a screening for special healthcare needs, to identify any ongoing special conditions of the member that requires a course of treatment or regular care monitoring and develop a treatment plan as necessary.

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

6.3.2.1- BH Psychosocial treatment Provided for: Mental Health Substance Use Disorder

Benefit includes, but not limited to psychotherapy, individual therapy, group therapy, family therapy, and case and medication management. Routine outpatient psychosocial treatment services are covered with no limitations if medically necessary.

6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

Benefit includes services for the medical management of withdrawal symptoms, inclusive of access to classes, FDA-approved medications, nicotine patches, and the Colorado QuitLine. Services have no limitations if medically necessary, however, some medications may have limitations. FDA-approved tobacco cessation medications are covered per age requirements for prescriptions. Nicotine Replacement Therapy is not currently approved for youth under 18 years old.

As the CHIP program in Colorado utilizes a managed care delivery model, MCOs have the latitude to select quantity limitations based on literature reviews and recommendations from their internal pharmacy and therapeutics committees. Colorado’s CHIP MCOs are not currently implementing any quantity limitations on tobacco cessation medications or are limiting to 180 days of treatment per 365 days.

Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the Act, MAT benefits are required for the treatment of opioid use disorders. However, if the state provides MAT for other SUD conditions, please include a description of those benefits below at section 6.3.2.3- BH.

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6.3.2.3- BH Medication Assisted Treatment Provided for: Substance Use Disorder

Colorado passed legislation HB19-1289, amending COLO. REV. STAT. § 10-16-148 requiring that health plans not impose any prior authorization requirements on any prescription medications approved by the Food and Drug Administration (FDA) for the treatment of substance use disorders. Quantity limitations for Opioid Use Disorder MAT medications offered on the CHIP benefit include the following:

• Butorphanol Tartrate Nasal Spray (Quantity Limit = 1 bottle/30 days) • Naloxone injection (Quantity Limit= 2 injections/fill)

Currently, there are no quantity limitations for Alcohol Use Disorder MAT medications on the CHIP benefit. Once in a 12-month period, health benefit plans must cover a 5-day supply of at least one FDA-approved substance use disorder treatment medication, without prior authorization per COLO. REV. STAT. § 10-16-104(5.5)(III)(B) (2018)).

6.3.2.3.1- BH Opioid Use Disorder

MAT medications for Opioid Use Disorder are included on the CO CHIP formulary, and any other MAT medications may be obtained through a prior authorization process. Some MAT drugs may have quantity limitations in place.

6.3.2.3.2- BH Alcohol Use Disorder

MAT medications for alcohol use disorder are included on the CO CHIP formulary, and any other MAT medications may be obtained through a prior authorization process. Some MAT drugs may have quantity limitations in place.

6.3.2.3.3- BH Other

MAT medications for tobacco cessation are included on the CO CHIP formulary, and any other MAT medications may be obtained through a prior authorization process. Some MAT drugs may have quantity limitations in place.

6.3.2.4- BH Peer/ Caregiver Support Provided for: Mental Health Substance Use Disorder

Peer and caregiver support services are not required covered benefits within the CHP+ benefit. However, while it is not a required benefit, CHIP MCO’s have the option to cover caregiver support services. MCO’s differentiate between peer and caregiver support. One of our plans covers peer support but not caregiver.

Another covers caregiver support when the caregiver is a MCO member. One MCO contracts peer, caregiver, and rehabilitation services to community mental health centers. One of our plans

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does not offer peer or caregiver support.

6.3.2.5- BH Respite Care Provided for: Mental Health Substance Use Disorder

Respite Care services are not required covered benefits within the CHP+ benefit. However, while it is not a required benefit, CHIP MCO’s have the option to cover Respite Care services. When covered by CHP MCO’s, Respite Care is based on medical necessity. Prior authorization may be required.

6.3.2.6- BH Intensive in-home services Provided for: Mental Health Substance Use Disorder

Treatment for mental health or substance use disorder in a home-setting allows for a strong focus on community and home-based care. Services may be like intensive outpatient, for example, but not limited to, individual counseling/therapy, family therapy, case and medication management, crisis intervention, diagnostic evaluation. In-home treatment is provided when medically necessary. Prior authorization may be required.

In-home mental health and SUD benefits are only covered when determined medically necessary, and require prior authorization. MCOs cover these services in-home when mental health and SUD services traditionally covered in an outpatient setting have been determined to have not been effective.

6.3.2.7- BH Intensive outpatient Provided for: Mental Health Substance Use Disorder

Benefit includes, but not limited to individual therapy, group therapy, family therapy, crisis intervention, diagnostic evaluation, case and medication management. Intensive outpatient services covered without limitation if medically necessary.

6.3.2.8- BH Psychosocial rehabilitation Provided for: Mental Health Substance Use Disorder

CHIP MCO’s cover a variety of psychosocial rehabilitation services, based on the individuals needs of the patient. These services are covered without limitation if medically necessary.

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit, please indicate that in the benefit description. If there are differences between these benefits, such as the staffing or intensity of the setting, please specify those in the description of the benefit’s amount, duration, and scope.

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6.3.3- BH Day Treatment Provided for: Mental Health Substance Use Disorder

Day treatment services for mental health can include, but not limited to, evaluation, observation, monitoring, and individual, group, or family therapy. This benefit has no limitation if medically necessary. The state considers day treatment and partial hospitalization to be the same benefit.

Day treatment services for substance use disorder can include services that are provided for the purposes of completing a medically safe withdrawal from alcohol or substances, observation, evaluation, medical monitoring and addiction treatment for alcohol and substance abuse.

6.3.3.1- BH Partial Hospitalization Provided for: Mental Health Substance Use Disorder

The state considers day treatment and partial hospitalization to be the same benefit. Currently, one of our health plans does not cover partial hospitalization for substance use disorder, as it is not part of our Medicaid benefit package. Network adequacy allows for intensive outpatient services rather than partial hospitalization, as one is required from ASAM level 2.

6.3.4- BH Inpatient services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18)) Provided for: Mental Health Substance Use Disorder

This benefit includes acute treatment provided in a psychiatric or general hospital, with covered services inclusive of, but not limited to, provider visits during a covered admission, room and board, ancillary services, group/individual therapy, medication management, medical supplies. Inpatient services require prior authorization to determine medical necessity. No limits apply if medically necessary.

Guidance: If applicable, please clarify any differences within the residential treatment benefit (e.g. intensity of services, provider types, or settings in which the residential treatment services are provided).

6.3.4.1- BH Residential Treatment Provided for: Mental Health Substance Use Disorder

This benefit covers a 24-hour structured treatment in a licensed residential facility in order to stabilize and provide a safe and supportive living environment, and/or to provide a supportive treatment environment to assist with the initiation or continuation of a patient’s recovery process. These services require prior authorization to determine medical necessity. Benefit has no

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limitation if medical necessary.

6.3.4.2- BH Detoxification Provided for: Substance Use Disorder

The MCO plans cover detoxification for Alcoholism and Substance Abuse, this includes services that are provided for the purpose of completing a medically safe withdrawal from alcohol or substances. Limit: Must be medically necessary, and member must complete the recommended course of treatment. Benefit has no limitation if medical necessary.

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or short term residential or other facility-based services in order to avoid inpatient hospitalization.

6.3.5- BH Emergency services Provided for: Mental Health Substance Use Disorder

This benefit includes emergency services provided in a hospital emergency department for treatment and stabilization of mental health or substance use disorder-related crisis. These services are covered without limitation.

6.3.5.1- BH Crisis Intervention and Stabilization Provided for: Mental Health Substance Use Disorder

This benefit covers unanticipated services rendered in the process of resolving a patient crisis, requiring immediate attention, that without intervention, which could result in the patient requiring a higher level of care. These services can be provided in a variety of settings, including, but not limited to, a via mobile crisis or a crisis stabilization unit. These services are covered without limitation.

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

Members new to the CHIP program can receive medically necessary covered services at the level of care received prior to enrollment for a transition period of up to 60 calendar days. Prenatal individuals who are in their second or third trimester of pregnancy, may continue to see their current provider until the completion of postpartum care.

Per state managed care contracts, MCO’s are required to implement mechanisms to provide an individual needs assessment after enrollment, and at any other time necessary, which includes a screening for special healthcare needs, to identify any ongoing special conditions of the member that requires a course of treatment or regular care monitoring and develop a treatment plan as necessary. For children who are identified as having special healthcare needs, MCO’s are required to establish and maintain procedures and policies to coordinate healthcare services with other agencies or entities such as those dealing with mental health and substance use disorders, public health, home and community-based care, Early Interventions and Supports, local school

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districts, child welfare, IDEA programs, Title V, and families, guardians, caregivers, and advocates.

Additionally, in accordance with Colorado Revised Statute 25.5-5-406(1)(g), members with special healthcare needs may continue to receive services from ancillary, or non-network providers at a level of care received prior to enrollment into an MCO’s plan, for a period of seventy-five calendar days.

6.3.7- BH Care Coordination Provided for: Mental Health Substance Use Disorder

Care coordination services are offered at no cost to CHIP members. Care coordinators is designed to support members navigating and understanding their benefits. CHIP MCO’s are required to provide comprehensive needs assessment and periodic reassessment, and care coordination services to help coordinate with various systems, community organizations, providers, family members advocates, and other necessary individuals and entities to address the complex, multi-factorial needs of each patient. These services are provided without limitation.

6.3.7.1- BH Intensive wraparound Provided for: Mental Health Substance Use Disorder

This benefit is based on an assessment of individual needs, this benefit offers comprehensive wraparound supports and resources to promote, maintain, and/or restore successful community living. These services are provided without limitation.

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

Care transition services are provided to members throughout transitions from institutional and inpatient settings to the community. Transition services can include but are not limited to, assisting members with chronic disease self-management, medication reconciliation, barrier mitigation, and navigation of the healthcare system.

CHIP MCO’s are required to establish policies and procedures to ensure coordination and continuity of care for members transitioning between healthcare setting or different levels of care. Care coordinators and care transition services and are provided to members throughout transitions from inpatient and institutional settings to the community. MCOs are required to implement transition of care procedures in a manner that promotes person and family centered care, assures service accessibility, attention to individual needs, continuity of care, maintenance of health, and independent living. The policies and procedures established by MCO’s are required to be comprehensive to ensure coordination of care between services a member receives from all providers, community-based organizations, and social supports. These services are provided without limitation and without prior authorization.

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

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Benefit includes case managers, available to CHIP members to provide services designed to assist and support a patient to gain access to needed medical, social, education, and other services as well as provide care coordination and care transition services, continuing care, and complex case management. These services are covered without limitation. Case management includes Transitions of Care, Continuing Care, Care Coordination and Complex Case Management. These services are considered routine services and are covered without prior authorization or benefit limits.

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder 6.4- BH Assessment Tools

6.4.1- BH Please specify or describe the tool(s) used by the state or each managed care entity:

ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use Disorders

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders

State-specific criteria (e.g. state law or policies) (please describe) Mental Health Substance Use Disorders

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Other (please describe) Mental Health Substance Use Disorders

No specific criteria or tools are required Mental Health Substance Use Disorders

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The State requires the use of validated, age-appropriate behavioral health assessment tool(s) by CHIP MCO’s. However, the State does not require the use of specific criteria or tools for mental health and substance use disorders, to allow for appropriate assessment, treatment, and intervention, as necessary.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools to determine possible treatments or plans of care, providing education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

The State requires that CHIP MCO’s provide an individual needs assessment at the time of enrollment, and at any other necessary time, inclusive of, but not limited to, assessment for behavioral health needs. MCO’s are required to develop an individual treatment plan, as necessary, based on the needs assessment and to avoid duplication of treatment, and are required to establish treatment objectives, treatment follow-up, the monitoring of outcomes and a process to ensure that treatment plans are revised as necessary. MCO contracts also require needs assessment findings to inform member outreach and care coordination. The State allows for flexibility in use of behavioral health assessment tools to allow for appropriate assessment, treatment, and intervention, as necessary. The MCO’s are responsible for conducting trainings and communications to providers to utilize the required assessment tools and follow-up for compliance.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex, or serious conditions.

(spa)(co-21-0034)(approval-package)Colorado CHIP SPA CO-21-0034: Approval Package (approved August 30, 2021, effective July 1, 2019)#

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Page 2 — Ms. Tracy Johnson

Sincerely, /Signed by Amy Lutzky/

Amy Lutzky Deputy Director

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(spa)(co-22-0036)(approval-package)Colorado CHIP SPA CO-22-0036: Approval Package (approved September 1, 2022, effective March 11, 2021)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

September 1, 2022

Cristen Bates Interim Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan Plus (CHP+) 1570 Grant Street Denver, CO 80203-1818

Dear Ms. Bates:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), CO-22- 0036, submitted on July 14, 2022, has been approved. Through this SPA, Colorado has demonstrated compliance with the American Rescue Plan Act of 2021 (ARP). This SPA has an effective date of March 11, 2021 and extends through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period, as described in section 1135(g)(1)(B) of the Social Security Act (the Act).

Section 9821 of the ARP amended sections 2103(c)(11)(B) and 2103(e)(2) of the Act to mandate coverage of COVID-19 testing, treatment, and vaccines and their administration without cost- sharing or amount, duration, or scope limitations. Sections 2103(c)(11)(B) and 2103(e)(2) of the Act also require states to cover, without cost sharing, the treatment of conditions that may seriously complicate COVID-19 treatment, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19. The state provided the necessary assurances to demonstrate compliance with the ARP in accordance with the requirements of sections 2103(c)(11)(B) and 2103(e)(2) of the Act.

Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 457.65 that the state submit SPAs that are related to the COVID-19 public health emergency by the end of the state fiscal year in which they take effect. CMS is allowing states that submit SPAs after the last day of the state fiscal year to have an effective date in the prior state fiscal year, but no earlier than the effective date of the public health emergency. Colorado requested a waiver to obtain an earlier effective date of March 11, 2021. This letter approves Colorado’s request for a March 11, 2021 effective date.

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Page 2 – Ms. Cristen Bates

Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Amy Lutzky Deputy Director On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services

cc: Courtney Miller, Director, Medicaid and CHIP Operations Group

Jackie Glaze, Deputy Director, Medicaid and CHIP Operations Group /Signed by Amy Lutzky/

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1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date. SPA #36 Date Amendment #36 Submitted: July 14, 2022 Date Amendment #36 Approved: XXXXXX Date Amendment #36 Effective: 03/11/2021

Effective 03/11/2021, Colorado added provisions to demonstrate compliance with the American Rescue Plan Act provisions that require states to cover treatment (including treatment of a condition that may seriously complicate COVID-19 treatment), testing, and vaccinations for COVID-19 without cost sharing in CHIP.

The State included consultation on this SPA in the tribal consultation log dated April 13, 2022. A copy of the relevant page of the consultation log is attached. 6.2.28 Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

Effective March 11, 2021 and through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period described in section 1135(g)(1)(B) of the Act, and for all populations covered in the CHIP state child health plan:

COVID-19 Vaccine: • The state provides coverage of COVID-19 vaccines and their administration, in accordance with the requirements of section 2103(c)(11)(A) of the Act.

COVID-19 Testing: • The state provides coverage of COVID-19 testing, in accordance with the requirements of section 2103(c)(11)(B) of the Act. • The state assures that coverage of COVID-19 testing is consistent with the Centers for Disease Control and Prevention (CDC) definitions of diagnostic and screening testing for COVID-19 and its recommendations for who should receive diagnostic and screening tests for COVID-19.

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• The state assures that coverage includes all types of FDA authorized COVID-19 tests.

COVID-19 Treatment: • The state assures that the following coverage of treatments for COVID-19 are provided without amount, duration, or scope limitations, in accordance with requirements of section 2103(c)(11)(B) of the Act: o The state provides coverage of treatments for COVID-19 including specialized equipment and therapies (including preventive therapies); o The state provides coverage of any non-pharmacological item or service described in section 2110(a) of the Act, that is medically necessary for treatment of COVID-19; and o The state provides coverage of any drug or biological that is approved (or licensed) by the U.S. Food & Drug Administration (FDA) or authorized by the FDA under an Emergency Use Authorization (EUA) to treat or prevent COVID-19, consistent with the applicable authorizations. Coverage for a Condition That May Seriously Complicate the Treatment of COVID-19: • The state provides coverage for treatment of a condition that may seriously complicate COVID-19 treatment without amount, duration, or scope limitations, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19, in accordance with the requirements of section 2103(c)(11)(B) of the Act.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge by age and income (if applicable) and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.3. Coinsurance or copayments

COVID-19 Vaccine: • The state provides coverage of COVID-19 vaccines and their administration without cost sharing, in accordance with the requirements of section 2103(c)(11)(A) and 2013(e)(2) of the Act.

COVID-19 Testing:

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• The state provides coverage of COVID-19 testing without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

COVID-19 Treatment: • The state provides coverage of COVID-19-related treatments without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

Coverage for a Condition That May Seriously Complicate the Treatment of COVID-19: • The state provides coverage for treatment of a condition that may seriously complicate COVID-19 treatment without cost sharing, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act. This coverage includes items and services, including drugs, that were covered by the state as of March 11, 2021.

(spa)(co-22-0039)(approval-package)Colorado CHIP SPA CO-22-0039: Approval Package (approved March 14, 2023, effective July 1, 2022)#

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Page 2 – Ms. Cristen Bates

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Sarah deLone Director

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Page 1 of 2 CHIP Eligibility State Name: Colorado OMB Control Number: 0938-1148 Transmittal Number: CO - 22 - 0039 Separate Child Health Insurance Program General Eligibility - Continuous Eligibility CS27 2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926; 2107(e)(1)(J) and 1902(e)(16) of the SSA Mandatory 12-Month Postpartum Continuous Eligibility in CHIP for States Electing This Option in Medicaid At state option in Medicaid, states may elect to provide continuous eligibility for an individual’s 12-month postpartum period consistent with section 1902(e)(16) of the SSA. If elected under Medicaid, states are required to provide the same continuous eligibility and extended postpartum period for pregnant individuals in its separate CHIP. A separate CHIP cannot implement this option if not also elected under the Medicaid state plan. State elected the Medicaid option to provide continuous eligibility through the 12- month postpartum period Yes The 12-month postpartum continuous eligibility applies for the period beginning on the effective date of this SPA (no earlier than April 1, 2022) and is available through March 31, 2027. The state assures the extended postpartum period available to pregnant targeted low-income children or targeted low- income pregnant women under section 2107(e)(1)(J) of the SSA is provided consistent with the following provisions: Individuals who, while pregnant, were eligible and received services under the state child health plan or waiver shall remain eligible throughout the duration of the pregnancy (including any period of retroactive eligibility) and the 12- month postpartum period, beginning on the day the pregnancy ends and ending on the last day of the 12th month consistent with paragraphs (5) and (16) of section 1902(e) of the SSA Continuous eligibility is provided to targeted low income children who are pregnant or targeted low-income pregnant women (if applicable) who are eligible for and enrolled under the state child health plan through the end of the 12-month postpartum period who would otherwise lose eligibility because of a change in circumstances, unless: The individual or representative requests voluntary disenrollment. The individual is no longer a resident of the state. The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to the individual. The individual dies. Unlike continuous eligibility for children, states providing the 12-month postpartum period may not end an individual’s continuous eligibility due to non-payment of premiums or becoming eligible for Medicaid. Consistent with section 2107(e)(1)(J) of the SSA, the state assures that continuous eligibility is provided through an individual’s pregnancy and 12-month postpartum period regardless of non-payment of premiums, or an individual becoming eligible for Medicaid. Benefits provided during the 12-month postpartum period must be the same scope of comprehensive services consistent with the benefit package elected by the state under section 2103(a) of the SSA that is available to targeted low income children and/or targeted low-income pregnant women and may include additional benefits as described in Section 6 of the CHIP state plan.

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Page 2 of 2 CHIP Eligibility Optional Continuous Eligibility for Children The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier. The CHIP Agency elects to provide continuous eligibility to children under this provision. Yes For children up to age 19 For children up to age The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends: At the end of the months continuous eligibility period. 12 The state assures that a child’s eligibility is not terminated during a continuous eligibility period, regardless of any changes in circumstances, unless: The child attains the age specified by the state Agency or age 19. The child or child's representative requests voluntary disenrollment. The child is no longer a resident of the state. The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative. The child dies. The child becomes eligible for Medicaid There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the 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 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20220204

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CO CHP 22-0039 addendum to CS27 form: Additional Information: The state provides the 12-month postpartum extension to lawfully residing immigrants. Renewal processing for individuals eligible for extended postpartum coverage includes the completion of an ex-parte review at the end of a pregnant member's 12-month postpartum period. This review verifies all available information on file and makes an eligibility determination without requesting additional information if possible. Approval notices are then sent according to the CHIP State Plan. In the event the information on file is insufficient to render a decision, a redetermination form is issued to the household at least 30 days prior to the end of the eligibility period. This form is pre-populated and may be returned by the member through varied submission modalities. The state utilized and continues to use its traditional communication pathways to publicize this benefit change and raise awareness, which includes its website, social media campaigns, partnerships with new organizations and extensive stakeholder outreach.

(spa)(co-23-0039)(approval-package)Colorado CHIP SPA CO-23-0039: Approval Package (approved October 30, 2023, effective July 1, 2023)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

October 30, 2023

Adela Flores-Brennan Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan Plus (CHP+) 1570 Grant Street Denver, CO 80203-1818

Dear Adela Flores-Brennan:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) CO- 23-0039, submitted on August 2, 2023, has been approved. Through this SPA, Colorado permanently removes enrollment fees for all CHIP beneficiaries. CO-23-0039 has an effective date of July 1, 2023.

Your title XXI project officer is Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: 410-786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

If you have any questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Sarah deLone

Director

/Signed by Sarah deLone/

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SPA number: CO-23-0039

Purpose of SPA: To clarify that Colorado does not collect enrollment fees or premiums in the CHIP program.

Date Amendment #39 submitted: 08-02-2023 Proposed effective date: 07-01-2023

The State included consultation on this SPA in the tribal consultation log dated August 19, 2022. A copy of the relevant page of the consultation log is attached.

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

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Both initial eligibility and annual renewal eligibility for CHP+ are determined either at the main office or at a decentralized eligibility site.

Applications may be received by mail or by Fax at the central office or during face-to-face interviews at the decentralized sites. Applicants may also complete applications online or drop off paper applications in person during central office business hours.

The State has developed and implemented an eligibility, enrollment, and application tracking system for CHP+. The system uses a sophisticated business rules engine and state-of-the-art secure Internet technologies to reduce the overall cost of administration and increase the speed and accuracy of screening for Medicaid eligibility, determining eligibility for CHP+ and enrolling children into the program.

Current employment income, self-employment income and cash income from other sources reported are used to qualify families with employment or retirement income. Verification of earned income is verified through the Income and Eligibility Verification System (IEVS), which extracts wage information reported by employers to the Colorado Department of Labor and Employment.

ELIGIBILITY DETERMINATION AND RENEWAL

Redetermination of Eligibility

Persons enrolled in CHP+ are enrolled for a period of twelve months. Renewal letters and packets are mailed to families at least 45 days before the day their CHP+ coverage terminates. Reminder letters are mailed to the family 30 days before the end-of-coverage date. Families are encouraged to return their completed renewal application at least 30 days prior to termination to allow continuity of care through their HMO. If the family does not resubmit a complete application by the ending date of coverage, the person’s eligibility may still be renewed. The only penalty is interrupted coverage.

At redetermination, renewal requires the same financial documentation as was required at the time of the family’s original application. A family will be fully processed for eligibility at each renewal period.

Enrollment in Health Plans All CHIP eligible children and prenatal individuals are enrolled into managed care organizations. At the time of eligibility determination and annually at the time of redetermination, members are notified which MCO they have been passively enrolled into. If the member wants to change MCO enrollment, members who live in service areas with multiple MCOs participating will have 90 days from the effective date of MCO enrollment at the time of eligibility determination and redetermination to contact the Department or its designee in order to select a different MCO. Once a member has selected an MCO or upon expiration of the 90-day period, the enrollee shall remain enrolled in that MCO until the time of redetermination.

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

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4.3.1 Limitation on Enrollment. Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(4)) (42CFR, 457.305(b))

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

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge by age and income (if applicable) and the service for which the charge is imposed or time period for the charge, as appropriate (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c)).

8.2.1. Premiums: Colorado does not impose premiums or enrollment fees as of July 1, 2022.

8.2.2. Deductibles: None

8.2.3. Coinsurance or copayments:

American Indian/Alaska Natives are exempt from co-payments.

The following copayments shall be due for enrollees at the time of service:

A. For families with income, at the time of eligibility determination, less than 101% of the federal poverty level, all copayments shall be waived, except for emergency and urgent/after hours care, which shall be three dollars per use (co-pay is waived if client is admitted to the hospital).

B. For families with income, at the time of eligibility determination, between 101% and 155% of the federal poverty level, the copayment is: 1. Two dollars per office visit; 2. Two dollars per outpatient mental health or substance abuse visit; 3. One dollar per prescription; 4. Two dollars per physical therapy, occupational therapy, or speech therapy visit; 5. Two dollars per vision visit; 6. Three dollars per use of emergency care and urgent/after hours care. (Co-pay is waived if client is admitted to the hospital.) 7. Two dollars per trip for emergency transport/ambulance. 8. Two dollars per inpatient hospital visit. 9. Two dollars per inpatient hospital stay, for physician services in the hospital. 10. Two dollars per outpatient hospital or ambulatory surgery center visit.

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C. For families with income, at the time of eligibility determination, between 156% and 212% of federal poverty level, the copayment is: 1. Five dollars per office visit; 2. Five dollars per outpatient mental health or substance abuse visit; 3. Three dollars per generic prescription; 4. Ten dollars per brand name prescription; 5. Five dollars per physical therapy, occupational therapy, or speech therapy visit; 6. Five dollars per vision visit; 7. Twenty dollars per use of urgent/after hours care. 8. Thirty dollars per use of emergency care (co-pay is waived if client is admitted to the hospital.) 9. Fifteen dollars per trip for emergency transport/ambulance. 10. Twenty dollars per inpatient hospital visit. 11. Five dollars per inpatient hospital stay for physician services in the hospital. 12. Five dollars per outpatient hospital or ambulatory surgery center visit. 13. Five dollars per date of service for laboratory and imaging services.

D. For families with income, at the time of eligibility determination, between 213% and 259% of federal poverty level, the copayment is: 1. Ten dollars per office visit; 2. Ten dollars per outpatient mental health or substance abuse visit; 3. Five dollars per generic prescription; 4. Fifteen dollars per brand name prescription; 5. Ten dollars per physical therapy, occupational therapy, or speech therapy visit; 6. Ten dollars per vision visit; 7. Thirty dollars per use of urgent/after hours care. 8. Fifty dollars per use of emergency care (co-pay is waived if client is admitted to the hospital.) 9. Twenty-five dollars per trip for emergency transport/ambulance. 10. Fifty dollars per inpatient hospital visit. 11. Ten dollars per inpatient hospital stay for physician services in the hospital. 12. Ten dollars per outpatient hospital or ambulatory surgery center visit. 13. Ten dollars per date of service for laboratory and imaging services.

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COVID-19 Testing: • The state provides coverage of COVID-19 testing without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

COVID-19 Treatment: • The state provides coverage of COVID-19-related treatments without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

8.3 Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(A)) (42CFR 457.505(b))

The Department worked closely with CHP+ stakeholders before putting forth this proposal to increase copayments. This change has been adopted into rule and was subject to the public rulemaking process. Stakeholders testified in favor of this change because it was a more acceptable alternative to the one put forth by the State Legislature, which would have increased cost sharing over 1000%. After rule adoption, the rules are published in the Colorado Register and posted to the Secretary of State website.

The Department gives CHP+ members and applicants a chart that describes plan options, and copayments based on income and family size.

8.7 Provide a description of the consequences for an enrollee or applicant who does not pay a charge (42CFR 457.570 and 457.505(c)).

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Guidance: Section 8.8.1is based on Section 2101(a) of the Act provides that the purpose of title XXI is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children.

(spa)(co-24-0041)(approval-package)Colorado CHIP SPA CO-24-0041: Approval Package (approved December 18, 2025, effective October 30, 2023)#

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Table of Contents

State/Territory Name: Colorado

State Plan Amendment (SPA) #: CO-24-0041

This file contains the following documents in the order listed:

1) Approval Letter 2) State Plan Pages

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18 SPA #39 Date Amendment #39 Submitted: August 2, 2023 Date Amendment #39 Approved: October 30, 2023 Date Amendment #39 Effective: 07/01/2023 Date Amendment #39 Implemented: 07/01/2023 Effective July 1, 2023, Colorado clarifies that the state does not collect enrollment fees or premiums in its CHIP program. SPA #40 Date Amendment #40 Submitted: November 16, 2024 Date Amendment #40 Approved: January 15, 2025 Date Amendment #40 Effective: January 1, 2025 Date Amendment #40 Implemented: January 1, 2025 SPA CO-24-0040-0002: This SPA implements the From Conception to End of Pregnancy (FCEP) population in CHIP, effective January 1, 2025, and revising the CS27 to reflect FCEP are provided with continuous eligibility. SPA CO-24-0040-A: This SPA updates the CHIP state plan regarding the FCEP population and implements a new health services initiative to provide postpartum care to mothers whose newborns were previously eligible for FCEP in CHIP. SPA #41 Date Amendment #41 Submitted: Date Amendment #41 Approved: Date Amendment #41 Effective: Date Amendment #41 Implemented: June 19, 2024 December 18, 2025 October 30, 2023 October 30, 2023 Through this SPA, the state removes outdated CHIP state plan language to ensure that the plan reflects the state’s approved program policies.

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The State included consultation on this SPA in the tribal consultation log dated 08/19/2022September 30, 2023. A copy of the relevant page of the consultation log is attached.

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

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

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

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

See Attachment 1 for a description of children’s insurance status by income and race and ethnicity.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.1005.

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4.1.2  Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group: CHP+ is available to children 0 through 18 years of age with family income at or below 2650% FPL. 4.1.2.1-PC Age: through birth (SHO #02-004, issued November 12, 2002)

4.1.3  Income of each separate eligibility group (if applicable): To be eligible, a child must be from a family whose annual income is at or below 2650% of the federal poverty level. Family size and income criteria are described in Attachment 2. 4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through

% of the FPL (SHO #02-004, issued November 12, 2002)

4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources): 4.1.5  Residency (so long as residency requirement is not based on length of time in state): A resident is anyone who is: 1) a U.S. citizen; or 2) a documented legal immigrant who has had an Alien Registration Card for 5 years or more and 3) a resident of Colorado. The state accepts self- declaration of residency. 4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility): No child is denied eligibility based on disability status. If the child receives SSI and is eligible for Medicaid, the child will be denied coverage because the child is eligible for Medicaid, not for reasons of disability status. 4.1.7  Access to or coverage under other health coverage: Both the application and the separate "Insurance Form" ask families questions about other insurance coverage. The plan administration seeks information about all other access to health care coverage, both public and private, on the application form before the child is enrolled in the plan and from providers once the child is determined eligible for the plan. A child will be found ineligible if the child: 1) is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) is a member of a family that is eligible for health benefits coverage under a State health benefits plan based on a family members employment with a public agency in the State; or 4) has had coverage under an employer plan with at least a 50% employer contribution during the three months prior to application. The Health Care Program for Children with Special Needs is not considered a private health plan and children covered under this plan may still be covered by CHP+.

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If the State finds that a child enrolled in CHP+ is retroactively eligible for Medicaid, the State will notify the family that the child will be disenrolled from CHP+ and enrolled into Medicaid in 10 days. The State may choose to enroll the child into Medicaid sooner than 10 days if the Medicaid benefit package offers necessary services that the CHP+ plan does not cover.

4.1.8  Duration of eligibility, not to exceed 12 months: Once a child has been accepted, he or she is continuously eligible for one year from the first day of the month of application unless the child moves from the state, turns 19 years old, or becomes eligible for or enrolled in Medicaid., or other private insurance. 4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

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

4.1.9.1 required. States should specify whether Social Security Numbers (SSN) are Social Security Numbers are not required.

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

4.1.9.2 Continuous eligibility. Children ages 0-18 may be continuously eligible. Once a child has been determined eligible, the child is continuously eligible for one year from the first day of the month of application unless the child moves from the state, turns 19 years old, or becomes eligible for or enrolled in Medicaid., or private health insurance.

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

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described in 42 CFR 457.342(a) cross-referencing 435.926(d).

Both initial eligibility and annual renewal eligibility for CHP+ are determined either at the main office or at a decentralized eligibility site.

Applications may be received by mail or by Fax at the central office or during face-to-face interviews at the decentralized sites. Applicants may also complete applications online, or drop off paper applications in person during central office business hours.

The State has developed and implemented an eligibility, enrollment and application tracking system for CHP+. The system uses a sophisticated business rules engine and state-of-the-art secure Internet technologies to reduce the overall cost of administration and increase the speed and accuracy of screening for Medicaid eligibility, determining eligibility for CHP+ and enrolling children into the program.

ELIGIBILITY DETERMINATION AND RENEWAL

Redetermination of Eligibility

Once the State has re-determined eligibility, a letter is sent to households that are above 150% and up to and including 2650% of the FPL to notify them that they owe an enrollment fee and have 30 days from the date of re determination to submit an enrollment fee. Coverage begins when the State receives the enrollment fee. If the enrollment fee is not submitted by the end of the 30 day period, the client’s coverage will end at the end of the redetermination period. Once the client pays the enrollment fee, coverage will resume.

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During a state or federally-declared disaster and at the state’s discretion, the state may implement the following changes to its enrollment and redetermination policies for beneficiaries living and/or working in state or federally-declared

disaster areas: • The state may temporarily use the regulatory timeliness exception for timely processing of CHIP applications under 42 CFR 457.340(d)(1). • The state may temporarily use the regulatory timeliness exception for timely processing of CHIP renewals under 42 CFR 457.340(d)(1).

Enrollment in Health Plans

All CHIP eligible children and prenatal individuals are enrolled into managed care organizations. At the time of eligibility determination and annually at the time of redetermination, members are notified which MCO they have been passively enrolled into. If the member wants to change MCO enrollment, members who live in service areas with multiple MCOs participating will have 90 days from the effective date of MCO enrollment at the time of eligibility determination and redetermination to contact the Department or its designee in order to select a different MCO. Once a member has selected an MCO or upon expiration of the 90-day period, the enrollee shall remain enrolled in that MCO until the time of redetermination.

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

The applicant must pay the annual enrollment fee in order for the child(ren) to enroll in CHP+. Once the State has determined eligibility (or automatic redetermination has occurred), a letter is sent to households that are above 150% and up to and including 2650% of the FPL to notify them. As of July 1, 2022 CHP+ does not require an enrollment fee. that they owe an enrollment fee and have 30 days from the date of determination (or redetermination) to submit an enrollment fee. Coverage begins when the State receives the enrollment fee. If the enrollment fee is not submitted by the end of the 30 day period, the client will be denied for non payment and will have to re-apply.

(spa)(co-24-0042)(approval-package)Colorado CHIP SPA CO-24-0042: Approval Package (approved July 16, 2024, effective October 1, 2023)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

July 16, 2024

Adela Flores-Brennan Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan Plus (CHP+) 1570 Grant Street Denver, CO 80203-1818

Dear Director Adela Flores-Brennan:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) CO-24-0042, submitted on June 25, 2024, has been approved. Through this SPA, Colorado has demonstrated compliance with both the Inflation Reduction Act (IRA) Section 11405(b)(1) and the longstanding requirement in regulations at 42 CFR § 457.410(b)(2) and 457.520(b)(4) to cover age-appropriate vaccines. This SPA has an effective date of October 1, 2023.

Section 11405(b)(1) of the IRA requires states with separate CHIPs that include coverage for adults to provide coverage and payment for approved adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), and their administration, without cost sharing. Current regulations at 42 CFR § 457.410(b)(2) and 457.520(b)(4) require states to cover age-appropriate vaccines and their administration in accordance with the recommendations of the ACIP without cost sharing. The state provided the necessary assurances to demonstrate compliance with both requirements.

Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Sarah deLone Director /Signed by Sarah deLone/

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SPA number: CO-24-0042

Purpose of SPA: This CHP SPA will demonstrate compliance with statutory amendments made by Section 11405(b)(1) of the IRA, which requires separate CHIPs to provide coverage and payment for approved vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration, without cost sharing.

Proposed effective date: 10-01-2023 Proposed implementation date: 10-01-2023

The State included consultation on this SPA in the tribal consultation log dated May 23, 2024. A copy of the relevant page of the consultation log is attached.

6.5-Vaccine coverages

Guidance: States are required to provide coverage for age-appropriate vaccines and their administration, without cost sharing. States that elect to cover children under the State plan (indicated in Section 4.1) should check box 6.5.1 States that elect to cover pregnant individuals under the State plan should also check box 6.5.2. States that elect to cover the from-conception-to-end-of-pregnancy population (previously referred to as the “unborn”) option under the State plan should also check box 6.5.3.

6.5.1- Vaccine coverage for targeted-low-income children.  The State provides coverage for age-appropriate vaccines and their administration in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP), without cost sharing. (Section 2103(c)(1)(D)) (42CFR 457.410(b)(2) and 457.520(b)(4)).

6.5.2- Vaccine coverage for targeted-low-income pregnant individuals.  The State provides coverage for approved adult vaccines recommended by the ACIP, and their administration, without cost sharing. (SHO # 23-003, issued June 27, 2023); (Section 2103(c)(12)).

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6.5.3-Vaccine coverage for from-conception-to-end-of-pregnancy population option. state provides coverage for age appropriate (child or adult) vaccines and their administration in accordance with the recommendations of the ACIP, without cost- sharing, to benefit the unborn child.

The

(spa)(co-25-0044)(approval-package)Colorado CHIP SPA CO-25-0044: Approval Package (approved April 6, 2026, effective January 1, 2025)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group April 6, 2026 Adela Flores-Brennan Medicaid Director Colorado Department of Health Care Policy and Financing Medicaid & Child Health Plan Plus (CHP+) 1570 Grant Street Denver, CO 80203-1818 Dear Director Adela Flores-Brennan: This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA), CO-25-0044, approved on April 6, 2026, with an effective date of January 1, 2025. Through this SPA, the state provides coverage of screenings, diagnostic services, and case management services (“pre-release services”) otherwise available under the CHIP state plan to targeted low-income children who are within a 30-day period prior to their release from a carceral facility. Additionally, Colorado modifies the state’s treatment of children who are inmates of a public institution when determining CHIP eligibility. The approval under this SPA, CO-25- 0044, to provide pre-release services will sunset on December 31, 2026, because Colorado needs to complete the outstanding actions listed below in order to be in full compliance with section 2102(d) of the Social Security Act (the Act). We appreciate the state’s efforts to undertake these actions to comply with section 2102(d) of the Act. 1. Carceral Facility Readiness: Colorado expects all facilities to standardize eligibility- related practices across facilities to support suspension and reinstatement of benefits. The state will also complete readiness assessments for the provision of pre-release services with all carceral facilities. Colorado expects state carceral facilities to be ready before county facilities. 2. System Updates: The state is completing system updates to its Medicaid Management Information System (MMIS) to create a limited benefit plan. Individuals who are determined eligible for Medicaid or CHIP during incarceration will be placed on the limited benefit plan, and Colorado will add the allowable reentry services to the limited benefit plan. Incarcerated members will remain on this plan until release through the state’s approved reentry 1115 demonstration, to ensure that only the allowable set of services is provided during incarceration. Providers will be able to bill for pre-release services beginning on the date each facility passes their readiness assessment. 3. Development of Partner and Public Education Materials: The state will work with its managed care entities and community providers to make educational materials available to members and ensure that partners understand program requirements and benefits. Colorado will leverage a broad range of communication strategies to ensure outreach to community-based providers and other stakeholders that have not traditionally provided or billed for CHIP services. Colorado will work with key stakeholders to refine messaging and communication protocols to improve engagement

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Page 2 – Director Flores-Brennan

with incarcerated members regarding CHIP coverage and services.

Once these outstanding actions have been completed, the state should submit a SPA to remove the sunset date for the pre-release services provisions from the CHIP state plan. CMS is available to provide technical assistance through this process to achieve timely completion of these remaining actions and to ensure compliance with section 2102(d) of the Act.

If you have questions about this letter, please contact Kristin Pacek, your CHIP Project Officer, at 410-786-5480 or kristin.pacek@cms.hhs.gov. She will also be reaching out to the state for a status update on these action items prior to this SPA’s sunset date.

Sincerely,

Mary Beth Hance

Director

Division of State Coverage Programs /Signed by Mary Beth Hance/

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SPA #44

Date Amendment #44 Submitted: June 16, 2025 Date Amendment #44 Approved: Date Amendment #44 Effective: January 1, 2025 Date Amendment #44 Implemented: Adds mandatory coverage, reimbursement, and attestations, for juveniles in a carceral setting, in accordance with Section 5121 of the Consolidated Appropriations Act of 2023. 1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

The State included consultation on this SPA in the tribal consultation log dated July 18, 2024April 30, 2025. A copy of the relevant page of the consultation log is attached.

[INSERTED AFTER TITLE “Superseding Pages of MAGI CHIP State Plan Material State: Colorado” at the end of fourth page of the table, which begins on page 24 of the full CHIP State Plan] Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) July 1, 2015 CO-16-0025 Eligibility Processing CS24 Eligibility Process Supersedes the current section 4.3 and 4.4 Approval Date: 09/06/17 Effective Date: January 1, 2016 CO-17-0026 Approval Date: 10/05/17 Effective Date: July 1, 2017 Non- Financial Eligibility CS15 MAGI- Based Income Methodolog ies Section 4.3: Supersede information on income eligibility and methods in CO- 13- 0015.

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3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. ☐ No, the State does not use a managed care delivery system for any CHIP populations. • Yes, the State uses a managed care delivery system for all CHIP populations. ☐ Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Effective January 1, 2025, Colorado’s From Conception to End of Pregnancy (FCEP) authority provides coverage for uninsured pregnant people with income up to and including 260% of the federal poverty level who are not otherwise eligible for Health First Colorado or CHP+. The FCEP population will receive the same CO-24-0040- 0002

Approval Date: 11/15/25 Effective Date: January 1, 2025 Separate Child Health Insurance Program Eligibility and General Eligibility CS9

CS27

Separate Child Health Insurance Program Eligibility – Coverage From Conception to Birth

Separate Child Health Insurance Program General Eligibility – Continuous Eligibility

Supersedes Section 4.1.2.1-PC and 4.19

Supersedes version approved in SPA 22- 0039.

CO-25-0044

Approval Date: Effective Date: January 1, 2025 Incarcerat ed CHIP Beneficia ries

CS31

Targeted Low-Income Children Who Become Incarcerated

Children Determined Eligible for CHIP While Incarcerated

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services through managed care and fee-for-service as Health First Colorado (Colorado Medicaid) and CHP+ members. Additionally, current and new enrollees in CHP+ who are incarcerated are excluded from managed care until the date of discharge from the carceral facility. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

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

8.2.3 Coinsurance or copayments: American Indian/Alaska Natives are exempt from co-payment and annual

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enrollment fees.

The following copayments shall be due for enrollees at the time of service:

B. For families with income, at the time of eligibility determination, between 101% and 155% of the federal poverty level, the copayment is: 1. Two dollars per office visit; 2. Two dollars per outpatient mental health or substance abuse visit; 3. One dollar per prescription; 4. Two dollars per physical therapy, occupational therapy or speech therapy visit; 5. Two dollars per vision visit; 6. Three dollars per use of emergency care and urgent/after hours care. (Co-pay is waived if client is admitted to the hospital.) 7. Two dollars per trip for emergency transport/ambulance. 8. Two dollars per inpatient hospital visit. 9. Two dollars per inpatient hospital stay, for physician services in the hospital. 10. Two dollars per outpatient hospital or ambulatory surgery center visit.

C. For families with income, at the time of eligibility determination, between 156% and 212% of federal poverty level, the copayment is: 1. Five dollars per office visit; 2. Five dollars per outpatient mental health or substance abuse visit; 3. Three dollars per generic prescription; 4. Ten dollars per brand name prescription; 5. Five dollars per physical therapy, occupational therapy or speech therapy visit; 6. Five dollars per vision visit; 7. Twenty dollars per use of urgent/after hours care. 8. Thirty dollars per use of emergency care (co-pay is waived if client is admitted to the hospital.) 9. Fifteen dollars per trip for emergency transport/ambulance. 10. Twenty dollars per inpatient hospital visit. 11. Five dollars per inpatient hospital stay for physician services in the hospital. 12. Five dollars per outpatient hospital or ambulatory surgery center visit. 13. Five dollars per date of service for laboratory and imaging services.

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5. Ten dollars per physical therapy, occupational therapy or speech therapy visit; 6. Ten dollars per vision visit; 7. Thirty dollars per use of urgent/after hours care. 8. Fifty dollars per use of emergency care (co-pay is waived if client is admitted to the hospital.) 9. Twenty-five dollars per trip for emergency transport/ambulance. 10. Fifty dollars per inpatient hospital visit. 11. Ten dollars per inpatient hospital stay for physician services in the hospital. 12. Ten dollars per outpatient hospital or ambulatory surgery center visit. 13. Ten dollars per date of service for laboratory and imaging services.

During a state or federally-declared disaster and at the state’s discretion, the state may waive copayments for CHIP beneficiaries who reside and/or work in state or federally-declared disaster areas.

COVID-19 Testing: • The state provides coverage of COVID-19 testing without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

COVID-19 Treatment: • The state provides coverage of COVID-19-related treatments without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

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For eligible incarcerated youth, copays are not required for pre-release services provided consistent with section 2102(d)(2) of the Act.

6.2.20.  Case management services (Section 2110(a)(20)) • Targeted Case Management (TCM) services are available for eligible juveniles who are inmates of a public institution, as defined in sections 2102(d) and 2110(b)(7) of the Act, who are within 90 days of their scheduled date of release from a public institution, and for 30 days following release. Colorado has an approved Section 1115 waiver to offer reentry services within 90 days of release that meet the minimum requirements of Section 5121 of the Consolidated Appropriations Act of 2023. Inmates of a public institution who are not incarcerated at a facility participating in the approved Section 1115 demonstration, will receive these services within 30 days prior to their release.

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Page 1 of 2 CHIP Eligibility V.20240322 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State Name: Colorado OMB Control Number: 0938-1148 Transmittal Number: CO - 25 - 0044 Incarcerated CHIP Beneficiaries CS31 2102(d) and 2110(b)(7) of the SSA Targeted Low-Income Children Who Become Incarcerated The state assures that it does not terminate eligibility for children enrolled in a separate CHIP because the child is an inmate of a public institution. States may either suspend CHIP coverage or continue to provide CHIP state plan (or waiver of such plan) services otherwise not covered by the carceral facility to children who are incarcerated. States that elect to suspend CHIP coverage for the duration of a child’s incarceration may implement a benefits or eligibility suspension. The state elects to suspend CHIP coverage for the duration of a child’s incarceration Yes If yes, then check an option below: Benefits suspension Eligibility suspension The state assures that it redetermines eligibility for any child prior to their release if it has been longer than 12 months since the child’s last redetermination and restores coverage for child health assistance to eligible children upon their release. Within the 30 days prior to release (or within one week of release, or as soon as practicable after release), the state assures that it provides eligible children with any screenings, diagnostic services, or case management services that would otherwise be available to children under the CHIP state plan (or waiver of such plan). Additional information regarding implementation of mandatory provisions of section 5121 of the Consolidated Appropriations Act, 2023 (CAA, 2023), including providing screenings, diagnostic services, or case management services: The state may determine that it is not feasible to provide the required services during the prerelease period in certain carceral facilities (e.g., identified local jails, youth correctional facilities, and state prisons) and/or certain circumstances (e.g., unexpected release or short-term stays). The state will maintain clear documentation in its internal operational plan regarding each facility and/or circumstances where the state determines that it is not Under section 5122 of the CAA, 2023, states may consider otherwise eligible children who are inmates pending disposition of charges as eligible for CHIP and provide all services covered under the CHIP state plan. The state elects to provide all CHIP state plan benefits (or waiver of such plan) to eligible children who are inmates pending disposition of charges.

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Page 2 of 2 CHIP Eligibility V.20240322 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Children Determined Eligible for CHIP While Incarcerated

(spa)(co-26-0045-chip)(approval-package)Colorado CHIP SPA CO-26-0045-CHIP: Approval Package (approved July 23, 2026, effective January 1, 2026)#

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Page 2 – Director Adela Flores-Brennan

The state shall ensure that the available title XXI administrative funding is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of these HSIs to the administration of the CHIP state plan. The state shall report annually to CMS the expenditures funded by these HSIs for each federal fiscal year.

Your Project Officer is Kristin Pacek. She is available to answer your questions concerning this amendment and other CHIP-related matters at kristin.pacek@cms.hhs.gov.

If you have additional questions, please contact Mary Beth Hance, Director, Division of State Coverage Programs at (410) 786-4299. We look forward to continuing to work with you and your staff.

Sincerely,

Jessica Stephens Acting Director /Signed by Jessica Stephens/

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SPA CHP CO-26-0045 Impacted Pages

SPA #45 Date Amendment #45 Submitted: May 20, 2026 Date Amendment #45 Approved: Date Amendment #45 Effective: January 1, 2026 Date Amendment #45 Implemented:

This SPA includes 4 community HSI programs to improve the lives of targeted low-income children in Colorado. Initiatives selected based on extensive stakeholder input include Home Visting, Safety Supplies, Food Pantries, and Reach out and Read to be implemented upon approval of the amendment.

Superseding Pages of MAGI CHIP State Plan Material State of Colorado

The State included consultation on this SPA in the tribal consultation log dated April 30May 29, 2025. A copy of the relevant page of the consultation log is attached. 2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10).

Postpartum Coverage To be implemented January 1, 2025, Colorado will use CHIP funds, within the 10 percent federal administrative expenditures cap allowed for states, to support the 12-month postpartum period of members per Colorado House Bill 22-1289. This extension includes full comprehensive benefits provided to Health First Colorado (Colorado Medicaid) and CHP+ eligible members. Postpartum coverage through the HSI will be available to the birthing parent and will last through the last day of the twelfth month of the postpartum period regardless of any subsequent changes in household income. This initiative targets the health of children under 19 because a child benefits from the postpartum care provided to the parent. All FCEP birth parents should receive

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comprehensive care during the postpartum period to assess their physical recovery from pregnancy and childbirth, address chronic conditions (such as diabetes or hypertension), address mental health issues (including postpartum depression), discuss reproductive health (including contraception and birth spacing), and ensure continuity of care. Newborns will be deemed eligible for continuous coverage as a Medicaid Needy Newborn or CHP+ Newborn at birth. Colorado plans to use an ex parte financial eligibility check at the time of entering the newborn into our eligibility system. The state is verifying newborn citizenship. Consistent with funding limitations under section 2105(c)(1) of the Social Security Act, the state will apply a proxy of 2% to HSI expenditures to account for individuals whose pregnancies do not end in a live birth that do not have other children in the home. In Colorado the payment structure for Health First Colorado members includes managed care delivery for behavioral health care and fee-for-service delivery for medical health care. CHP+ members are in full risk managed care. FCEP members will use the same delivery system as Medicaid or CHIP based on the birthing parent’s income. When the initial postpartum visit is rendered by the same provider or provider group as delivery, the provider or provider group bills with a comprehensive global code that includes all routine prenatal, delivery and postpartum care, or a partial global code for delivery and initial postpartum care, and all services are covered under the FCEP authority. Outside of the postpartum HSI, postpartum care is covered for FCEP only when care is rendered by the same provider or provider group and included in the global bill. Labor & Delivery for FCEP birth parents with a household income up to 195% FPL that is not billed as a part of the global bill will be covered via Emergency Medical Services (EMS). Labor & Delivery outside of the global bill for FCEP birth parents with a household income 196-260% FPL will be paid via FCEP. The State of Colorado assures that funding under this HSI will not supplant or match CHIP federal funds with other federal funds, nor will it allow other federal funds to supplant or match CHIP federal funds. The state will document the initiative’s progress on performance and outcomes, reporting regularly on the same metrics reported for Health First Colorado and CHP+ members. Colorado will report these metrics in the CHIP annual CARTS report.  Items or services funded: comprehensive benefit package identical to services available to Health First Colorado and CHP+ eligible members.  Target population and eligibility criteria: from-conception-to-end-of- pregnancy children of families with a household income up to 260% FPL who are not otherwise eligible for Health First Colorado or CHP+.  Geographic area: All 64 counties in the state of Colorado  Approximate estimated low-income children impacted: 7000

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Home Visting Colorado will use CHIP funds via a competitive grant program, within the 10 percent federal administrative expenditures cap allowed for states, for funding community organizations to provide neonatal and postnatal parenting education and home visiting and connecting low-income families to needed services in their communities. This initiative targets the health of children under 19 by providing education and support to targeted low-income families with children. Some home visiting programs receive other funding for Medicaid services, so HSI funds will be braided, only allowing services that are not targeted case management as defined in the Medicaid State Plan that are only allowable for Medicaid members. The state will ensure HSI funds are not supplanting or matching other federal funds by contracting with another state agency via interagency agreement to braid federal funding and ensuring funded training and parent education do not duplicate services reimbursed by Medicaid or CHP+. The state will also require grantees to assure HSI funds are not supplanting or matching other federal funds. The state will document the initiative’s progress on performance and outcomes, reporting in the CHIP Annual CARTS Report on the following metrics: number of families visited, number of visits, healthy pregnancy outcomes where possible.  Items or services funded: supplies for home visiting (safety, feeding, menstrual, brain development, oral health), training or personnel for visiting staff,  Target population: families with at-risk newborns, pregnant teens under 20 years of age,  Eligibility criteria: Low-income (household income is less than 200% FPL) birthing parents and families, who do not have to be first time pregnant person or Medicaid member.  Geographic area: Statewide, to include urban, rural, and frontier counties in Colorado.  Estimated low-income children impacted: 5,650. 100% of these families are estimated to be low income.

Reach out and Read Colorado will expand and improve the delivery of an AAP-endorsed, evidence- based model to promote early literacy, early learning and school readiness as part of routine pediatric primary care visits for children, birth to age 5. This initiative will contribute to transforming the standard of pediatric care for young children in Colorado to sharpen the focus on activities that support social and emotional development.

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This program targets the health of low-income children because starting in infancy, the AAP recommends that pediatric providers advise parents about the importance of reading aloud with their children and counseling them on developmentally appropriate shared-reading activities and the value of providing developmentally appropriate books at health supervision visits for children in low-income families. The state will ensure HSI funds are not supplanting or matching other federal funds because there are no state plan services that provide books and promote literacy. Reach out and Read Colorado does not receive any Medicaid or CHP+ funding and no services would be funded in duplicate. The state will document the initiative’s progress on performance and outcomes, reporting in the CHIP Annual CARTS Report on the following metrics: the # of children served; the # of children in low-income families served; the # of providers completing core training on the Reach Out and Read model; the # of providers trained to deliver the Reach Out and Read model from birth to 6 months of age; the # of new clinic sites launched; and the % of clinics achieving the highest quality rating (12/14 quality standards met.)

 Items or services funded: books and literacy training for pediatric primary care providers.  Target population: underserved and low-income families in Colorado  Eligibility criteria: Reach out and Read will conduct active outreach to pediatric clinics in rural underserved areas that provide primary care to children, from infancy through 5 years.  Geographic area: Statewide, with a focus on rural Colorado counties.  Estimated low-income children impacted: 100,000. 100% of these families are estimated to be low income. 

Safety Supplies Colorado will use CHIP funds via a competitive grant program, within the 10 percent federal administrative expenditures cap allowed for states, to meet the needs for families struggling to provide necessary resources for their children by funding hygiene and safety supplies for infants and children utilizing existing Colorado networks. This includes community centers and events that are already engaging with low-income families. This initiative targets the health of low-income children because one in three American families suffer from diaper need, defined as a lack of sufficient supply of diapers to keep a child clean, dry, and healthy. Providing supplies and education for safe sleep has decreased SIDS by 50% since the campaign began in 1994. Funding child safety seats, installation, inspection, and education for targeted low-income children will decrease the ticketing and number of improperly restrained

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children, or those transitioning out of the proper seat too young. The supplies provided support positive health outcomes for children and families. The state will ensure HSI funds are not supplanting or matching other federal funds by only funding supplies that do not fall in the scope of Medicaid or CHP+ reimbursed services. The state will also require grantees to assure HSI funds are not supplanting or matching other federal funds. The state will document the initiative’s progress on performance and outcomes, reporting in the CHIP Annual CARTS Report on the following metrics: number of distribution events, number of goods distributed, number of children served, and average total value of supplies provided.  Items or services funded: car seats, strollers, cribs, pack n plays, diapers, safety gates, , and staff development.  Target population: underserved and under-resourced communities with low-income families  Eligibility criteria: low-income children ages 0-5 identified by grant funded community organizations.  Geographic area: Colorado statewide with a focus on urban, frontier, and rural counties  Estimated low-income children impacted: 125,250. 100% of these families are estimated to be low-income.

Food Pantries Colorado will use CHIP funds, within the 10 percent federal administrative expenditures cap allowed for states, for a network of food pantries that provides fresh or frozen meat and produce and appliances to store food as well as transportation to deliver food for low-income families. This initiative targets the health of children under 19 because insufficient food and nutrition can significantly harm a child’s physical, mental, and behavioral health and development. This initiative will target families experiencing high instances of generational poverty, limited access to resources, or homelessness. HSI funding for food pantries and supplies will not supplant USDA The Emergency Food Assistance Program (TEFAP) funding. The state HSI and TEFAP will continue to coordinate to ensure funding is not supplanted. The state plans to limit funding to food pantries to those that receive federal funds for less than 10% of their operating expenses. As a commitment to ensuring funds are not supplanted, grantee contracts will have an annual deliverable outlining funding source and how funding is braided and not supplanted. The state will ensure HSI funds are not supplanting or matching other federal funds by providing food to low-income families with food insecurity, which is not a reimbursable service under the Medicaid or CHIP state plan. The food pantries are not designed to replace or replicate medically necessary guidance or services. The state will document the initiative’s progress on performance and outcomes, reporting on the following metrics depending on the evidence-based model of

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the site: number of pantry sites supplied, number of appliances purchased, families enrolled or registered in programs requiring enrollment, events attended.  Items or services funded: food, food storage appliances, facilitator training program,  Target population: children and families with low and very low household food security  Eligibility criteria: families with children  Geographic area: Select Colorado urban, frontier, and rural counties

Estimated low-income children impacted: 25,000 per year. Over 51% of the children are estimated to be low-income.

9.10 Provide a 1-year projected budget (Section 2107(d)) (42CFR 457.140)

CHIP Budget Plan Template State: Colorado Federal Fiscal Year Costs Net Change Due to Amendment SPA Number: CHIP CO-26-0045 Federal Fiscal Year (FFY): 2026 FMAP rate: 65.00% 65.00% Benefit Costs

Managed care $283,764,359 $0 Fee for Service $143,120,532 $0 Premium Assistance Insurance Payments $0 $0 Other $0 $0 Total Benefit Costs $426,884,891 $0 Offsetting beneficiary cost sharing payments $0 $0 Net Benefit Costs $426,884,891 $0

Administration Costs

Personnel $789,173 $0 General administration $2,345,559 $0 Contractors/Brokers (e.g., enrollment contractors) $4,146,720 $0 Claims Processing $3,803,153 $0 Outreach/marketing costs $3,786,212 $0 Health Services Initiative

Home Visiting

$4,540,000 Food Pantries

$1,180,000 Baby Safety Supplies

$1,780,000 Reach out and Read

$500,000 Postpartum Care $3,510,500 Other $543,425 $0 Total Administration Costs $18,924,742 $8,000,000 10% Administrative Cost Ceiling (net benefit costs / 9) $47,431,655 $0

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Federal Share (multiplied by E-FMAP rate) $289,776,261 $5,200,000 State Share $156,033,372 $2,800,000 TOTAL PROGRAM COSTS $445,809,633 $8,000,000

Note: The Federal Fiscal Year (FFY) runs from October 1st through September 30th.

Budget Assumptions:

Note: The Federal Fiscal Year (FFY) runs from October 1st through September 30th.

Budget Assumptions:

FFY: 2025 # of eligibles $ PMPM Managed Care 92,942 $229,38 Fee for Service 63,756 $209.76 Total PMPM

$221.40

Source(s) of non-federal funding used for state match: General Fund

Other Assumptions:

DELETE

(spa)(co-26-0047)(approval-package)Colorado CHIP SPA CO-26-0047: Approval Package (approved August 18, 2026, effective January 1, 2026)#

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continued care with the member’s same health-care provider or health-care facility if the member’s Managed Care Organization (MCO) is changed. The continued care will be provided under the member’s new MCO plan as if the provider or facility is in-network, for up to ninety (90) days if certain conditions exist.

SPA #44

Date Amendment #44 Submitted: June 16, 2025 Date Amendment #44 Approved: April 6, 2026 Date Amendment #44 Effective: January 1, 2025 Date Amendment #44 Implemented: Adds mandatory coverage, reimbursement, and attestations, for juveniles in a carceral setting, in accordance with Section 5121 of the Consolidated Appropriations Act of 2023. SPA #45 Date Amendment #45 Submitted: May 20, 2026 Date Amendment #45 Approved: Date Amendment #45 Effective: January 1, 2026 Date Amendment #45 Implemented: This SPA includes 4 community HSI programs to improve the lives of targeted low-income children in Colorado. Initiatives selected based on extensive stakeholder input include Home Visiting, Safety Supplies, Food Pantries, and Reach out and Read to be implemented upon approval of the amendment. SPA #46 Date Amendment #46 Submitted:

May 11, 2026 Date Amendment #46 Approved: Date Amendment #46 Effective:

July 1, 2026 Date Amendment #46 Implemented:

July 1, 2026

The State added assurance language that no annual, lifetime, or other aggregate dollar limitations are imposed on any medical or dental services covered under the CHIP State Plan consistent with 42 C.F.R. 457.490(a).

SPA #47 Date Amendment #46 Submitted:

Date Amendment #46 Approved: Date Amendment #46 Effective:

January 1, 2026 Date Amendment #46 Implemented:

Adds assurance that the state does not terminate eligibility for pregnant women enrolled in a separate CHIP because the pregnant woman is an inmate of a public institution, in accordance with Section 205 of the Consolidated Appropriations Act of 2024.

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The State included consultation on this SPA in the tribal consultation log dated March 25May 19, 2026. A copy of the relevant page of the consultation log is attached.

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Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) July 1, 2015

CO-16-0025 Eligibility Processing CS24 Eligibility Process Supersedes the current section 4.3 and 4.4 Approval Date: 09/06/17 Effective Date: January 1, 2016

CO-17-0026

Approval Date: 10/05/17 Effective Date: July 1, 2017 Non- Financial Eligibility CS15 MAGI-Based Income Methodologies Section 4.3: Supersede information on income eligibility and methods in CO- 13-0015. CO-24-0040-0002

Approval Date: 11/15/25 Effective Date: January 1, 2025 Separate Child Health Insurance Program Eligibility and General Eligibility CS9

CS27

Separate Child Health Insurance Program Eligibility – Coverage From Conception to Birth

Separate Child Health Insurance Program General Eligibility – Continuous Eligibility

Supersedes Section 4.1.2.1-PC and 4.19

Supersedes version approved in SPA 22-0039.

CO-25-0044CO-26-0047

Approval Date: April 6, 2026 Effective Date: January 1, 20252026 Incarcerat ed CHIP Beneficia ries

CS31

Targeted Low-Income Children Who Become Incarcerated

Children Determined Eligible for CHIP While Incarcerated

Targeted Low-Income Pregnant Women Who Become Incarcerated Eligibility Not Terminated Supersedes version approved in SPA CO-25-0044

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Page 1 of 2 CHIP Eligibility V.20260217 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State Name: Colorado OMB Control Number: 0938-1148 Transmittal Number: CO - 26 - 0047 Incarcerated CHIP Beneficiaries CS31 2102(d) and 2110(b)(7) of the SSA Targeted Low-Income Children Who Become Incarcerated The state assures that it does not terminate eligibility for children enrolled in a separate CHIP because the child is an inmate of a public institution. States may either suspend CHIP coverage or continue to provide CHIP state plan (or waiver of such plan) services otherwise not covered by the carceral facility to children who are incarcerated. States that elect to suspend CHIP coverage for the duration of a child’s incarceration may implement a benefits or eligibility suspension. The state elects to suspend CHIP coverage for the duration of a child’s incarceration Yes If yes, then check an option below: Benefits suspension Eligibility suspension The state assures that it redetermines eligibility for any child prior to their release if it has been longer than 12 months since the child’s last redetermination and restores coverage for child health assistance to eligible children upon their release. Within the 30 days prior to release (or within one week of release, or as soon as practicable after release), the state assures that it provides eligible children with any screenings, diagnostic services, or case management services that would otherwise be available to children under the CHIP state plan (or waiver of such plan). Additional information regarding implementation of mandatory provisions of section 5121 of the Consolidated Appropriations Act, 2023 (CAA, 2023), including providing screenings, diagnostic services, or case management services: The state may determine that it is not feasible to provide the required services during the prerelease period in certain carceral facilities (e.g., identified local jails, youth correctional facilities, and state prisons) and/or certain circumstances (e.g., unexpected release or short-term stays). The state will maintain clear documentation in its internal operational plan regarding each facility and/or circumstances where the state determines that it is not Under section 5122 of the CAA, 2023, states may consider otherwise eligible children who are inmates pending disposition of charges as eligible for CHIP and provide all services covered under the CHIP state plan. The state elects to provide all CHIP state plan benefits (or waiver of such plan) to eligible children who are inmates pending disposition of charges.

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Page 2 of 2 CHIP Eligibility V.20260217 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Children Determined Eligible for CHIP While Incarcerated

Generally, children who apply for CHIP when they are in a carceral facility are not eligible because of the eligibility exclusion for inmates of a public institution under section 2110(b) of the Act. However, section 2110(b)(7) of the Act provides an exception to this eligibility exclusion for children who are within 30 days prior to their release. The state assures that they will process any application submitted on behalf of a child and make an eligibility determination for child health assistance upon their release from the institution. Children who apply and are found eligible within 30 days prior to their release will be provided screening and diagnostic services, and case management services that are otherwise available under the CHIP state plan (or waiver of such plan). Targeted Low-Income Pregnant Women Who Become Incarcerated The state assures that it does not terminate eligibility for pregnant women enrolled in a separate CHIP because the pregnant woman is an inmate of a public institution. States may either suspend CHIP coverage or continue to provide CHIP state plan (or waiver of such plan) services otherwise not covered by the carceral facility to pregnant women who are incarcerated. States that elect to suspend CHIP coverage for the duration of a pregnant woman's incarceration may implement a benefits or eligibility suspension. The state elects to suspend CHIP coverage for the duration of a pregnant woman's incarceration Yes If yes, then check an option below: Benefits suspension Eligibility suspension

(spa)(co-cspa-6)(current-state-plan)Colorado CHIP SPA CO-CSPA-6: Current State Plan (approved December 23, 2005, effective July 1, 2005)#

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

Effective Date:

Approval Date: 1

OMB #: 0938-0707 Exp. Date:

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

Preamble

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

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

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

Form CMS-R-211

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

Effective Date:

Approval Date: 2

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

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

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

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

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

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

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

Name: Karen Reinertson

Position/Title: Executive Director, Colorado Department of Health Care Policy and Financing Name: Marilyn Golden

Position/Title: Division Director for the Office of Operations and Finance Name: Barbara Ladon

Position/Title: Director, Children’s Basic Health Plan d.b.a. Child Health Plan Plus (CHP+)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

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

Effective Date:

Approval Date: 3 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

1.1.1

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

1.1.2.

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

1.1.3.

A combination of both of the above.

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

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

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

Effective date:

July 1, 2005 Implementation date: December 23, 2005

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

Effective Date:

Approval Date: 4 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1 Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

See Attachment 1 for a description of children’s insurance status by income and race and ethnicity.

2.2 Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR457.80(b))

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

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

Colorado identifies and enrolls children eligible to participate in public health insurance programs through a significantly broad outreach strategy through both public and private partners and through direct appeals to families in the media and in their communities. Significantly, one of the most successful efforts after five years of operation has been and continues to be word of mouth that has been generated by the positive experiences of members and local partners.

One important method of enrollment that has simplified the process for families is the development of a simplified, joint application that partners and the agency can use to enroll children and families in either Medicaid or CHP+. This simplified application can be obtained through the standard Medicaid outreach and enrollment process, as well as through the standard CHP+ outreach and enrollment processes.

1. Medicaid, administered by the Colorado Department of Health Care Policy and Financing, provides health coverage to low-income children and families, elderly and disabled Coloradoans. Colorado takes the

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

Effective Date:

Approval Date: 5 following steps to enroll children in Medicaid:

• County social services departments determine a person’s eligibility for Medicaid. Presumptive eligibility sites (Federally Qualified Health Centers and Planned Parenthood clinics), county nurse’s offices, doctor’s offices and Indian Health Centers determine presumptive Medicaid eligibility and enroll pregnant women. Infants up to twelve months old born to Medicaid- enrolled women are guaranteed Medicaid eligibility for twelve months.

• Outstationed eligibility sites (FQHCs, Disproportionate Share Hospitals, and local county health departments) help people apply for Medicaid by collecting and sending their applications and paperwork to the county department of social services office for eligibility determination.

• Posters, brochures, and a 1-800 number provide Medicaid information to potentially eligible families at several locations, including public assistance offices.

• The CHP+ screens applicants for Medicaid eligibility. When an applicant appears to be Medicaid eligible: the CHP+ central office refers applications to Medicaid technicians located at the CHP+ office who process the application for the family. This process accelerates enrollment. Satellite eligibility determination sites refer directly to county department of social services for application processing.

2. The CHP+ is a public/private partnership providing subsidized health insurance for children in low-income families statewide who are not eligible for Medicaid. The CBHP Policy Board provided oversight and policy development. CHP+ is administered by the Department of Health Care Policy and Financing through private contractors who provide various services. These organizations manage the routine administrative matters associated with CHP+.

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

Effective Date:

Approval Date: 6 health centers; United Way agencies; public health departments; county departments of social services; Women, Infants, and Children programs; and many others. These extensive partnerships represent an extraordinary commitment statewide to enroll uninsured children as part of the CHP+ comprehensive marketing and outreach strategy. In addition, CHP+ program initiated a targeted television advertising campaign and began testing employer-based outreach activities. All of these activities represent Colorado’s interest in reaching families in every way possible.

2.2.2 The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership.

CHP+ has created an extensive marketing and outreach program encompassing strategies that range from grass roots networking to mass market advertising campaigns. These efforts have been implemented to reach families many different ways with different messages. To better evaluate the effectiveness of these strategies, CHP+ implemented a large-scale, application-source tracking system in March 2000. The system allows an application to be traced back to the initial source without relying on self-reported referral data. This tracking system will continue to be used to monitor trends and results from marketing and outreach campaigns.

Community-Based Partnerships: A cornerstone of the CHP+ outreach strategy is to maintain and build on community partnerships. To reach all eligible families through as many avenues as possible, CHP+ works with more than 2000 partners. These include: schools; Head Start programs; family resource centers; community health centers; United Way agencies; public health departments; county departments of social services; Women, Infants, and Children nutrition programs; faith-based organizations and a myriad of others. Experience has shown that multiple contacts throughout the community are important to the eventual enrollment of an eligible child.

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

Effective Date:

Approval Date: 7

Hispanic-Related Partnerships: In order to reach the substantial Hispanic population in Colorado, CHP+ has partnered specifically with LARASA and the Mexican Consulate to explore appropriate avenues to reach this subpopulation. LARASA staffs a CHP+ advisory council that represents Hispanic business, faith-based and community service leaders. These community leaders advise CHP+ regarding the special needs of the Hispanic population.

Managed Care Organizations: One method of partnering has been the implementation of joint media campaigns in which four of the six managed care organization partners have participated. These purchased advertisements were structured so that each partner received airtime when marketing would be most effective. Most managed care partners have committed extensive time and effort to reach disenrollees, as well as to find new enrollees through advertisements, partnerships and events. All of CHP+’s managed care partners participate in various community events throughout the state.

Advertising and Earned Media: CHP+ experienced an increased number of applications from concentrated advertising campaigns. Spikes in requests for information are consistently noted after television advertisements or newspaper stories about the program appear. Television continues to rank as the highest source of referral for individual applications. CHP+ and managed care organizations team together to purchase targeted television advertisements because they are so effective. County Departments of Social Services: County departments of social services provide support to low-income families in communities ranging from food stamps and Women, Infants, and Children programs to child care and Colorado Works. Many CHP+ referrals come from these programs. In addition, because federal law mandates linkage between CHP+ and Medicaid (for example, through a common application) about 20% of CHP+ applications are submitted through the Medicaid application process managed directly by county departments of social services.

Satellite Eligibility Determination Sites: CHP+ has a network of 73 satellite eligibility determination sites statewide, including multiple locations for some sites. These sites comprise community health centers, county nursing services, school-based health

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

Effective Date:

Approval Date: 8 centers and other community providers, and have been an essential component of the programs outreach and enrollment activities. As part of their contract with CHP+, they are required to provide outreach to their community for CHP+ and have access to an on-line enrollment system to accelerate program enrollment.

Schools: Schools are consistently one of the most frequently cited sources of referral by applicants. Increasing numbers of school districts are partnering with CHP+ to assure the children they serve know about the program.

Community Health Centers: The Colorado Community Health Network has made involving its members in Medicaid and CHP+ outreach a priority. Community health centers are the largest group of primary care providers throughout the state serving low-income children. Some serve as satellite eligibility determination sites while others participate in community coalitions to enroll children in Medicaid and CHP+.

Covering Kids Colorado: A significant partner in developing community-based outreach has been Covering Kids Colorado, which is a Robert Wood Johnson Foundation funded grant program administered by the Colorado Department of Public Health and Environment. The program has focused on three distinct communities, Denver City and County along with Adams and Prowers Counties, to assure all children eligible for CHP+ and Medicaid are enrolled in their respective programs. Covering Kids has employed a community-based partnership strategy similar to the one used by CHP+. Colorado has received a Covering Kids and Families Grant from the Robert Wood Johnson Foundation in 2002. This grant will be administered by a coalition of community groups including the Colorado Community Health Network, the Colorado Childrens’ Campaign and Catholic Charities. The program will focus on three distinct communities, Denver City and County, the Mountain ski area counties of Eagle, Pitkin and Garfield, and Pueblo City and County. Community Voices: Denver Health and Hospital Corporations Community Voices program is a joint Kellogg Foundation and Colorado Trust funded program, which has among its goals to improve the health of Denver’s medically underserved through innovations in community outreach, enrollment in publicly funded health insurance programs like CHP+, as well as small employment health

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

Effective Date:

Approval Date: 9 plans, and clinical case management. Community Voices efforts are designed to demonstrate that culturally sensitive community outreach to underserved populations improves enrollment of eligible individuals into plans, while engaging and empowering communities to assume greater responsibility for health.

Indian Health Services: CHP+ has contracts with Indian Health Services in all areas of the state to allow tribal clinics to deliver health care to Native Americans.

2.3 Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

1. The Health Care Program for Children with Special Needs (HCP) is a joint state/federal program administered by the Colorado Department of Public Health and Environment for children age 20 and under who have a physical disability that interferes with normal growth and development. HCP helps pay medical bills and provides follow-up for children diagnosed with a clinically qualifying handicapping condition. Children with conditions eligible for the program are identified through county nursing services, health care providers, Child Find coordinators in public schools, and local Early Childhood Connections staff.

2. Colorado Indigent Care Program (CICP), administered by the Colorado Department of Health Care Policy and Financing, is a state and federally funded provider reimbursement program that discounts the cost of medical care at its participating health facilities for adults as well as children. If a person is eligible for Medicaid or CHP+, he or she is ineligible for CICP. Covered services vary by participating hospitals or clinics, but generally include hospital costs such as inpatient stays, surgery, and prescription drugs. All children deemed eligible for the above mentioned programs are directed toward them at CICP-participating providers. Colorado takes the following steps to enroll children in the Colorado Indigent Care Program (CICP):

• CICP-contracted providers (primarily FQHCs, DSH hospitals, and participating clinics) screen children for CICP eligibility during their visit, assist with completing the application, and determine eligibility for the program.

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

Effective Date:

Approval Date: 10 CICP. Children are referred to CHP+ first if the safety net providers determine that a client is not eligible for Medicaid.

3. Cover Colorado, established in 1990 by the Colorado General Assembly as a quasi-governmental entity, provides health insurance to individuals, including children, who are denied commercial health insurance by private carriers because of a pre-existing medical condition. Cover Colorado and CHP+ often compare enrollment and disenrollment information to discern trending that may be relevant to both programs.

4. Community Health Centers offer a wide range of health care to people who may need some financial assistance with their medical bills. Colorado has 15 community health centers with more than 50 clinic sites in medically under-served areas of the state. Community health centers provide comprehensive primary care services including care for acute and chronic illness, injuries, family planning and prenatal care, emergency care, diagnostic services and prescriptions.

Community Health Centers, many of who are Federally Qualified Health Centers, take the following steps to enroll children in Medicaid, CHP+, the Colorado Indigent Care ProgramCICP, or the health center’s sliding fee scale plan:

• Provide a financial screen for each new patient or family. • Provide information on and explanation of the program(s) that the family members are eligible for. • Assist with completing applications and collecting necessary documentation for eligibility determination. • Determine eligibility on-site or forward applications to the determining agency and communicate with family about eligibility status. • Assist families when their financial situation and eligibility changes to transition to the appropriate program.

If a patient/family is not eligible for any program, the health center uses its sliding fee scale to determine the fee according to family size and income.

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

Effective Date:

Approval Date: 11 completing application forms for Medicaid and the CHP+. In Colorado, Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) outreach workers and administrative case managers are a part of local public health agency staff who facilitate access to Medicaid and to CHP+ services for eligible children.

6. Maternal and Child Health Block Grant (Title V of the Social Security Act) funds in Colorado are "passed through" to local public health agencies and other qualified non-profit agencies where they are used to support a number of activities on behalf of women and children, particularly those of low income. State Title V staff provide oversight, consultation and standards to assure appropriate utilization of these funds. When families are ineligible for any insurance plan, or when there is not another provider of free or reduced price health care (i.e. community or rural health centers) available or accessible, these public health agencies provide direct services to low- income children. Services provided in local public health agencies are almost always provided by public health nurses. Services include comprehensive well child clinic services, including developmental and physical assessments, immunizations, and parent education. Families under 100% FPL pay nothing for these services. Others pay on a sliding fee scale.

7. School-based health centers (SBHC) provide comprehensive primary care services including care for acute and chronic illness, injuries, family planning and prenatal care, some diagnostics services and prescriptions. SBHCs provide services at no charge. However, patients are asked whether or not they have health care coverage. The degree to which the SBHCs bill for reimbursement depends on the administrative capabilities of the center and whether a CHP+ participating managed care organization contracts with them. SBHCs facilitate application to Medicaid, CHP+ or CICP when documentation of family income and assets is obtainable without jeopardizing students confidentiality.

8. The Special Nutritional Program for Women, Infants and Children (WIC) provides nutritious food to supplement the regular diet of pregnant women, breast-feeding women, infants, and children under age five who meet state income standards. Women and children under five years old qualify if the combined family income is at or below 185% of the federal poverty level. WIC staff encourage pregnant women and parents and guardians of infants under 12 months of age to apply for Medicaid and CHP+.

9.The Commodity Supplemental Food Program (CSFP) provides infant formula and nutritious foods to supplement the diet of pregnant and postpartum women and children under age 6. Women who live in Conejos, Costillo, Denver, Mesa, Rio Grande or Weld counties and who have a combined family income at or below 185% of the federal poverty level qualify for the program. Staff encourage

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

Effective Date:

Approval Date: 12 pregnant women and parents and guardians of infants under 12 months of age to apply for Medicaid and CHP+.

(spa)(co-cspa-6)(current-state-plan)(page-13)Page 13#

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

Effective Date:

Approval Date: 13 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

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

The program uses MCOs for health care delivery services. The statewide provider network established by the former Colorado Child Health Plan has been expanded to care for children who are eligible for CHP+ but who have not yet been enrolled in a HMO (HMOs generally initiate coverage on the first of the month only) and those children who live in areas where no service is available.

Health Maintenance Organizations

State legislation (House Bill 97-1304) requires that only plans willing to contract with Medicaid are eligible to serve CHP+ clients. This will ensure that clients are not forced to change providers each time their financial situation changes the program for which they are eligible (Medicaid or CHP+). The CHP+ program contracts with managed care organizations serving a significant number of commercial and Medicaid clients statewide. These plans vary in structure, service area and membership.

Contract standards are based on a review of standards from the following sources: National Association of Insurance Commissioners (NAIC) Model Acts, National Committee for Quality Assurance (NCQA) Accreditation Standards, and Quality Improvement System for Managed Care (QISMC) standards.

CHP+ HMO contractors have to pass the examination of three entities: the Colorado Division of Insurance (DOI), the Department of Public Health and Environment (CDPHE) and the Colorado Department of Health Care Policy and Financing (HCPF). The DOI grants HMO licenses based on a review of financial stability, adequate provider subcontracts, access to care and quality of care. The DOI subcontracts the quality and access review to the CDPHE. When a licensed plan applies for a Medicaid contract, HCPF reviews several aspects of the plans operation including provider network, utilization, management, access to care, quality improvement and grievance procedures. HCPF reviews the Medicaid plans that apply to serve CHP+ clients. Where CHP+ contract standards vary from those of DOI and HCPF, the Department conducts additional reviews in coordination with the Medicaid, DOI, CDPHE, or other purchaser reviews.

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

Effective Date:

Approval Date: 14

Essential Community Providers: As required by state legislation (House Bill 97- 1304), CHP+ only contracts with HMOs that are willing to contract with the Colorado Medicaid program. To retain their Medicaid contracts, these HMOs must fulfill the statutory requirements of SB 97-75 with regard to use of ECPs. Therefore, the CHP+ managed care network includes these providers. ECPs include community health centers, community mental health centers, public health agencies, school-based clinics, family planning clinics, and other indigent care providers.

Self-Insured Managed Care Network

The former CHP+ developed its own statewide provider network, with provider contracts held by the University of Colorado Health Sciences Center (UCHSC). UCHSC held those contracts through a Memorandum of Understanding with the Department through June 30, 1999. As of July 1, 1999, HCPF has taken over responsibility for provider contracts. The Department contracts with a single entity to manage all aspects of the self-insured managed care network. These physicians, hospitals and ancillary service providers provide services covered by the CHP+ comprehensive benefit package in areas where HMO services are not available, mainly rural areas. The self-insured managed care network provides the same benefit package through a managed care system that is provided through the HMOs in a managed care system.

3.2 Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

The self insured managed care network and the HMOs use managed care utilization standards to assure that enrollees only receive appropriate and medically necessary care.

(spa)(co-cspa-6)(current-state-plan)(page-15)Page 15#

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

Effective Date:

Approval Date: 15 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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

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

4.1.1

Geographic area served by the Plan: The plan is available statewide, in all 64 Colorado counties.

4.1.2

Age: CHP+ is available to children 0 through 18 years of age.

4.1.3

Income: To be eligible, a child must be from a family whose annual income is at or below 200% of the federal poverty level. Family size and income criteria are described in Attachment 2.

4.1.4

Resources (including any standards relating to spend downs and disposition of resources): None

4.1.5

Residency (so long as residency requirement is not based on length of time in state) :A resident is anyone who is: 1) a U.S. citizen; or 2) a documented legal immigrant who has had an Alien Registration Card for 5 years or more and 3) a resident of Colorado. The state accepts self-declaration of residency.

4.1.6

Disability Status (so long as any standard relating to disability status does not restrict eligibility): No child is denied eligibility based on disability status. If the child receives SSI and is eligible for Medicaid, the child will be denied coverage because the child is eligible for Medicaid, not for reasons of disability status.

4.1.7

Access to or coverage under other health coverage: Both the application and the separate "Insurance Form" ask families questions about other insurance coverage. The plan administration seeks information about all other access to health care coverage, both public and private, on the application form before the child is enrolled in the plan and from providers once the child is determined eligible for the plan. A child will be found ineligible if the child: 1) is covered under a group health plan or under health insurance

(spa)(co-cspa-6)(current-state-plan)(page-16)Page 16#

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

Effective Date:

Approval Date: 16 coverage as defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) is a member of a family that is eligible for health benefits coverage under a State health benefits plan based on a family members employment with a public agency in the State; or 4) has had coverage under an employer plan with at least a 50% employer contribution during the three months prior to application. The Health Care Program for Children with Special Needs is not considered a private health plan and children covered under this plan may still be covered by CHP+.

4.1.8

Duration of eligibility: Once a child has been accepted, he or she is continuously eligible for one year from the postmark date of the complete application unless the child moves from the state, turns 19 years old, or becomes eligible for or enrolled in Medicaid, or other private insurance.

4.1.9

Other standards (identify and describe):

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

4.2.1

These standards do not discriminate on the basis of diagnosis.

4.2.2

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income.

4.2.3

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

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

Both initial eligibility and annual renewal eligibility for CHP+ are determined either at the main office or at a decentralized eligibility site.

All applications are received by mail or by Fax at the central office or during face- to-face interviews at the decentralized sites. Applications may also be dropped off in person during central office business hours.

The State has developed and implemented an eligibility, enrollment and application tracking system for CHP+. The system is designed to utilize a sophisticated business rules engine and state-of-the-art secure Internet technologies to reduce the overall cost of administration and increase the speed

(spa)(co-cspa-6)(current-state-plan)(page-17)Page 17#

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

Effective Date:

Approval Date: 17 and accuracy of screening for Medicaid eligibility, determining eligibility for CHP+ and enrolling children into the program.

Current employment income, self-employment income and cash income from other sources reported is used to qualify families with employment or retirement income. Verification of earned income must be provided if the applicant earned money during the previous month of the date of application. Earned income may be verified by current wage stubs, a note from an employer, a phone call to an employer (if permitted by applicant), or ledgers or receipts for self-employed applicants.

ELIGIBILITY DETERMINATION AND RENEWAL

Redetermination of Eligibility

Enrollment in Health Plans

Applicants who live in areas served by HMOs must select a HMO to enroll in the CHP+. A family can select an HMO by indicating their HMO choice on the application form when they apply to the CHP+. When applications are received without an HMO selection, eligibility technicians attempt to contact the family to facilitate selection. If the technician cannot contact the family, the applicant is assigned an HMO and a letter is sent to the family. The family must either accept the assignment or make a different selection in order to be enrolled in CHP+. Families who live in areas of the state that are not served by an HMO will receive care through the CHP+ managed care network.

CHP+ applications include information on health plan service area. Applicants are instructed to select an HMO and are offered a 1-800 number to answer questions they may have. Enrolled persons receive services through the CHP+ managed care network until their HMO enrollment is effective. Enrollees can

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

Effective Date:

Approval Date: 18 receive care through the CHP+ managed care network for a period of 14 to 45 days until the effective date of HMO coverage.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

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

In the event the Department makes a determination to limit enrollment to ensure that the program maintains sufficient funds, enrollment in CHP+ shall be halted.

The Department accepts applications for enrollment at times when sufficient funding is available to justify enrolling more individuals. The Department may limit the number of children to be enrolled according to the funds available for the program. When the Department has established that all of the funds appropriated for this program are obligated, the Department, in accordance with 457.65(b), will notify CMS in writing that a freeze in enrollment has taken place, or will take place.

During an enrollment cap, applications will be screened for Medicaid in the same manner as currently described in the approved State Plan Amendment. If the applicant appears to be Medicaid eligible, the application will be referred to Medicaid. If the applicant does not appear to be Medicaid eligible, the application will be returned to the applicant with a letter explaining the cap. The letter will also encourage the applicant to apply again when the enrollment cap is lifted.

An enrollment cap will not affect current enrollees. Reenrollment applications will be screened for Medicaid and the CHP+ and enrolled in exactly the same way as prior to the cap. Siblings and newborns to existing enrollees will continue to be enrolled using currently approved procedures. Applicants will be enrolled in CHP+ if they are determined eligible after being screened for Medicaid.

As funds become available through the budget process, the cap will be lifted. Public notice will occur using the methods used as described for the implementation of the cap. Applicants will be screened and enrolled in the order of receipt. CMS will be notified any time the cap will be lifted based on the criteria listed above.

No waiting list will be maintained for CHP+.

The administration of an enrollment cap will be communicated prior to

(spa)(co-cspa-6)(current-state-plan)(page-19)Page 19#

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

Effective Date:

Approval Date: 19 implementation by providing in writing; a posting on the Internet, a letter to the legislature, and policymakers throughout the state. It will also be presented to the Medical Services Board, members of which are appointed according to political affiliation, geographic representation, and provider or recipient status. A news release will be provided to the media on how the new applications will be responded to. No waiting list will be maintained for interested CHP+ applicants. A notice of the removal of a cap will be provided to media, interested parties, and policy makers at the appropriate time.

Based on the criterion described above, Colorado has implemented a cap effective November 1, 2003. This cap will be lifted in accordance with the above procedures as funds become available.

4.4 Describe the procedures that assure that:

4.4.1 Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

Medicaid Screening

The State has developed and implemented an eligibility, enrollment and application tracking system for CHP+. The system utilizes a sophisticated business rules engine and state-of-the-art secure Internet technologies to reduce the overall cost of administration and increase the speed and accuracy of screening for Medicaid eligibility, determining eligibility for CHP+ and enrolling children into the program.

Using the rules set, a precise determination of income for the Medicaid Budget Unit, including applicable income disregards, has been included to screen for Medicaid eligibility. Screening for Medicaid eligibility occurs at the time of application. For each child listed on the application, the system displays whether or not the child is eligible for Medicaid. The family of a child found to be eligible for Medicaid receives a letter indicating that the child cannot be insured by the plan because the child appears to be eligible for Medicaid. If the application originated at the CHP+ central office, the application is then forwarded to Medicaid Eligibility Technicians located at the central CHP+ administrative office; if the application

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

Effective Date:

Approval Date: 20 originated at a satellite eligibility determination site, it is forwarded to the county department of social services and the family is given a 1-800- phone number to call with further questions. The family will be notified that the application will be reconsidered if Medicaid Technicians determine that the person is ineligible for Medicaid. CHP+ requests that the family provide the Medicaid denial letter.

Families who apply for Medicaid are informed about CHP+ and families applying for CHP+ are informed about Medicaid. The joint Medicaid/ CHP+ application notifies the applicant that information will be shared with both Medicaid and CHP+ to determine eligibility for both programs.

Other Creditable Coverage Screening

The joint Medicaid/CHP+ application, asks the applicant to report any health insurance coverage. If the family reports creditable coverage (most group health plans and health insurance coverage), the child will be found ineligible. Providers contracting with the CHP+ are required contractually to notify the plan whenever they have reason to believe a member has coverage other than CHP+. CHP+ then verifies coverage with the insurance carrier and notifies the family that they will be disenrolled.

If an applicant has received health insurance in the last three months and the employer paid more than 50% of the premium, there is a three month lock out period for the applicant.

4.4.2 The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

CHP+ applicants are screened for Medicaid eligibility at the central site and decentralized sites. Medicaid-eligible person’s applications are referred to county social service offices and Medicaid technicians housed in the CHP+ administrative offices. CHP+ eligibility staff follow up on these referrals with clients and notify eligibility staff that they have made a referral. Children who appear to be Medicaid eligible are only enrolled in CHP+ after they have received a denial letter from the State Medicaid staff. State Medicaid staff have access to important information concerning cases referred to Medicaid from CHP+ through the eligibility system. A 1-800 number is used to facilitate client questions concerning the disposition of their application that has been referred to Medicaid but originated with CHP+.

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

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Approval Date: 21 4.4.3 The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

County departments of social services provide support to low-income families in communities ranging from food stamps and Women, Infants, and Children programs to child care and Colorado Works. Many CHP+ referrals come from these programs. In addition, because federal law mandates linkage between CHP+ and Medicaid (for example, through a common application) about 20% of CHP+ applications are submitted through the Medicaid application process managed directly by county departments of social services.

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

4.4.4.1

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

The joint Medicaid/CHP+ application asks whether the applicant has been covered under an employer health benefits plan with at least a 50% employer contribution during the three months prior to application. A person is ineligible for the CHP+ if they have had such coverage in the noted time period, unless the coverage was terminated due to a loss of employment. The joint application also asks whether the applicant currently has group or individual coverage and will deem the person ineligible if he/she has such coverage. CHP+ eligibility technicians verify this information with the families’ employers if necessary.

4.4.4.2

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

4.4.4.3

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

4.4.4.4

If the state provides coverage under a premium

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

Effective Date:

Approval Date: 22 assistance program, describe:

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

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

CHP+ has contracts with Indian Health Services in all areas of the state to allow tribal clinics to deliver health care to Native Americans. Because the federal legislation governing the Indian Health Services has regulations against the use of managed care, CHP+ pays these facilities fee-for- service. These primary care contracts continue to allow Native Americans full access to specialty providers through a managed care environment (though still paid fee-for-service.)

CHP+ works directly with the Indian Health Resource Center to reach out to Native Americans living in the Denver metro area, home to nearly half of Colorado’s Native Americans. CHP+ conducts outreach to Native Americans living in the remainder of the state, much of which is rural, through local public health nurses and caseworkers. In Southwestern Colorado, case workers at the San Juan Basin Health Department in Durango will provide outreach at two Indian Health Centers at the Ute Mountain Ute Indian Reservation near Towaoc and Southern Ute Indian Reservation in Ignacio.

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

Effective Date:

Approval Date: 23 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

CHP+ created an extensive marketing and outreach program encompassing strategies that range from grass roots networking to mass market advertising campaigns. These efforts have been implemented to reach families many different ways with different messages.

To better evaluate the effectiveness of these strategies, CHP+ implemented a large-scale, application-source tracking system in March 2000. The system allows an application to be traced back to the initial source without relying on self- reported referral data. This tracking system will continue to be used to monitor trends and results from marketing and outreach campaigns.

1. Community Partnerships A cornerstone of the CHP+ outreach strategy is to maintain and build on community partnerships. To reach all eligible families through as many avenues as possible, CHP+ works with more than 2000 partners. These include: schools; Head Start programs; family resource centers; community health centers; United Way agencies; public health departments; county departments of social services; Women, Infants, and Children nutrition programs; faith-based organizations and a myriad of others. So far, the most effective efforts in actually enrolling families are through schools, doctors’ offices, health departments, community health centers, and departments of social services.

2. Hispanic-Related Partnerships: In order to reach the substantial Hispanic population in Colorado, CHP+ partnered specifically with LARASA and the Mexican Consulate to explore appropriate avenues to reach this subpopulation. LARASA staffs a CHP+ advisory council that represents Hispanic business, faith-based and community service leaders. These community leaders advise CHP+ regarding the special needs of the Hispanic population.

3. Managed Care Organizations Managed care organizations have increased their CHP+ outreach. One method of partnering has been the implementation of joint media campaigns in which a majority of managed care partners have participated. These purchased

(spa)(co-cspa-6)(current-state-plan)(page-24)Page 24#

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

Effective Date:

Approval Date: 24 advertisements were structured so that each partner received air time when marketing would be most effective. All of CHP+’s managed care partners have participated in various community events throughout the state.

4. Advertising and Earned Media Television ranks as the highest source of referral for individual applications. CHP+ and managed care organizations team together to purchase targeted television advertisements. 5. County Departments of Social Services County departments of social services provide support to low-income families in communities ranging from food stamps and Women, Infants, and Children programs to child-care and Colorado Works. Many CHP+ referrals come from these programs. About 20% of CHP+ applications are submitted through the Medicaid application process managed by county departments of social services. CHP+ continues to focus on ways to minimize delays in referrals so that eligible children can be enrolled in an expeditious manner.

6. Satellite Eligibility Determination Sites CHP+ has a network of 73 satellite eligibility determination sites (SED sites) statewide, including multiple locations for some sites. These sites comprise community health centers, county nursing services, school-based health centers, Indian Health Centers and other community providers, and have been an essential component of the programs outreach and enrollment activities. As part of their contract with CHP+, they are required to provide outreach to their community for CHP+ and have access to an on-line eligibility program to accelerate program enrollment. SED sites account for more than 30% of submitted applications.

7. Schools Schools are consistently one of the most frequently cited sources of referral by applicants. Increasing numbers of school districts are partnering with CHP+ to assure the children they serve know about CHP+. In 2001, more than 60% of all school districts in the state participated in CHP+ outreach activities including coordination with National School Lunch Program information, disseminating materials about CHP+ to families or allowing CHP+ partners and staff to present to family-related functions.

8. Community Health Centers The Colorado Community Health Network has made involving its members in Medicaid and CHP+ outreach a priority. Community health centers are the largest group of primary care providers throughout the state serving low-income

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

Effective Date:

Approval Date: 25 children. Some serve as satellite eligibility determination sites. Others participate in community coalitions that enroll children in Medicaid and CHP+.

9. Covering Kids Colorado A significant partner in developing community-based outreach has been Covering Kids Colorado, which is a Robert Wood Johnson Foundation funded grant program administered by the Department of Public Health and Environment. Colorado will be received a Covering Kids and Families Grant from the Robert Wood Johnson Foundation in 2002. This grant is administered by a coalition of community groups including the Colorado Community Health Network, the Colorado Children’s Campaign and Catholic Charities. The program focuses on three distinct communities, Denver City and County, the Mountain ski area counties of Eagle, Pitkin and Garfield, and Pueblo City and County. 10. Community Voices This is a joint Kellogg Foundation and Colorado Trust funded program, which has among its goals to improve the health of Denver’s medically underserved through innovations in community outreach, enrollment in publicly funded health insurance programs like CHP+, as well as small employment health plans, and clinical case management. Community Voices efforts are designed to demonstrate that culturally sensitive community outreach to underserved populations improves enrollment of eligible individuals into plans, while engaging and empowering communities to assume greater responsibility for health. Staff at the Department met regularly with the Denver Health and Hospital Corporations Community Voices team to explore program successes, as well as, identify and resolve issues that might impede enrollment and access to care.

11. Toll Free Number and Website CHP+ maintains a toll free telephone number so that community partners, members and potential members can obtain information about the program. In addition, CHP+ maintains a website (www.cchp.org) that can be used as a reference tool for community partners, members and potential members. CHP+ has observed a steady increase in web-based traffic regarding the program over the past two years. Both the toll free telephone number and website have Spanish options. For other languages, CHP+ relies on AT&T’s language line. This is publicized on program materials.

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

Effective Date:

Approval Date: 26 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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

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

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

6.1.1.1

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3

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

6.1.2

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

6.1.3

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

6.1.4

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1

Coverage the same as Medicaid State plan 6.1.4.2

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire

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

Effective Date:

Approval Date: 27 Medicaid population 6.1.4.4

Coverage that includes benchmark coverage plus additional coverage 6.1.4.5

Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7

Other (Describe)

6.2 The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

See Attachment 3 Benefits

6.2.1

Inpatient services (Section 2110(a)(1))

6.2.2

Outpatient services (Section 2110(a)(2))

6.2.3

Physician services (Section 2110(a)(3))

6.2.4

Surgical services (Section 2110(a)(4))

6.2.5

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

6.2.6

Prescription drugs (Section 2110(a)(6))

6.2.7

Over-the-counter medications (Section 2110(a)(7))

6.2.8

Laboratory and radiological services (Section 2110(a)(8))

6.2.9

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

6.2.10

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

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

Effective Date:

Approval Date: 28 6.2.11

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

6.2.12

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

6.2.13

Disposable medical supplies (Section 2110(a)(13))

6.2.14

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

Nursing care services (See instructions) (Section 2110(a)(15))

6.2.16

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17

Dental services (Section 2110(a)(17)) *Dental benefits were effective 2/1/02. Please see Attachment 3.

6.2.18

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

6.2.19

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

6.2.20

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

6.2.21

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

6.2.22

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

6.2.23

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

6.2.24

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

6.2.25

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26

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

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

Effective Date:

Approval Date: 29

6.2.27

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

6.2.28

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

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

6.3.1

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

6.3.2

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

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

6.4.1

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

6.4.1.1 Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

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

Effective Date:

Approval Date: 17 and accuracy of screening for Medicaid eligibility, determining eligibility for CHP+ and enrolling children into the program.

ELIGIBILITY DETERMINATION AND RENEWAL

Redetermination of Eligibility

Enrollment in Health Plans

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

Effective Date:

Approval Date: 18 receive care through the CHP+ managed care network for a period of 14 to 45 days until the effective date of HMO coverage.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

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

In the event the Department makes a determination to limit enrollment to ensure that the program maintains sufficient funds, enrollment in CHP+ shall be halted.

No waiting list will be maintained for CHP+.

The administration of an enrollment cap will be communicated prior to

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

Effective Date:

Based on the criterion described above, Colorado has implemented a cap effective November 1, 2003. This cap will be lifted in accordance with the above procedures as funds become available.

4.4 Describe the procedures that assure that:

Medicaid Screening

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

Effective Date:

Other Creditable Coverage Screening

If an applicant has received health insurance in the last three months and the employer paid more than 50% of the premium, there is a three month lock out period for the applicant.

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

Effective Date:

4.4.4.1

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

4.4.4.2

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

4.4.4.3

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

4.4.4.4

If the state provides coverage under a premium

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

Effective Date:

Approval Date: 22 assistance program, describe:

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

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

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

Effective Date:

Approval Date: 23 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

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

Effective Date:

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

Effective Date:

Approval Date: 25 children. Some serve as satellite eligibility determination sites. Others participate in community coalitions that enroll children in Medicaid and CHP+.

(spa)(co-cspa-6)(current-state-plan)(page-39)Page 39#

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

Effective Date:

Approval Date: 26 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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

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

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

6.1.1.1

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3

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

6.1.2

6.1.3

6.1.4

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1

Coverage the same as Medicaid State plan 6.1.4.2

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire

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

Effective Date:

Approval Date: 27 Medicaid population 6.1.4.4

Coverage that includes benchmark coverage plus additional coverage 6.1.4.5

Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6

Other (Describe)

See Attachment 3 Benefits

6.2.1

Inpatient services (Section 2110(a)(1))

6.2.2

Outpatient services (Section 2110(a)(2))

6.2.3

Physician services (Section 2110(a)(3))

6.2.4

Surgical services (Section 2110(a)(4))

6.2.5

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

6.2.6

Prescription drugs (Section 2110(a)(6))

6.2.7

Over-the-counter medications (Section 2110(a)(7))

6.2.8

Laboratory and radiological services (Section 2110(a)(8))

6.2.9

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

6.2.10

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

Effective Date:

Approval Date: 28 6.2.11

6.2.12

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

6.2.13

Disposable medical supplies (Section 2110(a)(13))

6.2.14

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

Nursing care services (See instructions) (Section 2110(a)(15))

6.2.16

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17

Dental services (Section 2110(a)(17)) *Dental benefits were effective 2/1/02. Please see Attachment 3.

6.2.18

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

6.2.19

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

6.2.20

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

6.2.21

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

6.2.22

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

6.2.23

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

6.2.24

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

6.2.25

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26

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

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

Effective Date:

Approval Date: 29

6.2.27

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

6.2.28

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

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

6.3.1

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

6.3.2

6.4.1

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

Effective Date:

Approval Date: 30 6.4.1.2 The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

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

6.4.2

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

6.4.2.1 Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2 The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3 The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

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

Effective Date:

Approval Date: 31 Section 7. Quality and Appropriateness of Care

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

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

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1

Quality standards 7.1.2

Performance measurement 7.1.3

Information strategies 7.1.4

Quality improvement strategies

CHP+ will use quality standards, performance measures, information strategies, and quality improvement studies to assure high-quality care for CHP+ enrollees. The CHP+ program will use quality assurance methods and tools such as NCQA accreditation standards, National Association of Insurance Commissioners (NAIC) standards, Quality Improvement System for Managed Care (QISMC), Healthplan Employer Data and Information Set (HEDIS), Consumer Assessment of Health Plans Survey (CAHPS) data, standard Division of Insurance reports and quality improvement study data. The CHP+ will use standards, performance measures, consumer information, and quality improvement methods for HMOs and for the CHP+ provider network.

The Department is in the process of negotiating a contract with a vendor to perform Quality Assurance activities. The Contractor will provide consulting services that incorporate Federal and State requirements that address ongoing quality assessment and improvement strategy for the CHP+ Program contracting program. The strategy, among other things, will include:

• Physician credentialing in the self-insured managed care network • Performance based contracting standards • Self-insured managed care network HEDIS calculation audit • HEDIS analysis for all plans

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

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

Effective Date:

Approval Date: 32 7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

The Department will contract with a quality assurance vendor to measure HEDIS indicators such as the following: • Childhood Immunizations • Adolescent Immunizations • Children’s access to primary care practitioners • Appropriate medications for children with asthma • Well child visits

7.2.2 Access to covered services, including emergency services as defined in 42 CFR §457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Adequate access to emergency services is assured for all Colorado managed care enrollees by a Division of Insurance regulation that took effect on July 1, 1997. This regulation (4-2-17) specifies that a managed care organization cannot deny an emergency claim if a "prudent lay person would have believed that an emergency medical condition or life or limb threatening emergency existed." The regulation also restricts the use of prior authorizations for emergency care and the denial of emergency care provided by non-network providers.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollees medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

Benefit procedures exist for members with chronic, complex, or serious medical conditions. All of the managed care organizations must comply with the Department of Insurance regulations regarding access to and adequacy of specialists.

The following are the benefits for persons with chronic conditions: • Any combination of 30 treatment days for inpatient physical, occupational, and/or speech therapy per injury or illness. The services must be received within six months from the date on which the illness or injury occurred. • Any combination of 30 treatments for outpatient physical, occupational, and/or speech therapy per illness or injury or diagnosed neurological, muscular, or structural abnormality per

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

Effective Date:

Approval Date: 33 year.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

The CHP+ prior authorizations are consistent with commercial packages. The contracted managed care organizations and the self- insured network are required to comply with the State regulations set forth by the Division of Insurance.

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

Effective Date:

Approval Date: 34 Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1

YES

8.1.2

NO, skip to question 8.8.

8.2 Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1 Annual Enrollment Fee:

For families above 151% of the Federal Poverty level it is: $25 for 1 child and $35 for two or more.

8.2.2 Deductibles: None

8.2.3 Coinsurance or copayments:

American Indian/Alaska Natives are exempt from co-payment and annual enrollment requirements.

8.2.4 Other:

8.3 Describe how the public will be notified, including the public schedule, of this cost-sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

The Medical Services Board, a rule making body appointed by the Governor and confirmed by the Senate, was created by the Legislature effective July 1, 1994 with rule making authority for the Medicaid program. During the 2001 session, rule making authority was moved from the former Children’s Basic Health Plan Policy Board (which was disbanded) to the Medical Services Board. This new structure puts rule making authority in the same body for both the Medicaid and CHP+, which increases the opportunity for streamlining

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

Effective Date:

Approval Date: 35 and consolidation between programs. The Medical Services Board is subject to the regulations of the Administrative Services Act which provides direction to rule making boards throughout the state on public input around the rule making process.

Rules governing the CHP+ program are drafted and placed on the WEB and the public is noticed regarding the hearing of the rules at the Medical Services Board meeting. The Medical Services Board hears testimony prior to passing rules. After rule adoption, the rules are published in the Colorado Registry and are placed on the WEB.

A chart describes coverage options, the cost sharing requirements for annual enrollment fees and specific services (copayments) based on income and family size, and the plans they can choose. A booklet designed specifically for a lower income audience describes how managed care plans work, and how to make a good choice for ones children.

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

8.4.1

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530)

8.4.2

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

The following procedures will be considered well-baby and well- child care:

CPT-4 codes: Preventive medicine codes: 99381-New patient under one year; 99382-New Patient age 1-4 years; 99383-New patient ages 5-11 years; 99384- New patient ages 12 through 17 years; 99391-Established patient under one year; 99392- Established patient ages 1-4 years; 99393-Established patient ages 5 through 11 years; 99394 – Established patient aged 12-17; 99431- Newborn care (history and examination); 99432-Normal newborn care.

Evaluation and Management Codes: 99201-99205-New patient; 99211-99215-Established patient.

ICD-9-CM codes: V20-V20.2-Health supervision of infant and child; V70.0-General medical examination (routine); V70.3-V70.9-General

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

Effective Date:

Approval Date: 36 medical examination.

All infants and children should be seen by a Primary Care Provider regularly for immunizations (shots) and check-ups. The CHP+ follows the well-child visits schedule recommended by the American Academy of Pediatrics. The American Academy of Pediatric recommends that children receive well-child visits at the following ages: 1 week, 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months 18 months, 2 years, 3 years, 4 years, 5 years 6 years, 8 years, 10 years, 11 years, 12 years, and 13 years.

8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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

Annual enrollment fees for families through 151% FPL will be waived. For families between 151% and 200%, the annual enrollment fee shall be $25 for one eligible child and $35 for two or more eligible children.

State planners feel that few families will reach their 5% limit. An analysis of the States fee schedule suggests that cumulative cost sharing will rarely exceed 1% of the family’s adjusted gross income. However, CHP+ administrative personnel make families aware of the aggregate limit on cost sharing through a number of information and educational sources. Through direct communication with families, the CHP+ marketing and outreach efforts often discuss the aggregate limit on cost sharing. The first direct written communication with CHP+ families instructs parents that the expenditures on their child(ren)s health care through CHP+ should not exceed 5% of family income. Through contracts with Managed Care Organizations, the CHP+ administration ensure that the plans make their enrollees aware of the aggregate limit on cost sharing by including information regarding the cost-sharing limit in their member handbooks.

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

Effective Date:

Approval Date: 37 The State has adopted the "shoe box" approach to reimburse families who exceed the 5% limit. Families are required to track expenditures based on he calculation of family income provided by the state and to submit receipts for all expenditures in excess of the 5% limit. Since the eligibility process will determine an “eligibility income” for each family, that family will receive notification of the exact dollar figure that will represent 5% of the family’s adjusted gross income.

Once they submit evidence that they have exceeded the 5% cap, the state will issue them a "co-pay exempt" sticker to be placed on their membership card. Providers and plans will be informed that enrollees with this sticker are not being charged co-payment for any service. The 5% limit is calculated on the family’s income at the time of eligibility determination. This cap is cited on the enrollment card. The cap will be recalculated if a family applies for a redetermination before the year is complete.

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

The joint application includes a question asking the applicant to indicate their ethnicity. Alaskan Native and American Indian are two of the choices. When this information is entered into the computerized eligibility and tracking system, the rules engine recognizes ethnicity and determines a $0 co-payment. This $0 is printed out on the enrollees’ card. The provider uses this card to determine the co-payment to be charged to the patient.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)) If an enrollee does not pay the annual enrollment fee within the 30 days after the notice, they are denied for the program.

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

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, co- payments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollees’ family income has declined prior to disenrollment for non payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate

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

Effective Date:

Approval Date: 38 enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

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

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

8.8.1

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220)

8.8.2

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

8.8.4

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

(spa)(co-cspa-6)(current-state-plan)(page-52)Page 52#

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

Effective Date:

Approval Date: 39 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

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

Strategic objectives are to: 1. Improve health status of children in Colorado with a focus on preventive, and early primary treatment. 2. Decrease the proportion of children in Colorado who are uninsured. 3. Encourage employer based coverage. 4.Coordinate and consolidate with other health care programs providing services to children to create a seamless health care delivery system for low-income children. 5. Improve access to dental care for children.

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

1. Improve health status of children in Colorado with a focus on preventive, and early primary treatment. Performance Goals: • Develop measurable performance goals with the Quality Improvement committee by January 2003. • Contract with a Quality Assurance vendor by September 2002.

2. Decrease the proportion of children in Colorado who are uninsured.

Performance Goals:

• By FY 04-05 the Department is to have an enrollment rate of 85% of the estimated eligible population every year.

3. Encourage employer based coverage.

(spa)(co-cspa-6)(current-state-plan)(page-53)Page 53#

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

Effective Date:

Approval Date: 40 Performance Goals:

• Maintain the three month lock out period for those applicants having had employer paid health insurance (employer paying at least 50%) within three months of application. • Continue to ask if the applicant has other insurance on the joint application.

4. Coordinate and consolidate with other health care programs providing services to children to create a seamless health care delivery system for low-income children.

Performance Goals:

• Evaluate the transfer process of cases to State Medicaid Technicians at the administrative offices in FY 03-04.

5. Improve access to dental care for children. Performance Goals: • Conduct a quality assurance dental survey by June 2003. • Develop a plan for improved care based on the results of the Dental Survey. • Assure network adequacy.

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

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid.

9.3.2

The reduction in the percentage of uninsured children.

9.3.3

The increase in the percentage of children with a usual source of care.

9.3.4

The extent to which outcome measures show progress on one or more of the health problems identified by the state.

(spa)(co-cspa-6)(current-state-plan)(page-54)Page 54#

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

Effective Date:

Approval Date: 41 9.3.5

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6

Other child appropriate measurement set. List or describe the set used. 9.3.7

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1

Immunizations 9.3.7.2

Well child care 9.3.7.3

Adolescent well visits 9.3.7.4

Satisfaction with care 9.3.7.5

Mental health 9.3.7.6

Dental care 9.3.7.7

Other, please list: 9.3.7.8

Performance measures for special targeted populations.

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

9.5 The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

Colorado’s S-CHIP estimated baseline of uncovered, low-income children is 172,457, with a CHP+ eligibles baseline estimate of 69,157. This is a revision since the estimate submitted to HCFA in the 1998 annual report. The Department felt the availability of more recent data, specific to Colorado, provided opportunity to derive an estimate that would more closely reflect the current status of children in the state.

Colorado's S-CHIP began with year 2000 population projections for children under age 19 for each county in the state. The source of these projections was the Colorado Demography Information Service within the Colorado Division of Local Government. Then, using individual county uninsured rates (published in the 1997 Colorado Health Source Book: Insurance, Access, and Expenditures, April 1998, and funded by the Rose Community Foundation and The Colorado Trust), each county's population projection was multiplied by its uninsured rate to get the number of uninsured under age 19 in that county. The Colorado Health Source Book derived the method for determining its uninsured rates from "Estimating County Percentages of Uninsured People," Inquiry, 28:413-419 (1991), and used a three-year average of 1995-1996-1997 CPS data from the March Supplements. County uninsured rates ranged from 9.0% to 40.9% among the 63 counties in Colorado, varying widely from the overall state estimate of

(spa)(co-cspa-6)(current-state-plan)(page-55)Page 55#

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

Effective Date:

Approval Date: 42 15.2%. The computed county estimates of uninsured under age 19 were summed to get a total for the state. The following tables summarize this methodology:

Number of Children Who Are Uninsured

Colorado 1997 County Uninsured rates (Colorado Demography Information Service) 2000 Colorado Population under Age 19 # of Uninsured under Age 19 (Sum of County Estimates)

Uninsured under 19

Range = 9.0% - 40.9%

1,145,447

172,457

This represents all uninsured children in the state, at all income levels. To determine the number of children who would be S-CHIP-eligible, or at or below 185% of the federal poverty level (FPL), The Department used an estimate from the American Academy of Pediatrics (AAP) which says that S-CHIP-eligibles under 200% FPL in the state comprise 40.1% of the uninsured under age 19. The source for this estimate was AAP’s analysis of 1994-1997 March Current Population Survey Supplements and a 1998 Census Bureau child population projection. Each county's under-19 uninsured estimate was multiplied by this percentage to get S-CHIP eligibles by county, which were then summed to get a state total. (If 40.1% is applied to the state total number of uninsured under age 19, instead of each county's total, a slightly different estimate is obtained, but the difference is negligible, attributable to the rounding of county estimates.)

Number of Uninsured Children Who Are S-CHIP-Eligible:

AAP CHIP-Eligible Percentage (Using 1994-1997 CPS and Census 1998 projection) Number of Uninsured under Age 19 2000 Colorado Population under Age 19, Uninsured, and under 200% FPL

Uninsured under age 19

40.1%

172,457

69,157

It is this final estimate -- 69,157 -- against which Colorado's S-CHIP measures its performance in reducing the proportion of uncovered, low-income children in the state, for FFY 1998 and FFY 1999.

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

(spa)(co-cspa-6)(current-state-plan)(page-56)Page 56#

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

Effective Date:

Approval Date: 43 9.7 The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

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

Provide a budget for this program. Include details on the planned use of funds and sources of the non-Federal share of plan expenditures. (Section 2107(d))

Attachment 4

9.8.1

Section 1902(a)(4)(C) (relating to conflict of interest standards)

9.8.2

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment)

9.8.3

Section 1903(w) (relating to limitations on provider donations and taxes)

9.8.4

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

Six working teams were created to design the core elements of the CHP+ and to promote ongoing public input into the plan. The CHP+ teams recommended benefits and cost sharing were applied to the CHP+ proposed in this Title XXI State Plan. The six teams were: 1) benefits design and pricing; 2) eligibility, enrollment, and management information system design; 3) financing; 4) marketing and outreach; 5) employer advisory group; and 6) contracting and quality assurance. A Policy Board reviewed team recommendations and gave strategic direction to the Department of Health Care Policy and Financing. The individuals who were members of these working teams had the opportunity to provide input into the development of CHP+, from the early stages of the decision-making process up to and beyond implementation. These working teams were staffed and led by individuals representing the Department, the business community, the insurance industry, providers, children’s advocates, schools, employers, and other public and private programs providing services to children.

(spa)(co-cspa-6)(current-state-plan)(page-57)Page 57#

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

Effective Date:

Approval Date: 44 Benefits Design and Pricing. This team was responsible for designing the benefit package and developing cost-sharing and subsidy structures. This team developed price estimates for the benefit package under different cost sharing and subsidy structures scenarios. Members of this team represented advocates for low-income families, the Colorado Division of Insurance, mental health providers, EPSDT outreach workers, providers of care to handicapped children, pediatricians, community health centers, and managed care organizations. Marketing and Outreach. This team was responsible for developing a marketing plan and outreach strategy for partnering with schools, doctors offices, employers, social service providers, and public health entities throughout the state. This team recommended to the Department the most effective outreach plan, materials design, and marketing strategy to ensure that eligible families are notified that this product was available and how they could apply. The team developed a long term, phased plan for outreach and marketing CHP+. Not only school systems were tapped, but team members, through their varied work in the community were natural advocates and enlisted volunteers who could advocate for CHP+, throughout the state. Members of this team represented schools, day care centers, managed care organizations, providers, children’s advocacy groups, and CHP+. Eligibility, Enrollment, and Management Information Systems Design. This team was responsible for developing an eligibility and enrollment system that would be flexible, simple to administer, and meet the long-term needs of CHP+. This team was also responsible for developing recommendations for the rules by which a child would be deemed eligible for the program. Members of this team included representatives from managed care organizations, the Medicaid program in the Department of Health Care Policy and Financing, the Program for Children with Special Health Care Needs, Indian tribes, community health centers, CHP+ philanthropic provider clinics, and other providers. Financing. This team was responsible for identifying funding streams available to finance the program, preparing budget projections, developing estimates of the number of children that would be enrolled, and creating mechanisms to ensure that CHP+ would be fiscally sound. Members of this team included representatives from community health centers, the Colorado Indigent Care Program, the Office of State Planning and Budgeting, the CHP+, and the Department of Health Care Policy and Financings budget and accounting offices. Employer Advisory Group. This team presented recommendations to the Department regarding mechanisms to ensure that CHP+ did not become a substitute for employer-based coverage. This group established a means for the Department and employers to coordinate coverage for children eligible for the program, create incentives for employers to assist the Department with outreach and eligibility determination, and presented recommendations as to how the

(spa)(co-cspa-6)(current-state-plan)(page-58)Page 58#

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

Effective Date:

Approval Date: 45 subsidy can be structured to ensure that employees did not drop employer-based coverage. Membership of this team represented a broad base of employers and business organizations such as US West, Kodak, and Mile Hi Child Care Centers. Contracting and Quality Assurance: This team was responsible for developing purchasing strategies and contract standards for the CHP+ program. The team reviewed options for purchasing, pricing and quality assurance from Medicaid and commercial models. Policy Board: The initial Department-appointed Policy Board reviewed key team recommendations and gave strategic guidance to the Department of Health Care Policy and Financing in the design and implementation of CHP+. This group was comprised of high-level private sector business managers, hospitals, providers, children’s advocates, the insurance industry, the General Assembly, the Colorado Department of Public Health and Environment, and the Colorado Division of Insurance. The Department-appointed Policy Board disbanded after the passage of House Bill 98-1325, which became law on April 21, 1998. A provision of that legislation created an 11-member Policy Board charged with promulgating rules for the as CHP+.

Upon dissolution of the Policy Board in August 2001, public input is received through a variety of methods:

• Rule Making: At the time of any presentation of a rule to be approved by the Board, interested advocates are notified of the rule and public testimony is encouraged at the Board meeting; • Department staff meet regularly with patient advocacy groups; • Drafts of items requesting public input are placed on the CHP+ Website; • Any member of the public has the right to correspond directly with Board members.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

CHP+ contracts with Indian Health Services providers as SED sites. We receive valuable information from local tribes from the organizations that serve the local American Indian tribes around the barriers to providing health insurance to this population. Because the Indian Health Services provides routine health care services to this population, it is difficult to demonstrate the need for health insurance. We are

(spa)(co-cspa-6)(current-state-plan)(page-59)Page 59#

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

Effective Date:

Approval Date: 46 constantly looking for ways to market to this population.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d).

A special committee was created as a part of the Policy Board to study dental provider adequacy. This committee represented advocacy groups, dental providers, State Health Department staff and Board members. The rules were presented to the State Medical Assistance Advisory Council and staff brought their recommendation to add language requiring the inclusion of Essential Community Providers to the Policy Board in the dental network was accepted.

A dental benefit was added effective February 1, 2002. Prior to the effective date, the former Children’s Basic Health Plan Policy Board and the State Medical Assistance and Services Advisory Council forums were used as mechanisms for public notice and input. The State Medical Assistance and Services Advisory Council is a group with specialized knowledge and experience to be added to that available in the Department of Health Care Policy & Financing, and provides a two-way channel of communication with the individuals, organizations, and institutions in the community that, with the administrating Agency, provide and/or pay for medical care and services.

Once the rules were adopted, they were published on the CHP+ Web site. All adopted rules are also sent to the Secretary of State and published in the Colorado Code of Regulations.

The administration of an enrollment cap will be communicated prior to implementation by providing in writing: posting on the Internet, a letter to the legislature, and policymakers throughout the state. It will also be presented to the Medical Services Board, the rule making body for the CHP+, members of which are appointed according to political affiliation, geographic representation, and provider or recipient status. A news release will be provided to the media on the procedures related to the cap. No waiting list will be maintained for interested CHP+ applicants. A notice of the removal of a cap will be provided to media, interested parties, and policy makers at the appropriate time.

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

(spa)(co-cspa-6)(current-state-plan)(page-60)Page 60#

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

Effective Date:

Approval Date: 47 Planned use of funds, including: • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment.

Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

Attachment 4

(spa)(co-cspa-6)(current-state-plan)(page-61)Page 61#

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

Effective Date:

Approval Date: 48 Section 10. Annual Reports and Evaluations (Section 2108)

10.1 Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1

The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

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

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

(spa)(co-cspa-6)(current-state-plan)(page-62)Page 62#

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

Effective Date:

Approval Date: 49 Section 11. Program Integrity (Section 2101(a))

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

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

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9)

11.2.1

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents)

11.2.2

Section 1124 (relating to disclosure of ownership and related information)

11.2.3

Section 1126 (relating to disclosure of information about certain convicted individuals)

11.2.4

Section 1128A (relating to civil monetary penalties)

11.2.5

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6

Section 1128E (relating to the National health care fraud and abuse data collection program)

(spa)(co-cspa-6)(current-state-plan)(page-63)Page 63#

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

Effective Date:

Approval Date: 50 Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the states Medicaid plan.

Eligibility and Enrollment Matters

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

If an applicant does not agree with the eligibility determination assessed by the contractor, the applicant may appeal the decision. This appeal must be in writing and within 30 days of the eligibility determination letter. If the appeal cannot be favorably resolved with the contractor, the appeal is taken to the Grievance Committee. The Grievance Committee consists of the appeal staff person from the contractor, an eligibility technician, and three staff persons from the Department of Health Care Policy and Financing. The three staff persons have never seen the case before and are well versed in the rules of the program. Applicants may attend the committee meeting by telephone, in person, or may send a representative and may have access to all documents that were used to determine their eligibility. All communication needs are taken care of for the applicant during a committee meeting; i.e. translation. A final decision is made during the Grievance Committee meeting and the applicant is notified of the decision within 10 days. All decisions made in the Grievance Committee are final.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR §457.1120.

Within the MCO contracts are provisions regarding health services matters. The Contractor is to agree to adequately staff and maintain a Member services and Complaint response function to explain operations, assist in the selection of a PCP, assist in how to make appointments and recording and responding to member complaints, or oral expressions of dissatisfaction with the Contractors plan.

The Contractor shall process prospective, concurrent and retrospective reviews, and have in place procedures for complaints and appeals of Adverse Determinations that comply with the requirements concerning these activities contained in Title 10, C.R.S., and Colorado Division of Insurance regulations. All determinations of Medical Necessity of Covered Services are subject to these appeal processes.

(spa)(co-cspa-6)(current-state-plan)(page-64)Page 64#

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

Effective Date:

Approval Date: 51

Premium Assistance Programs

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

(spa)(co-cspa-6)(factsheet)Colorado CHIP SPA CO-CSPA-6: Factsheet (approved December 23, 2005, effective July 1, 2005)#

(spa)(co-cspa-6)(factsheet)(page-1)Page 1#

COLORADO TITLE XXI STATE PLAN FACT SHEET

Name of Plan:

Child Health Plan Plus (CHP+)

Date Plan Submitted:

October 14, 1997 Date Plan Approved:

February 18, 1998 State Plan Effective Date:

April 22, 1998

Date Amendment # 1 Submitted:

January 19, 1999 Date Amendment # 1 Approved:

September 21, 1999 Date Amendment # 1 Effective:

April 22, 1998

Date Amendment #2 Submitted:

December 20, 2000 Date Amendment #2 Approved:

March 28, 2001 Date Amendment #2 Effective:

October 1, 2000

Date Amendment #3 Submitted:

December 27, 2000 Date Amendment #3 Approved:

March 28, 2001

Date Amendment #3 Effective:

October 1 2000 Date Amendment #4 Submitted:

June 28, 2002 Date Amendment #4 Approved:

April 24, 2003 Date Amendment #4 Effective:

February 1, 2002

Date Amendment #5 Submitted:

December 17, 2003 Date Amendment #5 Approved:

March 9, 2004 Date Amendment #5 Effective:

November 1, 2003

Date Amendment #6 Submitted:

September 27, 2005 Date Amendment #6 Approved:

December 23, 2005 Date Amendment #6 Effective:

July 1, 2005

Date Amendment # 7 Submitted: May 30, 2007 Date Amendment # 7 Withdrawn:

May 23, 2008

Date Amendment # 8 Submitted:

June 25, 2008 Date Amendment # 8 Approved:

May 6, 2009 Date Amendment # 8 Effective:

March 1, 2008

Date Amendment #9 Submitted:

April 30, 2010 Date Amendment # 9 Approved:

July 28, 2010 Date Amendment #9 Effective:

May 1, 2010

Background

• On October 14, 1997, Colorado submitted a Title XXI State Plan to expand

children’s access to health coverage by building on the experience and

infrastructure of the Colorado Child Health Plan (CCHP), an existing State-only

(spa)(co-cspa-6)(factsheet)(page-2)Page 2#

program providing basic medical services to low-income children, and established

Child Health Plan + (CHP+), a separate child health program.

• Coverage was initially provided to children through age 17 with family incomes at or

below 185 percent of the Federal Poverty Level (FPL).

Amendments

• Effective April 22, 1998, Colorado amended its Title XXI State Plan to expand

coverage to children through age 18 with family incomes at or below to 185

percent of the FPL.

• Colorado submitted its second amendment on December 20, 2000, to eliminate

premiums and implement an annual enrollment fee for families with incomes

between 151 and 185 percent of the FPL.

• On December 27, 2000, Colorado submitted an amendment to its Title XXI State

Plan to make changes in its application and enrollment process and in its service

delivery system.

• Colorado submitted its fourth amendment on June 28, 2002, to update and amend

the SCHIP State Plan to indicate compliance with the final SCHIP regulations and

to add dental benefits for children. The addition of the dental benefit was effective

February 1, 2002.

• On December 10, 2003, Colorado submitted its fifth amendment to provide

Colorado with the authority to implement and to subsequently revoke an

enrollment freeze, as the State budget allows. A freeze on enrollment became

effective on November 1, 2003, and will remain in place until either additional

funds become available, or the number of enrolled children no longer obligates all

appropriated funds.

• On September 27, 2005, Colorado submitted its sixth amendment to raise the

upper eligibility limit for children covered under the State plan from 185 percent

of the Federal Poverty Level (FPL) up to 200 percent of the FPL.

•

On May 30, 2007, Colorado submitted its seventh amendment to require individuals

to establish residency before applying for the SCHIP program. The amendment was

withdrawn on May 23, 2008.

• On June 25, 2008, Colorado submitted its eighth amendment to add a new income disregard of 2.5 percent of FPL only for families above 200 percent of FPL after allowable deductions (e.g. child support payments) are applied. If the family is above 200 percent of the FPL, the child qualifies for CHIP. If the family remains above 200 percent of the FPL after allowable deductions, and the 2.5 percent disregard, the child is denied coverage under CHIP. The State is requesting a retroactive date of March 1, 2008.

(spa)(co-cspa-6)(factsheet)(page-3)Page 3#

• On April 30, 2010, Colorado submitted its ninth amendment to increase the upper income level to 250 percent of the FPL. The SPA adds the following out-of- pocket cost changes. For all families above 151 percent of the FPL there will be a $25 enrollment fee for one child, a $35 enrollment fee for two or more children. In addition, while copayments of $5 per office visit will be charged to families with incomes that fall between 151 and 200 percent FPL, families with incomes from 201 to 250 percent of FPL will be asked to pay $10 per office visit. The State requested a retroactive effective date of May 1, 2010.

Children Covered Under Program • The State reported that 102,395 children were ever enrolled in the program during Federal Fiscal Year 2009.

Administration • The Department of Health Care Policy and Financing administers CHP+ with

subcontracts for provider network administration, enrollment, outreach, and

customer service.

Health Care Delivery System

• The program uses MCOs for health care delivery services. The statewide provider

network established by the former Colorado Child Health Plan has been expanded

to care for children who are eligible for CHP+ but who have not yet been enrolled in

a HMO (HMOs generally initiate coverage on the first of the month only) and

those children who live in areas where no service is available.

• The State contracts directly with provider practices to deliver covered benefits to

children in areas of the State where HMOs are not available.

Benefit Package

• Colorado is using a benchmark-equivalent benefit package. The benefit package

includes inpatient services; outpatient services; physician services; surgical

services; dental services; vision services; prescription drugs; lab and radiology

services; prenatal care and family planning services; inpatient and outpatient

mental health services; outpatient substance abuse treatment services; durable

medical equipment; home and community-based health care; case management

services; physical and occupational therapy; hospice care; medical transportation;

organ transplant and skilled nursing facility care.

Crowd-Out Strategy

• Information on access to health care coverage is collected. There is a 3-month

waiting period for applicants who had coverage with at least a 50 percent

employer contribution.

• The State will monitor for substitution. Reports are generated on a monthly basis

(spa)(co-cspa-6)(factsheet)(page-4)Page 4#

that break out application denials due to other insurance and access to State

employee benefits.

Cost Sharing

• Colorado’s cost sharing plan ranges from $2 to $10 per office visit depending on family income. Native American families pay no out of pocket costs. In no case does cost sharing exceed the 5 percent of family income limit.

State Outreach and Enrollment Activities

•

CHP+ created an extensive marketing and outreach program encompassing

strategies that range from grass roots networking to mass market advertising

campaigns. These efforts have been implemented to reach families in many

different ways with different messages.

Coordination between SCHIP and Medicaid

•

The State uses a joint application. Eligibility is first determined for Medicaid. If

the child is determined ineligible, eligibility is then determined for CHP+ •

State statutes mandate that only plans willing to contract with Medicaid are

eligible to serve CHP+ members. This message ensures continuity of care if a

child becomes eligible for Medicaid.

Financial Information

Total FFY 2010 SCHIP allotment--$100,696,000 FFY 2010 Enhanced Federal Matching Rate—65%

Date last updated: July 8, 2010

(spa)(co-cspa-9)(approval-package)Colorado CHIP SPA CO-CSPA-9: Approval Package (approved June 28, 2010, effective May 1, 2010)#

(spa)(co-cspa-9)(approval-package)(page-1)Page 1#

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Center for Medicaid, CHIP and Survey & Certification

June 28, 2010

William Heller, Director Child Health Plan Plus Colorado Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203-1818

Dear Mr. Heller:

Your ninth title XXI Children’s Health Insurance Program (CHIP) State plan amendment (SPA) submitted on May 4, 2010, with revised State plan pages and additional information submitted on June 28, 2010, has been approved. This amendment has a retroactive effective date of May 1, 2010.

This SPA allows Colorado to obtain Federal matching funds to expand the upper income eligibility level for targeted low-income children from 200 percent of the Federal poverty level (FPL) to 250 percent of the FPL. Children in this new expansion group will be subject to a premium. The State projects it will provide coverage to an additional 6,300 children in Federal Fiscal Year (FFY) 2010, and an additional 15,000 children FFY 2011.

We note that the eligibility standards, methodologies and procedures (including the imposition of premiums) applicable to the new expansion group are less restrictive than those in effect on March 23, 2010, since these children would not have been eligible at all on that date. Thus, there is no issue related to the CHIP maintenance of effort requirements under section 2101(b) of the Affordable Care Act.

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

Centers for Medicare & Medicaid Services

Center for Medicaid, CHIP and Survey & Certification

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8686

Facsimile: (410) 786-5943

E-mail: june.milby@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Milby and to Mr. Richard Allen, Associate Regional Administrator in our Denver Regional Office. Mr. Allen’s address is:

(spa)(co-cspa-9)(approval-package)(page-2)Page 2#

Page 2 – Mr. William Heller

Denver Regional Office 1600 Broadway, Suite# 700 Denver, Colorado 80202-4967 (303) 844-4024

If you have additional questions, please contact Ms. Victoria Wachino, Director, Family and Children’s Health Programs Group at (410) 786-5647.

We look forward to continuing to work with you and your staff.

Sincerely,

/s/

Cindy Mann

Director

cc: Richard Allen, ARA, CMS Region VIII, Denver

(spa)(co-cspa-12)(approval-package)Colorado CHIP SPA CO-CSPA-12: Approval Package (approved April 25, 2013, effective January 1, 2013)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

April 25, 2013

William Heller Director, Child Health Plan Plus Colorado Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203-1818

Dear Mr. Heller:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number 12, submitted on January 23, 2013, with additional information submitted on March 29, 2013, has been approved.

This SPA allows Colorado to make the following changes to its program, effective January 1, 2013.

1. Change Colorado’s CHP+ program from a separate program to a combination program and outline the new Federal Poverty Level requirements for children eligible for CHP+ and Medicaid. This CHIP SPA removes these children from the CHIP state plan.

2. Transition pregnant women from coverage in Colorado’s 1115 Demonstration to coverage in the CHIP state plan. 3. Add eligibility for children of state employees as long as they meet all other eligibility requirements. 4. Revise the process for enrollment in managed care. 5. Revise language surrounding the ten day noticing procedure. 6. Clarify that families have the option to share information for purposes of determining express lane eligibility. During the review of this amendment request, it was noted that in some counties of the state, there is only one Managed Care Organization (MCO) available to deliver care for CHIP eligible families. This is not compliant with 1932(a)(4) of the Social Security Act, which requires that individuals be allowed to disenroll from the managed care entity and have the option to receive CHIP health care benefits through alternate means. In our discussions with your staff, we understand that a

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second MCO would not be supported in these counties. We will continue to work with the state on a resolution to this issue. We also look forward to reviewing any available reports to assess network adequacy for CHIP enrollees, while providing technical support to assist the state with meeting this requirement.

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

Centers for Medicare & Medicaid Services

Center for Medicaid, CHIP and Survey & Certification

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2176

Facsimile: (410) 786-5943

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

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

Denver Regional Office Colorado State Bank Building 1600 Broadway, Suite# 700 Denver, Colorado 80202-4967

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of Children's Health Insurance Programs (410) 786-5143. Thank you for your continued efforts to improve coverage for Colorado’s children and families.

We look forward to continuing to work with you and your staff.

Sincerely,

/s/

Cindy Mann

Director

cc: Richard Allen, ARA, CMS Region VIII, Denver

(spa)(co-cspa-12)(current-state-plan)Colorado CHIP SPA CO-CSPA-12: Current State Plan (approved April 25, 2013, effective January 1, 2013)#

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

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

State/Territory:

Colorado

(Name of State/Territory)

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

____________________________________________________________________________ Suzanne Brennan, Medical and CHP+ Program Administration Office Director / Date Signed

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

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

Name: Susan E. Birch Position/Title: Executive Director, Colorado Department of Health Care Policy and Financing Name: John Bartholomew Position/Title: Director of the Office of Financial and Administrative Services Name: William Heller Position/Title: Director, Children’s Basic Health Plan d/b/a Child Health Plan Plus (CHP+)

*Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program

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2 (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

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

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

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

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3 state plan.

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

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4 and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below:

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

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

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

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

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6 a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

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

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7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements 1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)( 1)); (42 CFR 457.70):

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

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

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

1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1. and 1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval.

1.1.3.

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

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2  Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3  Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Guidance: The effective date as specified below is defined as the date on which the State begins to

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

Original Plan Date Plan Submitted:

October 14, 1997 Date Plan Approved:

February 18, 1998 State Plan Effective Date: April 22, 1998

On October 14, 1997, Colorado submitted a Title XXI State Plan to expand children’s access to health coverage by building on the experience and infrastructure of the Colorado Child Health Plan (CCHP), an existing State-only program providing basic medical services to low-income children, and established Child Health Plan + (CHP+), a separate child health program. Coverage was initially provided to children through age 17 with family incomes at or below 185 percent of the Federal Poverty Level (FPL).

Date Amendment # 1 Submitted: January 19, 1999 Date Amendment # 1 Approved: September 21, 1999 Date Amendment # 1 Effective:

April 22, 1998

Effective April 22, 1998, Colorado amended its Title XXI State Plan to expand coverage to children through age 18 with family incomes at or below to 185 percent of the FPL.

Date Amendment #2 Submitted: December 20, 2000 Date Amendment #2 Approved:

March 28, 2001 Date Amendment #2 Effective:

October 1, 2000

Colorado submitted its second amendment on December 20, 2000, to eliminate premiums and implement an annual enrollment fee for families with incomes between 151 and 185 percent of the FPL.

Date Amendment #3 Submitted: December 27, 2000 Date Amendment #3 Approved:

March 28, 2001

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9 Date Amendment #3 Effective:

October 1 2000

On December 27, 2000, Colorado submitted an amendment to its Title XXI State Plan to make changes in its application and enrollment process and in its service delivery system.

Date Amendment #4 Submitted: June 28, 2002 Date Amendment #4 Approved:

April 24, 2003 Date Amendment #4 Effective:

February 1, 2002

Colorado submitted its fourth amendment on June 28, 2002, to update and amend the SCHIP State Plan to indicate compliance with the final SCHIP regulations and to add dental benefits for children. The addition of the dental benefit was effective February 1, 2002.

Date Amendment #5 Submitted: December 17, 2003 Date Amendment #5 Approved:

March 9, 2004 Date Amendment #5 Effective:

November 1, 2003

On December 10, 2003, Colorado submitted its fifth amendment to provide Colorado with the authority to implement and to subsequently revoke an enrollment freeze, as the State budget allows. A freeze on enrollment became effective on November 1, 2003, and will remain in place until either additional funds become available, or the number of enrolled children no longer obligates all appropriated funds.

Date Amendment #6 Submitted: September 27, 2005 Date Amendment #6 Approved:

December 23, 2005 Date Amendment #6 Effective:

July 1, 2005

On September 27, 2005, Colorado submitted its sixth amendment to raise the upper eligibility limit for children covered under the State plan from 185 percent of the Federal Poverty Level (FPL) up to 200 percent of the FPL.

Date Amendment # 7 Submitted: May 30, 2007 Date Amendment # 7 Withdrawn: May 23, 2008

On May 30, 2007, Colorado submitted its seventh amendment to require individuals to establish residency before applying for the SCHIP program. The amendment was

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10 withdrawn on May 23, 2008.

Date Amendment # 8 Submitted: June 25, 2008 Date Amendment # 8 Approved:

May 6, 2009 Date Amendment # 8 Effective:

March 1, 2008

On June 25, 2008, Colorado submitted its eighth amendment to add a new income disregard of 2.5 percent of FPL only for families above 200 percent of FPL after allowable deductions (e.g. child support payments) are applied. If the family is above 200 percent of the FPL, the child qualifies for CHIP. IF the family remains above 200 percent of the FPL after allowable deductions, and the 2.5 percent disregard, the child is denied coverage under CHIP. The State requested a retroactive date of March 1, 2008.

Date Amendment #9 Submitted:

April 30, 2010 Date Amendment # 9 Approved:

July 28, 2010 Date Amendment #9 Effective:

May 1, 2010

On April 30, 2010, Colorado submitted its ninth amendment to increase the upper income level to 250 percent of the FPL. The SPA adds the following out-of-pocket cost changes. For all families above 151 percent of the FPL there will be a $25 enrollment fee for one child, a $35 enrollment fee for two or more children. In addition, while copayments of $5 per office visit will be charged to families with incomes that fall between 151 and 200 percent FPL, families with incomes from 201 to 250 percent of FPL will be asked to pay $10 per office visit. The State requested a retroactive effective date of May 1, 2010.

Date Amendment # 10 Submitted: April 16, 2012 Date Amendment # 10 Approved: September 17, 2012 Date Amendment # 10 Effective:

April 1, 2012

This State Plan Amendment includes the following changes: o Puts the State Plan into the revised CHIP State Plan template that was issued in 2011. o Adds Express Lane Eligibility. o Adds the Tribal Consultation policy and procedure. o Clarifies the State’s presumptive eligibility and 12-month continuous eligibility policies for CHIP. o Adds the Income and Eligibility Verification System as a method for verifying income. o Clarifies the State’s CHIP Dental Services, as required in the revised State Plan template. o Increases the annual enrollment fee for families with income greater than 205% and

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11 up to 250% of the FPL, to $75 for one child and $105 for two or more children.

SPA # 11 Date SPA # 11 Submitted: __August 30, 2012_ Date SPA # 11 Approved: __December 10, 2012 Date SPA # 11 Effective: __July 1, 2012

SPA # 11 Description: This State Plan Amendment increases the copayments for some services and adds copayments for services that previously had none.

SPA # 12 Date SPA # 12 Submitted: _January 18, 2013 Date SPA # 12 Approved: __April 25, 2013 Date SPA # 12 Effective: __January 1, 2013

SPA # 12 Description: This State Plan Amendment includes the following changes: o Changes Colorado’s CHIP program from a Separate Program to a Combination Program. Under or uninsured children 6 through 18 years of age with family income above 100% FPL and at or below 133% FPL are covered through a Medicaid Expansion. Under or uninsured pregnant women with family income above 133% FPL and at or below 185% FPL are also covered through a Medicaid Expansion. Uninsured pregnant women with family income at or below 250% FPL that are ineligible for Medicaid are moved from the Section 1115 Waiver to coverage through the CHIP State Plan. No changes are made to the income eligibility requirements of populations already covered though the CHIP SPA. o Adds eligibility for children of State employees as long as they meet all other eligibility requirements. o Revises language surrounding the ten day noticing procedure. o Modifies Express Lane Eligibility to comply with instructions from the Centers for Medicare and Medicaid Services. o Adds passive enrollment to the MCO assignment and selection process for children. o Updates eligibility screening process and methods used to coordinate with other health coverage programs.

The State included consultation on this SPA in the tribal consultation log dated 8/01/2012. A copy of the relevant page of the consultation log is attached.

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

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

See Attachment 1 for a description of children’s insurance status by income and race and ethnicity.

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

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)) ; (ARRA #2, CHIPRA #3, issued May 28, 2009)

Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health

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13 Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

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

The Colorado CHP+ program meets the requirements described above through execution of a formal consultation agreement with American Indian health programs in Colorado. Together with the Department of Health Care Policy and Financing (the Department), the parties to the consultation agreement include the Southern Ute Indian Tribe, the Ute Mountain Ute Tribe, Denver Indian Health and Family Services, the Colorado Department of Public Health and Environment, and the Office of the Lieutenant Governor of Colorado.

The Department intends to use the following process, as described in the consultation agreement, to seek advice on a regular ongoing basis from the parties:

Programmatic Action Log Update On a bi-monthly basis (approximately every sixty days) each state agency (the Department of Public Health and Environment and the Department of Health Care Policy and Financing) shall distribute to the Tribes and the UIHO Urban Indian Health Organization a Programmatic Action Log Update. The Update shall contain a continuous list of Programmatic Actions that each state agency is developing or initiating. The Update has a short description of each Programmatic Action, any clearly foreseeable Tribal implications, important dates, or implementation timeframes, and if the Programmatic Action is considered an Actionable Item. The Update shall indicate a date by which additional consultation must be requested by a Tribe or the UIHO (thirty days from receipt of the Update). The Update shall also contain an area to track whether additional consultation was requested, and by whom, and to update current status or resolution of Programmatic Actions.

Additional Consultation A Tribe or UIHO may request additional consultation on any Actionable Item on the Update or on any question, concern, policy, practice, or issue within the scope of the state agencies’ responsibilities relating to the health of American Indians or Alaska Natives living in Colorado. Actionable Items on the Update shall indicate a date by which a Tribe or the UIHO must request additional consultation thirty days from receipt of the Update Additional consultation shall be

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14 initiated by written notice may be in the form of an email from a designated Tribal or UIHO Liaison(s) and directed to a designated Indian Health Liaison(s). Consultation may include but shall not be limited to meetings (face-to-face or via teleconference), written correspondence, including emails, presentations, and discussions at the Colorado Commission of Indian Affairs Health and Wellness Committee meetings. When consultation is completed, a written response from one or both state agencies to the party that requested the consultation shall be sent describing the final determination or outcome regarding the topic of consultation. This information shall also be included on the Programmatic Action Log Update.

Meetings: Face-to-Face and Remotely The state agencies, Tribes, and UIHO all together or individually, shall meet face-to-face no less than once per fiscal year and as resources allow. As necessary, the state agencies, Tribes, and UIHO, all together or individually, shall meet remotely via teleconference or videoconference to discuss outstanding issues or hold consultations as described above.

Section 3. Methods of Delivery and Utilization Controls

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

Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems. Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to CMS’ Regional Office servicing them for review and approval.

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

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

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

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

Health Maintenance Organizations

State legislation (House Bill 97-1304) requires that only plans willing to contract with Medicaid

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16 are eligible to serve CHP+ clients. This will ensure that clients are not forced to change providers each time their financial situation changes the program for which they are eligible (Medicaid or CHP+). The CHP+ program contracts with managed care organizations serving a significant number of commercial and Medicaid clients statewide. These plans vary in structure, service area and membership.

Essential Community Providers: As required by state legislation (House Bill 97-1304), CHP+ only contracts with HMOs that are willing to contract with the Colorado Medicaid program. To retain their Medicaid contracts, these HMOs must fulfill the statutory requirements of SB 97-75 with regard to use of ECPs. Therefore, the CHP+ managed care network includes these providers. ECPs include community health centers, community mental health centers, public health agencies, school-based clinics, family planning clinics, and other indigent care providers.

Self-Insured Managed Care Network

The Department contracts with a single entity to manage all aspects of the self-insured managed care network. These physicians, hospitals and ancillary service providers provide services covered by the CHP+ comprehensive benefit package in areas where HMO services are not available, mainly rural areas. The self-insured managed care network provides the same benefit package through a managed care system that is provided through the HMOs in a managed care system.

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

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

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4) (42CFR 457.490(b))

The self-insured managed care network and the HMOs use managed care utilization standards to assure that enrollees only receive appropriate and medically necessary care.

Section 4. Eligibility Standards and Methodology Guidance: The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. Included on the template is a list of potential eligibility standards. Please check off the standards that will be used by the state and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, describe how they will be applied and under what circumstances they will be applied.

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

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group : The Medicaid expansion will increase eligibility to under or uninsured children 6 through 18 years of age with family income above 100% FPL and at or below 133% FPL and to under or uninsured pregnant women with family income above 133% FPL and at or

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18 below 185% FPL.

4.1.

Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a) and 457.320(a)) 4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option. SSA verification is used to verify citizenship and identity. An automated response from SSA confirms that the self-reported data is consistent with SSA data and meets citizenship and identity verification requirements. No further action is required for the applicant.

4.1.1  Geographic area served by the Plan if less than Statewide: The plan is available statewide, in all 64 Colorado counties. 4.1.2  Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group: CHP+ is available to children 0 through 18 years of age with family income at or below 250% FPL.

4.1.2.1-PC Age: _______________ through birth (SHO #02-004,

issued November 12, 2002)

4.1.3  Income of each separate eligibility group (if applicable): To be eligible, a child must be from a family whose annual income is at or below 250% of the federal poverty level. Family size and income criteria are described in Attachment 2.

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through

________% of the FPL (SHO #02-004, issued November 12, 2002)

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19 and private, on the application form before the child is enrolled in the plan and from providers once the child is determined eligible for the plan. A child will be found ineligible if the child: 1) is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) has had coverage under an employer plan with at least a 50% employer contribution during the three months prior to application. The Health Care Program for Children with Special Needs is not considered a private health plan and children covered under this plan may still be covered by CHP+. Children who are a members of a family that is eligible for health benefits coverage under a State health benefits plan based on a family member’s employment with a public agency in the state may be covered under this plan (as described in Section 4.4.1) if they meet all other eligibility criteria.

If the State finds that a child enrolled in CHP+ is retroactively eligible for Medicaid, the State will notify the family that the child will be disenrolled from CHP+ and enrolled into Medicaid in 10 days. If there are fewer than 10 days remaining in the month in which the child is determined eligible for Medicaid, CHP+ eligibility is extended through the last day of the following month. The State may choose to enroll the child into Medicaid sooner than 10 days if the Medicaid benefit package offers necessary services that the CHP+ plan does not cover.

4.1.8  Duration of eligibility, not to exceed 12 months: Once a child has been accepted, he or she is continuously eligible for one year from the postmark date of the complete application unless the child moves from the state, turns 19 years old, or becomes eligible for or enrolled in Medicaid, or other private insurance. 4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

4.1.9.1 States should specify whether Social Security Numbers (SSN) are required. Social Security Numbers are not required.

Guidance: States should describe their continuous eligibility process and populations

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20 that can be continuously eligible.

4.1.9.2 Continuous eligibility. Children ages 0-18 may be continuously eligible. Once a child has been determined eligible, the child is continuously eligible for one year from the postmark date of the complete application unless the child moves from the state, turns 19 years old, or becomes eligible for or enrolled in Medicaid, or private health insurance.

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1- PW, 8.1.2-PW, and 9.10 when electing this option. 4.1.0-P Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option. SSA verification is used to verify citizenship and identity. An automated response from SSA confirms that the self- reported data is consistent with SSA data and meets citizenship and identity verification requirements. No further action is required for the applicant. 4.1.1-P Geographic area served by the Plan if less than Statewide: The plan is available statewide, in all 64 Colorado counties. 4.1.2-P Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group: Pregnant women of any age who meet the income requirements in section 4.1.3-P are eligible. 4.1.3-P Income of each separate eligibility group (if applicable): To be eligible, a pregnant woman must be from a family whose annual income is at or below 250% of the federal poverty level. Family size and income criteria are described in Attachment 2. 4.1.5-P Residency (so long as residency requirement is not based on length of time in state): A resident is anyone who is: 1) a U.S. citizen; or 2) a documented legal immigrant who has had an Alien Registration Card for 5 years or more and 3) a resident of Colorado. The state accepts self- declaration of residency. 4.1.7-P Access to or coverage under other health coverage: Both the application and the separate "Insurance Form" ask families questions about other insurance coverage. The plan administration seeks information about all other access to health care coverage, both public and private, on the application form before the pregnant woman is

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21 enrolled in the plan and from providers once she is determined eligible for the plan. A pregnant woman will be found ineligible if she: 1) is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid.

If the State finds that a client enrolled in CHP+ is retroactively eligible for Medicaid, the State will notify the client that she will be disenrolled from CHP+ and enrolled into Medicaid in 10 days. If there are fewer than 10 days remaining in the month in which the client is determined eligible for Medicaid, CHP+ eligibility is extended through the last day of the following month. The State may choose to enroll the client into Medicaid sooner than 10 days if the Medicaid benefit package offers necessary services that the CHP+ plan does not cover.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1)“lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In other words, a State that chooses to cover pregnant women under this option must otherwise cover pregnant women under their State plan as described in 4.1.11. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1993(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is:

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22 (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women.

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23 Elected for children under age _____.

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

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

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

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

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

standards do not cover children of higher income families without covering

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

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

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

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

income children.

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

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

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

standards do not cover children of higher income families without covering

children with a lower family income.

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

existing medical condition.

Both initial eligibility and annual renewal eligibility for CHP+ are determined either at the main office or at a decentralized eligibility site.

Applications may be received by mail or by Fax at the central office or during face-to-face interviews at the decentralized sites. Applicants may also complete applications online, or drop off paper applications in person during central office business hours.

ELIGIBILITY DETERMINATION AND RENEWAL

Redetermination of Eligibility

Persons enrolled in CHP+ are enrolled for a period of twelve months. Renewal letters and packets are mailed to families at least 45 days before the day their CHP+ coverage terminates. Reminder letters are mailed to the family 30 days before the end-of-coverage date. Families are encouraged to return their completed renewal application at least 30 days prior to termination to allow continuity of care through their managed care organization (MCO). If the family does not resubmit a complete application by the ending date of coverage, the person’s eligibility may still be renewed. The only penalty is interrupted coverage.

At redetermination, renewal requires the same financial documentation as was required at the time of the family’s original application. A family will be fully processed for eligibility at each

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25 renewal period.

Once the State has re-determined eligibility, a letter is sent to the households above 150% and at or below 250% of the FPL which owe an enrollment fee to notify them that they have 30 days from the date of re-determination to submit the enrollment fee. Coverage begins when the State receives the enrollment fee. If the enrollment fee is not submitted by the end of the 30-day period, the client’s coverage will end at the end of the redetermination period. Once the client pays the enrollment fee, coverage will resume.

Enrollment in Health Plans

All pregnant women are enrolled in the CHP+ managed care network for the entire enrollment period. Eligible children who live in areas served by MCOs, however, must enroll in an MCO. Once eligibility has been determined, the families of these children have the opportunity to select a participating MCO in their county of residence. If the family has notified the Department or its designee of its chosen MCO prior to the last business day of the month during which the child was determined eligible, the child shall be enrolled in that MCO. If the family has not chosen an MCO, the child shall be enrolled in an MCO by the Department or its designee. In areas of the state where there is only one participating MCO available, the Department or its designee select that MCO and enroll the child.

Families are notified of the MCO in which their children are enrolled and are offered a 1-800 number to answer any questions they may have or change their MCO. If the family wants to change MCOs, it will have 90 days from the effective date of the MCO enrollment to contact the Department or its designee in order to select a different MCO. Once an enrollee has selected an MCO or upon expiration of the 90 day period, the enrollee shall remain enrolled in that MCO for the remainder of the eligibility period. Families who live in areas of the state that are not served by an MCO continue to receive care through the CHP+ managed care network.

For renewal applications, the Department or its designee reassigns the eligible child to the participating MCO they were enrolled in during the previous enrollment period. Families of eligible children may notify the Department or its designee within their re-enrollment period, if they wish to change the MCO enrollment.

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

The applicant must pay the annual enrollment fee in order for the child(ren) to enroll in CHP+. Once the State has determined eligibility (or automatic redetermination has occurred), a letter is sent to households that are above 150% and at or below 250% of the FPL to notify them that they owe an enrollment fee and have 30 days from the date of determination (or redetermination) to submit an enrollment fee. Coverage begins when the State receives the enrollment fee. If the enrollment fee is not submitted by the end of the 30-day period, the client will be denied for non- payment and will have to re-apply.

In the event the Department makes a determination to limit enrollment to ensure that the program maintains sufficient funds, enrollment in CHP+ shall be halted.

No waiting list will be maintained for CHP+.

The administration of an enrollment cap will be communicated prior to implementation by providing in writing; a posting on the Internet, a letter to the legislature, and policymakers throughout the state. It will also be presented to the Medical Services Board, members of which

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27 are appointed according to political affiliation, geographic representation, and provider or recipient status. A news release will be provided to the media on how the new applications will be responded to. No waiting list will be maintained for interested CHP+ applicants. A notice of the removal of a cap will be provided to media, interested parties, and policy makers at the appropriate time.

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

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

State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the

requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355). The State provides presumptive eligibility for children and pregnant women, and meets the requirement in 42 CFR 457.355. The State does not require verification of citizenship status for purposes of presumptive eligibility.

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

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

4.3.3.1-EL Also indicate whether the Express Lane option is

applied to (1) initial eligibility determination, (2) redetermination, or (3) both. The Express Lane option is applied to both initial eligibility determination and redetermination.

4.3.3.2-EL List the public agencies approved by the State as

Express Lane agencies. Free/reduced lunch programs.

4.3.3.3-EL List the components/components of CHIP eligibility

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

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28 Express Lane option. Express Lane Eligibility is used to determine income only. The free/reduced lunch program uses the income levels specified for the program by the USDA. The income level for free lunch is 130% of the FPL, and the income level for reduced lunch is 185% FPL. Data from free/reduced lunch does not replace the Medicaid/CHP+ eligibility process; it only prompts the State to open a case. Children up to 133% FPL are eligible for Medicaid, and children at or below 250% FPL are eligible for CHP+.

4.3.3.4-EL Describe the option used to satisfy the screen and

enrollment requirements before a child may be enrolled under

title XXI. Citizenship and identity are verified through the SSA interface.

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

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

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

4.4.1.  only targeted low-income children who are ineligible for Medicaid or not

covered under a group health plan or health insurance (including access to a

State health benefits plan) are furnished child health assistance under the plan.

(Sections 2102)(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR

457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply

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a waiting period for pregnant women.

The State uses an integrated system that determines eligibility for public assistance programs including Medicaid, CHP+, the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and many others. In determining eligibility for CHP+, the eligibility system will first run eligibility rules for Medicaid. If the applicant is determined to be eligible for Medicaid, the applicant is enrolled in Medicaid and CHP+ eligibility is denied. If the applicant is determined to be ineligible for Medicaid, the system will run eligibility rules for CHP+. If the applicant is determined to be eligible for CHP+, the applicant is enrolled in CHP+. Because the State uses an integrated system and a joint application, eligibility is run for both programs without applicants or eligibility technicians performing additional steps. At the end of the eligibility determination process, the system automatically generates and sends notices to the applicants informing them of which program(s) they are approved for and which are denied. The Department also contracts with an eligibility and enrollment vendor that processes most CHP+ applications, provides application assistance and customer service.

County departments of social services provide support to low-income families in communities ranging from food stamps and Women, Infants, and Children programs to child care and Colorado Works. Many CHP+ referrals come from these programs. In addition, because federal law mandates linkage between CHP+ and Medicaid (for example, through a common application) some CHP+ applications are submitted through county departments of social services.

Other Creditable Coverage Screening

The joint Medicaid/CHP+ application, asks the applicant to report any health insurance coverage. If the family reports creditable coverage (most group health plans and health insurance coverage), the child or pregnant woman will be found ineligible. Providers contracting with the CHP+ are required contractually to notify the plan whenever they have reason to believe a member has coverage other than CHP+. CHP+ then verifies coverage with the insurance carrier and notifies the family that they will be disenrolled.

If a child has received health insurance in the last three months and the employer paid more than 50% of the premium, there is a three month lock out period for the applicant. There is no waiting period for pregnant women.

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30 Children of state employees will be enrolled into CHP+ if they meet all other technical eligibility requirements including income limits and lack of health insurance. Per section 10203(b)(2)(D) of the Affordable Care Act, States are permitted to extend CHIP eligibility to children of State employees who are otherwise eligible under the Title XXI (CHIP) State Plan to the extent that one of two conditions is met. These conditions are described in a new section 2110(b)(6) of the Social Security Act (added by the Affordable Care Act and amended by Public Law 111-309) and are referred to as the hardship and the maintenance of agency contribution conditions.

Colorado will monitor whether it meets the maintenance of agency contribution criteria on an annual basis. The methodology outlined above will be used each year to ensure that Colorado’s contribution towards the cost of employee dependent coverage remains no less than its contribution in 1997, adjusted for inflation.

4.4.2.  children found through the screening process to be potentially eligible for

medical assistance under the State Medicaid plan are enrolled for assistance

under such plan; (Section 2102)(b)(3)(B)) (42CFR, 457.350(a)(2))

As explained in Section 4.4.1, Colorado uses an integrated system that determines eligibility for various public assistance programs, including Medicaid and CHP+. The joint Medicaid/CHP+ application notifies applicants that information will be shared with both Medicaid and CHP+ to determine eligibility for both programs. The eligibility system first runs eligibility rules for Medicaid prior to determining eligibility for CHP+. If the applicant is determined to be eligible for Medicaid, the applicant is enrolled in Medicaid and CHP+ eligibility is denied. The applicant then receives notice of this determination and their enrollment.

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

enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR,

431.636(b)(4))

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31 As explained in Section 4.4.1, Colorado uses an integrated system that determines eligibility for public assistance programs including Medicaid, CHP+, and many others. The joint Medicaid/CHP+ application notifies applicants that information will be shared with both Medicaid and CHP+ to determine eligibility for both programs. The eligibility system first runs eligibility rules for Medicaid prior to determining eligibility for CHP+. If the applicant is determined to be eligible for Medicaid, the applicant is enrolled in Medicaid and CHP+ eligibility is denied. If the applicant is determined to be ineligible for Medicaid, the system runs eligibility rules for CHP+. If the applicant is determined to be eligible for CHP+, the applicant is enrolled in CHP+ and receives notice of this determination and their enrollment.

4.4.4.  the insurance provided under the State child health plan does not substitute for

coverage under group health plans; states should check the appropriate box.

(Section 2102)(b)(3)(C)) (42CFR, 457.805) (42CFR 457.810(a)-(c))

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium

assistance program, describe: 1) the minimum period without coverage

under a group health plan. This should include any allowable exceptions

to the waiting period; 2) the expected minimum level of contribution

employers will make; and 3) how cost-effectiveness is determined.

4.4.5  Child health assistance is provided to targeted low-income children in the State who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

CHP+ has contracts with Indian Health Services in all areas of the state to allow tribal clinics to deliver health care to Native Americans. Because the federal legislation governing the Indian Health Services has regulations against the use of managed care, CHP+ pays these facilities fee-for-service. These primary care contracts, continue to allow Native Americans full access to specialty providers through a managed care environment (though still paid fee-for-service.)

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

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

requirements:

The State will continue to use the screen and enroll procedures required under section

2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

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

Section 5. Outreach and Coordination 5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42CFR 457.80(b))

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

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

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

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Colorado identifies and enrolls children eligible to participate in public health insurance programs through a broad outreach strategy through both public and private partners and through direct appeals to families in the media and in their communities. One of the most successful efforts after five years of operation has been and continues to be word of mouth that has been generated by the positive experiences of members and local partners.

One important method of enrollment that has simplified the process for families is the development of a simplified, joint application that partners and the agency can use to enroll children and families in both Medicaid or CHP+. This simplified application can be obtained through the standard Medicaid outreach and enrollment process, as well as through the standard CHP+ outreach and enrollment processes.

• County social services departments determine a person’s eligibility for Medicaid. Presumptive eligibility sites (Federally Qualified Health Centers and Planned Parenthood clinics), county nurses offices, doctor’s offices and Indian Health Centers determine presumptive Medicaid eligibility and enroll pregnant women. Infants up to twelve months old born to Medicaid-enrolled women are guaranteed Medicaid eligibility for twelve months.

• Posters, brochures, and a 1-800 number provide Medicaid information to potentially eligible families at several locations, including public assistance offices.

• Colorado uses an integrated system that determines eligibility for public assistance programs including Medicaid, CHP+, and several others. Because the State uses an integrated system and a joint application, eligibility is run for both Medicaid and CHP+ without applicants or eligibility technicians performing additional steps. Through this system, any clients applying for CHP+ are automatically screened for Medicaid eligibility prior to being screened for CHP+ eligibility. (See section 4.4.1 for more details)

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34 2. CHP+ is a public/private partnership providing subsidized health insurance for children in low-income families statewide who are not eligible for Medicaid. The Medical Services Board provided oversight and policy development. CHP+ is administered by the Department of Health Care Policy and Financing through private contractors who provide various services. These organizations manage the routine administrative matters associated with CHP+.

National data and three years of experience have shown that reaching out on a local level is the most effective way to reach eligible families. CHP+ has continued its efforts to partner with many community-based organizations throughout the year. CHP+ created partnerships with approximately 2000 community-based organizations including: schools; Head Start programs; family resource centers; community health centers; United Way agencies; public health departments; county departments of social services; Women, Infants, and Children programs; and many others. These extensive partnerships represent an extraordinary commitment statewide to enroll uninsured children as part of the CHP+ comprehensive marketing and outreach strategy. In addition, CHP+ program initiated a targeted television advertising campaign and began testing employer-based outreach activities. All of these activities represent Colorado’s interest in reaching families in every way possible.

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

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

The Healthy Communities initiative does the marketing and outreach for CHP+. The Healthy Communities outreach and case management model takes into account that many families do not always understand the distinction between Medicaid and CHP+. Healthy Communities uses Family Health Coordinators who increase awareness of CHP+ and Medicaid programs, offer face-to-face application assistance, educate families on the value of preventative health services, link clients to providers that will serve as the client’s Medical Home, and explain the reenrollment process.

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To better evaluate the effectiveness of these strategies, CHP+ implemented a large-scale, application-source tracking system in March 2000. The system allows an application to be traced back to the initial source without relying on self-reported referral data. This tracking system will continue to be used to monitor trends and results from marketing and outreach campaigns.

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

• The non-CICP community health centers and other safety net providers who determine Medicaid eligibility refer clients to a CICP provider if they determine that a client is not eligible for Medicaid, but may be eligible for CICP. Children are referred to CHP+ first if the safety net providers determine that a client is not eligible for Medicaid.

3. Cover Colorado, established in 1990 by the Colorado General Assembly as a quasi- governmental entity, provides health insurance to individuals, including children, who are

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36 denied commercial health insurance by private carriers because of a pre-existing medical condition. Cover Colorado and CHP+ often compare enrollment and disenrollment information to discern trending that may be relevant to both programs.

Community Health Centers, many of who are Federally Qualified Health Centers, take the following steps to enroll children in Medicaid, CHP+, the Colorado Indigent Care Program (CICP), or the health center’s sliding fee scale plan:

If a patient/family is not eligible for any program, the health center uses its sliding fee scale to determine the fee according to family size and income.

5. County public health departments identify low income, uninsured children through referrals from a variety of sources including: Women, Infant and Children (WIC), child health and immunization clinics, other community health providers (including private physicians), community health and social services agencies and schools, Headstart centers, Early Childhood Connections (Part C), homeless shelters, and self-referrals. Public health staff refers families to any available health care insurance source for which they appear to be eligible, including Medicaid and CHP+ and work with local physicians to try and secure services on a reduced-fee basis. Many public health agency staff members assist families in completing application forms for Medicaid and the CHP+. In Colorado, Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) outreach workers and administrative case managers are a part of local public health agency staff who facilitate access to Medicaid and to CHP+ services for eligible children.

6. Maternal and Child Health Block Grant (Title V of the Social Security Act) funds in Colorado are "passed through" to local public health agencies and other qualified non-profit

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37 agencies where they are used to support a number of activities on behalf of women and children, particularly those of low income. State Title V staff provides oversight, consultation and standards to assure appropriate utilization of these funds. When families are ineligible for any insurance plan, or when there is not another provider of free or reduced price health care (i.e. community or rural health centers) available or accessible, these public health agencies provide direct services to low- income children. Services provided in local public health agencies are almost always provided by public health nurses. Services include comprehensive well child clinic services, including developmental and physical assessments, immunizations, and parent education. Families under 100% FPL pay nothing for these services. Others pay on a sliding fee scale.

7. School-based health centers (SBHC) provide comprehensive primary care services including care for acute and chronic illness, injuries, family planning and prenatal care, some diagnostics services and prescriptions. SBHCs provide services at no charge. However, patients are asked whether or not they have health care coverage. The amount of reimbursement for which SBHCs bill depends on the administrative capabilities of the center and whether a CHP+ participating managed care organization contracts with them. SBHCs facilitate application to Medicaid, CHP+ or CICP when documentation of family income and assets is obtainable without jeopardizing students’ confidentiality.

9. The Commodity Supplemental Food Program (CSFP) provides infant formula and nutritious foods to supplement the diet of pregnant and postpartum women and children under age 6. Women who live in Conejos, Costillo, Denver, Mesa, Rio Grande or Weld counties and who have a combined family income at or below 185% of the federal poverty level qualify for the program. Staff encourage pregnant women and parents and guardians of infants under 12 months of age to apply for Medicaid and CHP+.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP. Express lane eligibility streamlines the eligibility process and reduces administrative burden to eligibility sites and clients. If the school determines the child is eligible for Free or Reduced Lunch using the Free/Reduced Lunch application, the school will provide the application information to an eligibility site if the family opts-in to this service, and a Family Medicaid/ CHP+ application will be initiated. Currently, on the Free/Reduced Lunch application, families must opt in to share their information with Medicaid/CHP+.

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5.3 Strategies (formerly Section 5 “Outreach”) Guidance: Describe the procedures used by the State to accomplish outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) The description should include information on how the State will inform the target of the availability of the programs, including American Indians and Alaska Natives, and assist them in enrolling in the appropriate program.

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

The primary outreach strategy for the CHP+ program is Healthy Communities outreach. Healthy Communities uses Family Health Coordinators who increase awareness of CHP+ and Medicaid/EPSDT programs, offer face-to-face application assistance, educate families on the value of preventative health services, link clients to providers that will serve as the client’s Medical Home, and explain the reenrollment process.

In addition, the State uses the following strategies to reach people who may be eligible for the program:

1. Community Partnerships: A cornerstone of the CHP+ outreach strategy is to maintain and build on community partnerships. To reach all eligible families through as many avenues as possible, CHP+ works with more than 2000 partners. These include: schools; Head Start programs; family resource centers; community health centers; United Way agencies; public health departments; county departments of social services; Women, Infants, and Children nutrition programs; faith-based organizations and a myriad of others. So far, the most effective efforts in actually enrolling families are through schools, doctors’ offices, health departments, community health centers, and departments of social services.

2. Managed Care Organizations: Managed care organizations have increased their CHP+ outreach. One method of partnering has been the implementation of joint media campaigns in which a majority of managed care partners have participated. These purchased advertisements were structured so that each partner received air time when marketing would be most effective.

All of CHP+’s managed care partners have participated in various community events

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39 throughout the state.

3. Advertising and Earned Media: Television ranks as the highest source of referral for individual applications. CHP+ and managed care organizations team together to purchase targeted television advertisements.

4. County Departments of Social Services: County departments of social services provide support to low-income families in communities ranging from food stamps and Women, Infants, and Children programs to child-care and Colorado Works. Many CHP+ referrals come from these programs. About 20% of CHP+ applications are submitted through the Medicaid application process managed by county departments of social services. CHP+ continues to focus on ways to minimize delays in referrals so that eligible children can be enrolled in an expeditious manner.

5. Satellite Eligibility Determination Sites: CHP+ has a network of 73 satellite eligibility determination sites (SED sites) statewide, including multiple locations for some sites. These sites comprise community health centers, county nursing services, school-based health centers, Indian Health Centers and other community providers, and have been an essential component of the programs outreach and enrollment activities. As part of their contract with CHP+, they are required to provide outreach to their community for CHP+ and have access to an on-line eligibility program to accelerate program enrollment. SED sites account for more than 30% of submitted applications.

6. Schools: Schools are consistently one of the most frequently cited sources of referral by applicants. Increasing numbers of school districts are partnering with CHP+ to assure the children they serve know about CHP+. In 2001, more than 60% of all school districts in the state participated in CHP+ outreach activities including coordination with National School Lunch Program information, disseminating materials about CHP+ to families or allowing CHP+ partners and staff to present to family-related functions.

7. Community Health Centers: The Colorado Community Health Network has made involving its members in Medicaid and CHP+ outreach a priority. Community health centers are the largest group of primary care providers throughout the state serving low-income children. Some serve as satellite eligibility determination sites. Others participate in community coalitions that enroll children in Medicaid and CHP+.

8. Colorado Covering Kids and Families: A significant partner in developing community-based outreach has been Colorado Covering Kids and Families, which is a Robert Wood Johnson Foundation funded grant program administered by the Department of Public Health and Environment. Colorado received a Covering Kids and Families Grant from the Robert Wood Johnson Foundation in 2002. This grant is administered by a coalition of community groups including the Colorado Community Health Network, the Colorado Children’s Campaign and Catholic Charities. The program is active across the state.

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9. Community Voices: This is a joint Kellogg Foundation and Colorado Trust funded program, which has among its goals to improve the health of Denver’s medically underserved through innovations in community outreach, enrollment in publicly funded health insurance programs like CHP+, as well as small employment health plans, and clinical case management. Community Voices efforts are designed to demonstrate that culturally sensitive community outreach to underserved populations improves enrollment of eligible individuals into plans, while engaging and empowering communities to assume greater responsibility for health. Staff at the Department met regularly with the Denver Health and Hospital Corporations Community Voices team to explore program successes, as well as, identify and resolve issues that might impede enrollment and access to care.

10. Toll Free Number and Website: CHP+ maintains a toll free telephone number so that community partners, members and potential members can obtain information about the program. In addition, CHP+ maintains a website (www.cchp.org) that can be used as a reference tool for community partners, members and potential members. CHP+ has observed a steady increase in web-based traffic regarding the program over the past two years. Both the toll free telephone number and website have Spanish options. For other languages, CHP+ relies on AT&T’s language line. This is publicized on program materials.

Section 6. Coverage Requirements for Children’s Health Insurance

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

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

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

6.1.1.

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

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

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41 6.1.1.1.

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

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

6.1.1.2.

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

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

6.1.1.3.

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

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

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42 • hearing services.

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

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

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

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If ”existing comprehensive state-based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for ”existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide

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43 an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state-based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1.

Coverage the same as Medicaid State plan 6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver 6.1.4.3.

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

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in 457.420, plus additional c . Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.

Coverage that is the same as defined by existing comprehensive state-based coverage applicable only New York, Pennsylvania, or Florida (under 457.440 )

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than to coverage under one of the benchmark plans specified in 457.420, through u e of a benefit-by-benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in  457.431 to determine actuarial equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit

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44 comparison (Provide a sample of how the comparison will be done)

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other (Describe)

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

6.2. The State elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1.  Inpatient services (Section 2110(a)(1)) 6.2.2.  Outpatient services (Section 2110(a)(2)) 6.2.3.  Physician services (Section 2110(a)(3)) 6.2.4.  Surgical services (Section 2110(a)(4)) 6.2.5.  Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.  Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.  Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.  Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.  Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11.  Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

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45 6.2.12.  Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

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

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.15.

Nursing care services (Section 2110(a)(15)) 6.2.16.  Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.  Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.  Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.  Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.  Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.  Hospice care (Section 2110(a)(23))

6.2.24.

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

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46 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.  Medical transportation (Section 2110(a)(26))

6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28.  Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

6.2-DC Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3- DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999). The State does not cover this category of dental services. 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999). The State does not cover this category of dental services. 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999). The State does not cover this category of dental services. 9. Emergency Dental Services

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule

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47 Other (description attached)

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

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT2 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to

children eligible for dental-only supplemental services. Children eligible for

this option must receive the same dental services as provided to otherwise

eligible CHIP children (Section 2103(a)(5). Please update Sections 1.1-DS, 4.1- DS, 4.2-DS, and 9.10 when electing this option.

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

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

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48 6.3.2.

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

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The State may cross reference Section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community-based health delivery system. This allows the State to waive the 10% limitation on expenditures not used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a

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49 community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10% limitation will be used for other child health assistance for targeted low-income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42CFR, 457.1005(a))

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

Guidance: Check 6.6.2.if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary's satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3)) (42CFR, 457.1010)

6.4.2.

Purchase of Family Coverage- Describe the plan to purchase family coverage. Payment may be made to a State for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective. The State's cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an

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50 assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case-by-case basis, or on the cost of premium assisted coverage in the aggregate.

6.4.2.2. The State assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The State assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002 issued February, 2, 2010)A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)). Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children?

Yes

No.

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy 6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C). 6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan. 6.4.3.2.1-PA If the State is providing premium assistance for qualified employer- sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

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51 6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits. 6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F). 6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance 6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)). 6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA: Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool. 6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

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52 6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)). 6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

Section 7. Quality and Appropriateness of Care Guidance: Methods for Evaluating and Monitoring Quality- Methods to assure quality include the application of performance measures, quality standards consumer information strategies, and other quality improvement strategies.

Performance measurement strategies could include using measurements for external reporting either to the State or to consumers and for internal quality improvement purposes. They could be based on existing measurement sets that have undergone rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the use of standardized member satisfaction surveys (e.g., CAHPS) to assess members’ experience of care along key dimensions such as access, satisfaction, and system performance.

Quality standards are often used to assure the presence of structural and process measures that promote quality and could include such approaches as: the use of external and periodic review of health plans by groups such as the National Committee for Quality Assurance; the establishment of standards related to consumer protection and quality such as those developed by the National Association of Insurance Commissioners; and the formation of an advisory group to the State or plan to facilitate consumer and community participation in the plan.

Information strategies could include: the disclosure of information to beneficiaries about their benefits under the plan and their rights and responsibilities; the provision of comparative information to consumers on the performance of available health plans and providers; and consumer education strategies on how to access and effectively use health insurance coverage to maximize quality of care.

Quality improvement strategies should include the establishment of quantified quality

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53 improvement goals for the plan or the State and provider education. Other strategies include specific purchasing specifications, ongoing contract monitoring mechanisms, focus groups, etc.

Where States use managed care organizations to deliver CHIP care, recent legal changes require the State to use managed care quality standards and quality strategies similar to those used in Medicaid managed care.

Tools for Evaluating and Monitoring Quality- Tools and types of information available include, HEDIS (Health Employer Data Information Set) measures, CAHPS (Consumer Assessments of Health Plans Study) measures, vital statistics data, and State health registries (e.g., immunization registries).

Quality monitoring may be done by external quality review organizations, or, if the State wishes, internally by a State board or agency independent of the State CHIP Agency. Establishing grievance measures is also an important aspect of monitoring.

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

Guidance: The State must specify the qualifications of entities that will provide coverage and the conditions of participation. States should also define the quality standard they are using, for example, NCQA Standards or other professional standards. Any description of the information strategies used should be linked to Section 9. (Section 2102(a)(7)(A)) (42CFR, 457.495)

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (Section 2102(a)(7)(A)) (42CFR 457.495(a)) Will the State utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.  Quality standards 7.1.2.  Performance measurement

7.1.2 (a) CHIPRA Quality Core Set

7.1.2 (b)  Other

7.1.3.  Information strategies 7.1.4.  Quality improvement strategies

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54 Association of Insurance Commissioners (NAIC) standards, Quality Improvement System for Managed Care (QISMC), Healthplan Employer Data and Information Set (HEDIS), Consumer Assessment of Health Plans Survey (CAHPS) data, standard Division of Insurance reports and quality improvement study data. The CHP+ will use standards, performance measures, consumer information, and quality improvement methods for HMOs and for the CHP+ provider network.

Guidance: Provide a brief description of methods to be used to assure access to covered services, including a description of how the State will assure the quality and appropriateness of the care provided. The State should consider whether there are sufficient providers of care for the newly enrolled populations and whether there is reasonable access to care. (Section 2102(a)(7)(B))

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

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

The Department contracts with a quality assurance vendor to measure HEDIS indicators such as the following: • Childhood Immunizations • Adolescent Immunizations • Children’s access to primary care practitioners • Appropriate medications for children with asthma • Well child visits

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Adequate access to emergency services is assured for all Colorado managed care enrollees by a Division of Insurance regulation that took effect on July 1, 1997. This

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55 regulation (4-2-17) specifies that a managed care organization cannot deny an emergency claim if a "prudent lay person would have believed that an emergency medical condition or life or limb threatening emergency existed." The regulation also restricts the use of prior authorizations for emergency care and the denial of emergency care provided by non-network providers.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of- network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with State law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d)) Exigent medical circumstances may require more rapid response according to the medical needs of the patient.

The CHP+ prior authorizations are consistent with commercial packages. The contracted managed care organizations and the statewide provider network are required to comply with the State regulations set forth by the Division of Insurance.

Section 8. Cost-Sharing and Payment

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

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505) Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09-006, issued May 11, 2009)

8.1.1.  Yes

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56 8.1.2. No, skip to question 8.8.

8.1.1-PW

Yes 8.1.2-PW No, skip to question 8.8.

Guidance: It is important to note that for families below 150% of poverty, the same limitations on cost sharing that are under the Medicaid program apply. (These cost-sharing limitations have been set forth in Section 1916 of the Social Security Act, as implemented by regulations at 42 CFR 447.50-.59). For families with incomes of 150% of poverty and above, cost sharing for all children in the family cannot exceed 5% of a family's income per year. Include a statement that no cost sharing will be charged for pregnancy-related services. (CHIPRA #2, SHO # 09-006, issued May 11, 2009) (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1. Premiums: The CHP+ Program uses an annual enrollment fee rather than a monthly premium. For families above 151% of the Federal Poverty level, an annual enrollment fee is $25 for one child and $35 for two or more. For families with income greater than 205% and at or below 250% of the Federal Poverty Level, the annual enrollment is $75 for one child and $105 for two or more children.

8.2.2. Deductibles: None

8.2.3. Coinsurance or copayments:

American Indian/Alaska Natives are exempt from co-payment and annual enrollment fees.

The following copayments shall be due for enrollees at the time of service:

B. For families with income, at the time of eligibility determination, between 101% and 150% of the federal poverty level, the copayment is: 1. Two dollars per office visit;

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57 2. Two dollars per outpatient mental health or substance abuse visit; 3. One dollar per prescription; 4. Two dollars per physical therapy, occupational therapy or speech therapy visit; 5. Two dollars per vision visit; 6. Three dollars per use of emergency care and urgent/after hours care.(Co-pay is waived if client is admitted to the hospital.) 7. Two dollars per trip for emergency transport/ambulance. 8. Two dollars per inpatient hospital visit. 9. Two dollars per inpatient hospital stay, for physician services in the hospital. 10. Two dollars per outpatient hospital or ambulatory surgery center visit.

C. For families with income, at the time of eligibility determination, between 151% and 200% of federal poverty level, the copayment is: 1. Five dollars per office visit; 2. Five dollars per outpatient mental health or substance abuse visit; 3. Three dollars per generic prescription; 4. Ten dollars per brand name prescription; 5. Five dollars per physical therapy, occupational therapy or speech therapy visit; 6. Five dollars per vision visit; 7. Twenty dollars per use of urgent/after hours care. 8. Thirty dollars per use of emergency care (co-pay is waived if client is admitted to the hospital). 9. Fifteen dollars per trip for emergency transport/ambulance. 10. Twenty dollars per inpatient hospital visit. 11. Five dollars per inpatient hospital stay for physician services in the hospital. 12. Five dollars per outpatient hospital or ambulatory surgery center visit. 13. Five dollars per date of service for laboratory and imaging services.

D. For families with income, at the time of eligibility determination, between 201% and 250% of federal poverty level, the copayment is: 1. Ten dollars per office visit; 2. Ten dollars per outpatient mental health or substance abuse visit; 3. Five dollars per generic prescription; 4. Fifteen dollars per brand name prescription; 5. Ten dollars per physical therapy, occupational therapy or speech therapy visit; 6. Ten dollars per vision visit; 7. Thirty dollars per use of urgent/after hours care. 8. Fifty dollars per use of emergency care (co-pay is waived if client is admitted to the hospital.) 9. Twenty-five dollars per trip for emergency transport/ambulance. 10. Fifty dollars per inpatient hospital visit. 11. Ten dollars per inpatient hospital stay for physician services in the hospital. 12. Ten dollars per outpatient hospital or ambulatory surgery center visit.

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58 13. Ten dollars per date of service for laboratory and imaging services.

8.2.4. Other:

8.2-DS

Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)For children enrolled in the dental-only supplemental coverage, describe the amount of cost- sharing, specifying any sliding scale based on income. Also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, 6.2- DS, and 9.10 when electing this option. 8.2.1-DS Premiums: 8.2.2-DS Deductibles: 8.2.3-DS Coinsurance or copayments: 8.2.4-DS Other:

The Department worked closely with CHP+ stakeholders before putting forth this proposal to increase copayments. This change has been adopted into rule and was subject to the public rulemaking process. Stakeholders testified in favor of this change because it was a more acceptable alternative to the one put forth by the State Legislature, which would have increased cost sharing over 1000%. After rule adoption, the rules were published in the Colorado Register and posted to the Secretary of State website.

The Department gives CHP+ members and applicants a chart that describes plan options, annual enrollment fees, and copayments based on income and family size.

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

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59 appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

The following procedures will be considered well-baby and well-child care: CPT-4 codes: Preventive medicine codes: 99381-New patient under one year; 99382-New Patient age 1-4 years; 99383-New patient ages 5-11 years; 99384- New patient ages 12 through 17 years; 99391-Established patient under one year; 99392-Established patient ages 1-4 years; 99393-Established patient ages 5 through 11 years; 99394 – Established patient aged 12-17; 99431- Newborn care (history and examination); 99432-Normal newborn care.

Evaluation and Management Codes: 99201-99205-New patient; 99211-99215- Established patient.

ICD-9-CM codes: V20-V20.2-Health supervision of infant and child; V70.0- General medical examination (routine); V70.3-V70.9-General medical examination.

All infants and children should be seen by a Primary Care Provider regularly for immunizations (shots) and check-ups. The CHP+ follows the well-child visits schedule recommended by the American Academy of Pediatrics. The American Academy of Pediatrics recommends that children receive well-child visits at the following ages: 1 week, 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months 18 months, 2 years, 3 years, 4 years, 5 years 6 years, 8 years, 10 years, 11 years, 12 years, and 13 years.

8.4.3  No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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60 Through direct communication with families, the CHP+ marketing and outreach efforts often discuss the aggregate limit on cost sharing. The first direct written communication with CHP+ families instructs parents that the expenditures on their child(ren)s health care through CHP+ should not exceed 5% of family income. Through contracts with Managed Care Organizations, the CHP+ administration ensure that the plans make their enrollees aware of the aggregate limit on cost sharing by including information regarding the cost-sharing limit in their member handbooks.

The State has adopted the "shoe box" approach to reimburse families who exceed the 5% limit. Families are required to track expenditures based on the calculation of family income provided by the state and to submit receipts for all expenditures in excess of the 5% limit. Since the eligibility process will determine an “eligibility income” for each family, that family will receive notification of the exact dollar figure that will represent 5% of the family’s adjusted gross income.

Once they submit evidence that they have exceeded the 5% cap, the state will issue them a "co- pay exempt" sticker to be placed on their membership card. Providers and plans will be informed that enrollees with this sticker are not being charged co-payment for any service. The 5% limit is calculated on the family’s income at the time of eligibility determination. This cap is cited on the enrollment card. The cap will be recalculated if a family applies for a redetermination before the year is complete.

8.6 Describe the procedures the State will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost- sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

8.7 Provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

If an enrollee does not pay the annual enrollment fee within the 30 days after the notice, they are denied for the program.

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61 8.7.1 Provide an assurance that the following disenrollment protections are being applied:

Guidance: Provide a description below of the State’s premium grace period process and how the State notifies families of their rights and responsibilities with respect to payment of premiums. (42CFR 457.570(a))

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment.

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the State will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

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

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

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

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62 described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Section 9. Strategic Objectives and Performance Goals and Plan Administration Guidance: States should consider aligning its strategic objectives with those discussed in Section II of the CHIP Annual Report.

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

Strategic objectives are to: 1. Improve health status of children in Colorado with a focus on preventive, and early primary treatment. 2. Decrease the proportion of children in Colorado who are uninsured. 3. Encourage employer based coverage. 4. Coordinate and consolidate with other health care programs providing services to children to create a seamless health care delivery system for low-income children. 5. Improve access to dental care for children.

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

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

2. Decrease the proportion of children in Colorado who are uninsured. Performance Goals: • By FY 04-05 the Department is to have an enrollment rate of 85% of the estimated eligible population every year.

3. Encourage employer based coverage. Performance Goals: • Maintain the three month lock out period for those applicants having had employer paid health insurance (employer paying at least 50%) within three months of application.

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63 • Continue to ask if the applicant has other insurance on the joint application.

4. Coordinate and consolidate with other health care programs providing services to children to create a seamless health care delivery system for low-income children. Performance Goals: • Evaluate the transfer process of cases to State Medicaid Technicians at the administrative offices in FY 03-04.

Guidance: The State should include data sources to be used to assess each performance goal. In addition, check all appropriate measures from 9.3.1 to 9.3.8 that the State will be utilizing to measure performance, even if doing so duplicates what the State has already discussed in Section 9.

It is acceptable for the State to include performance measures for population subgroups chosen by the State for special emphasis, such as racial or ethnic minorities, particular high-risk or hard to reach populations, children with special needs, etc.

HEDIS (Health Employer Data and Information Set) 2008 contains performance measures relevant to children and adolescents younger than 19. In addition, HEDIS 3.0 contains measures for the general population, for which breakouts by children’s age bands (e.g., ages < 1, 1-9, 10-19) are required. Full definitions, explanations of data sources, and other important guidance on the use of HEDIS measures can be found in the HEDIS 2008 manual published by the National Committee on Quality Assurance. So that State HEDIS results are consistent and comparable with national and regional data, states should check the HEDIS 2008 manual for detailed definitions of each measure, including definitions of the numerator and denominator to be used. For states that do not plan to offer managed care plans, HEDIS measures may also be able to be adapted to organizations of care other than managed care.

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

Check the applicable suggested performance measurements listed below that the State plans to use: (Section 2107(a)(4)) 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid.

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64 9.3.2.  The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.  The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.  HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1.

Immunizations 9.3.7.2.

Well childcare 9.3.7.3.

Adolescent well visits 9.3.7.4.

Satisfaction with care 9.3.7.5.

Mental health 9.3.7.6.

Dental care 9.3.7.7.

Other, list: 9.3.8.

Performance measures for special targeted populations.

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

Guidance: The State should include an assurance of compliance with the annual reporting requirements, including an assessment of reducing the number of low-income uninsured children. The State should also discuss any annual activities to be undertaken that relate to assessment and evaluation of the program.

9.5.  The State assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the State’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

The State works with a vendor to analyze survey results from the American Community Survey to estimate the percentage of children who are eligible for CHP+ but not enrolled.

The State uses HEDIS to measure changes in health outcomes and health care related goals. The State’s estimated baseline of uncovered, low-income children is 172,457, with a CHP+ eligibles baseline estimate of 69,157. This is a revision since the estimate submitted to HCFA in the 1998 annual report. More recent data, specific to Colorado, provided opportunity to derive an estimate that would more closely reflect the current status of children in the state.

Colorado began with year 2000 population projections for children under age 19 for each county in the state. The source of these projections was the Colorado Demography

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65 Information Service within the Colorado Division of Local Government. Then, using individual county uninsured rates (published in the 1997 Colorado HealthSource Book: Insurance, Access, and Expenditures, April 1998, and funded by the Rose Community Foundation and The Colorado Trust), each county's population projection was multiplied by its uninsured rate to get the number of uninsured under age 19 in that county. The Colorado Health Source Book derived the method for determining its uninsured rates from "Estimating County Percentages of Uninsured People," Inquiry, 28:413-419 (1991), and used a three-year average of 1995-1996-1997 CPS data from the March Supplements.

County uninsured rates ranged from 9.0% to 40.9% among the 63 counties in Colorado, varying widely from the overall state estimate of 15.2%. The computed county estimates of uninsured under age 19 were summed to get a total for the state. The following tables summarize this methodology:

Number of Children Who Are Uninsured

Colorado 1997 County Uninsured rates (Colorado Demography Information Service) 2000 Colorado Population under Age 19 # of Uninsured under Age 19 (Sum of County Estimates) Uninsured under age 19

Range = 9.0% - 40.9%

1,145,447

172,457

This represents all uninsured children in the state, at all income levels. To determine the number of children who would be CHIP-eligible, or at or below 185% of the federal poverty level (FPL), the Department used an estimate from the American Academy of Pediatrics (AAP) which says that CHIP-eligibles under 200% FPL in the state comprise 40.1% of the uninsured under age 19. The source for this estimate was AAP’s analysis of 1994-1997 March Current Population Survey Supplements and a 1998 Census Bureau child population projection. Each county's under-19 uninsured estimate was multiplied by this percentage to get CHIP eligibles by county, which were then summed to get a state total. (If 40.1% is applied to the state total number of uninsured under age 19, instead of each county's total, a slightly different estimate is obtained, but the difference is negligible, attributable to the rounding of county estimates.)

Number of Uninsured Children Who Are S-CHIP-Eligible:

AAP CHIP-Eligible Percentage (Using 1994- 1997 CPS and Census 1998 projection)

Number of Uninsured under Age 19 2000 Colorado Population under Age 19, Uninsured, and under 200% FPL Uninsured under age 19

40.1%

172,457

69,157

It is this final estimate — 69,157 — against which Colorado's S-CHIP measures its performance in reducing the proportion of uncovered, low-income children in the state,

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66 for FFY 1998 and FFY 1999.

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

Guidance: The State should verify that they will participate in the collection and evaluation of data as new measures are developed or existing measures are revised as deemed necessary by CMS, the states, advocates, and other interested parties.

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

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

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

Guidance: Section 9.9 can include discussion of community-based providers and consumer representatives in the design and implementation of the plan and the method for ensuring ongoing public involvement. Issues to address include a listing of public meetings or announcements made to the public concerning the development of the children's health insurance program or public forums used to discuss changes to the State plan.

9.9. Describe the process used by the State to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

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67 working teams were staffed and led by individuals representing the Department, the business community, the insurance industry, providers, children’s advocates, schools, employers, and other public and private programs providing services to children.

Benefits Design and Pricing. This team was responsible for designing the benefit package and developing cost-sharing and subsidy structures. This team developed price estimates for the benefit package under different cost sharing and subsidy structures scenarios. Members of this team represented advocates for low-income families, the Colorado Division of Insurance, mental health providers, EPSDT outreach workers, providers of care to handicapped children, pediatricians, community health centers, and managed care organizations.

Marketing and Outreach. This team was responsible for developing a marketing plan and outreach strategy for partnering with schools, doctors offices, employers, social service providers, and public health entities throughout the state. This team recommended to the Department the most effective outreach plan, materials design, and marketing strategy to ensure that eligible families are notified that this product was available and how they could apply. The team developed a long term, phased plan for outreach and marketing CHP+. Not only school systems were tapped, but team members, through their varied work in the community were natural advocates and enlisted volunteers who could advocate for CHP+, throughout the state. Members of this team represented schools, day care centers, managed care organizations, providers, children’s advocacy groups, and CHP+.

Eligibility, Enrollment, and Management Information Systems Design. This team was responsible for developing an eligibility and enrollment system that would be flexible, simple to administer, and meet the long-term needs of CHP+. This team was also responsible for developing recommendations for the rules by which a child would be deemed eligible for the program. Members of this team included representatives from managed care organizations, the Medicaid program in the Department of Health Care Policy and Financing, the Program for Children with Special Health Care Needs, Indian tribes, community health centers, CHP+ philanthropic provider clinics, and other providers.

Financing. This team was responsible for identifying funding streams available to finance the program, preparing budget projections, developing estimates of the number of children that would be enrolled, and creating mechanisms to ensure that CHP+ would be fiscally sound. Members of this team included representatives from community health centers, the Colorado Indigent Care Program, the Office of State Planning and Budgeting, the CHP+, and the Department of Health Care Policy and Financings budget and accounting offices.

Employer Advisory Group. This team presented recommendations to the Department regarding mechanisms to ensure that CHP+ did not become a substitute for employer-based coverage. This group established a means for the Department and employers to coordinate coverage for children eligible for the program, create incentives for employers to assist the Department with outreach and eligibility determination, and presented recommendations as to how the subsidy can be

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68 structured to ensure that employees did not drop employer-based coverage. Membership of this team represented a broad base of employers and business organizations such as US West, Kodak, and Mile Hi Child Care Centers.

Contracting and Quality Assurance. This team was responsible for developing purchasing strategies and contract standards for the CHP+ program. The team reviewed options for purchasing, pricing and quality assurance from Medicaid and commercial models.

Policy Board. The initial Department-appointed Policy Board reviewed key team recommendations and gave strategic guidance to the Department of Health Care Policy and Financing in the design and implementation of CHP+. This group was comprised of high-level private sector business managers, hospitals, providers, children’s advocates, the insurance industry, the General Assembly, the Colorado Department of Public Health and Environment, and the Colorado Division of Insurance.

The Department-appointed Policy Board disbanded after the passage of House Bill 98-1325, which became law on April 21, 1998. A provision of that legislation created an 11-member Policy Board charged with promulgating rules for the as CHP+.

Upon dissolution of the Policy Board in August 2001, public input is received through a variety of methods: • Rule Making: At the time of any presentation of a rule to be approved by the Board, interested advocates are notified of the rule and public testimony is encouraged at the Board meeting; • Department staff meet regularly with patient advocacy groups; • Drafts of items requesting public input are placed on the CHP+ Website; • Any member of the public has the right to correspond directly with Board members.

9.9.1 Describe the process used by the State to ensure interaction with Indian Tribes and organizations in the State on the development and implementation of the procedures required in 42 CFR 457.125. States should provide notice and consultation with Tribes on proposed pregnant women expansions. (Section 2107(c)) (42CFR 457.120(c))

CHP+ contracts with Indian Health Services providers as SED sites and looks for ways to reach the tribal populations. In addition, CHP+ follows the tribal consultation process described in Section 2.3-TC Tribal Consultation Requirements.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), describe how and when prior public notice was provided as required in 42 CFR457.65(b) through (d).

a. Changing CHIP from a Separate Program to a Combination Program by expanding Medicaid: Public rule-making notice was published in the Colorado Register and the

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69 Department’s website on October 10, 2012.

b. Eligibility for children of state employees: Public rule-making notice was published in the Colorado Register and the Department’s website on November 10, 2012.

c. Coverage of uninsured pregnant women at or below 250% FPL through the CHIP State Plan: Public rule-making notice was published in the Colorado Register and the Department’s website on October 10, 2012.

d. Passive Enrollment: Public rule-making notice was published in the Colorado Register and the Department’s website on September 10, 2012.

9.9.3 Describe the State’s interaction, consultation, and coordination with any Indian tribes and organizations in the State regarding implementation of the Express Lane eligibility option. Indian tribes and organizations were consulted about Express Lane eligibility using the approved consultation agreement process. This consultation was sent to the tribes and organizations on December 20, 2011.

9.10 Provide a 1-year projected budget. A suggested financial form for the budget is below. The budget must describe: (Section 2107(d)) (42CFR 457.140)

• Planned use of funds, including: • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment. • projected expenditures for the separate child health plan, including but not limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, dental services, etc. All cost sharing, benefit, payment, eligibility need to be reflected in the budget. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Include a separate budget line to indicate the cost of providing coverage to pregnant women. • States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. • Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. • Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. • Provide a 1-year projected budget for all targeted low-income children covered

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70 under the state plan using the attached form. Additionally, provide the following: - Total 1-year cost of adding prenatal coverage - Estimate of unborn children covered in year 1 CHIP Budget STATE: Colorado FFY 2012-13 FFY 2013-14 Federal Fiscal Year

State's enhanced FMAP rate 65% 65%

Benefit Costs (Children 134-250% FPL)

Insurance payments

Managed care $123,610,596 $115,565,287 per member/per year cost $2,198.92 $2,399.44 Fee for Service

Benefit Costs (Prenatal 186-250% FPL)

Insurance payments

Managed care $19,864,698 $17,101,734 per member/per year cost $11,542.53 $13,435.08 Fee for Service

Total Benefit Costs $143,475,294 $132,667,021 (Offsetting beneficiary cost sharing payments) ($1,112,877) ($1,235,362) Net Benefit Costs $142,362,417 $131,431,659

Administration Costs

Personnel $729,263 $729,263 General administration $2,076,892 $2,076,892 Contractors/Brokers $686,349 $686,349 Claims Processing $0 $0 Outreach/marketing costs $500,000 $500,000 Other $0 $0 Total Administration Costs $3,992,504 $3,992,504 10% Administrative Cap $15,818,046 $14,603,518

Federal Share $95,130,699 $88,025,706 State Share $51,224,222 $47,398,457 Total Costs of Approved CHIP Plan $146,354,921 $135,424,163 NOTE: Include the costs associated with the current SPA. The Source of State Share Funds: State appropriations, Tobacco Settlement funds, enrollment fees for families with income 150% FPL and above, and Hospital Provider Fee funds.

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Section 10. Annual Reports and Evaluations Guidance:

The National Academy for State Health Policy (NASHP), CMS and the states developed framework for the annual report that states have the option to use to complete the required evaluation report. The framework recognizes the diversity in State approaches to implementing CHIP and provides consistency across states in the structure, content, and format of the evaluation report. Use of the framework and submission of this information will allow comparisons to be made between states and on a nationwide basis. The framework for the annual report can be obtained from NASHP’s website at http://www.nashp.org. Per the title XXI statute at Section 2108(a), states must submit reports by January 1st to be compliant with requirements.

10.1. Annual Reports. The State assures that it will assess the operation of the State plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.  The progress made in reducing the number of uninsured low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2.  The State assures it will comply with future reporting requirements as

they are developed. (42CFR 457.710(e))

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

10.3-DC Specify that the State agrees to submit yearly the approved dental benefit package and to submit quarterly current and accurate information on enrolled dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Website. Please update Sections 6.2-DC and 9.10 when electing this option.

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

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

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

11.2. The State assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a State under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8.

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72 (Previously items 9.8.6. - 9.8.9)

11.2.1.  42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.  Section 1124 (relating to disclosure of ownership and related information) 11.2.3.  Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.  Section 1128A (relating to civil monetary penalties) 11.2.5.  Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.  Section 1128E (relating to the National health care fraud and abuse data collection program)

Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan.

12.1. Eligibility and Enrollment Matters- Describe the review process for eligibility and

enrollment matters that complies with 42 CFR 457.1120. Describe any special processes and

procedures that are unique to the applicant’s rights when the State is using the Express Lane

option when determining eligibility.

Guidance: “Health services matters” refers to grievances relating to the provision of health care.

12.2. Health Services Matters- Describe the review process for health services matters

that comply with 42 CFR 457.1120.

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73 Contractors plan.

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

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74 Key for Newly Incorporated Templates The newly incorporated templates are indicated with the following letters after the numerical section throughout the template.

• PC- Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • PW- Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • TC- Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • DC- Dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • DS- Supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • PA- Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • EL- Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • LR- Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

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75 CMS Regional Offices CMS Regional Offices States Associate Regional Administrator Regional Office Address Region 1- Boston Connecticut Massachuset ts Maine New Hampshire Rhode Island Vermont Richard R. McGreal richard.mcgreal@cms.hhs.gov John F. Kennedy Federal Bldg. Room 2275 Boston, MA 02203-0003 Region 2- New York New York Virgin Islands New Jersey Puerto Rico Michael Melendez michael.melendez@cms.hhs.gov 26 Federal Plaza Room 3811 New York, NY 10278-0063

Region 3- Philadelphia Delaware District of Columbia Maryland Pennsylvania Virginia West Virginia Ted Gallagher ted.gallagher@cms.hhs.gov The Public Ledger Building 150 South Independence Mall West Suite 216 Philadelphia, PA 19106

Region 4- Atlanta Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee Jackie Glaze jackie.glaze@cms.hhs.gov

Atlanta Federal Center 4th Floor 61 Forsyth Street, S.W. Suite 4T20 Atlanta, GA 30303-8909 Region 5- Chicago Illinois Indiana Michigan Minnesota Ohio Wisconsin Verlon Johnson verlon.johnson@cms.hhs.gov 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 Region 6- Dallas Arkansas Louisiana New Mexico Oklahoma Texas Bill Brooks bill.brooks@cms.hhs.gov 1301 Young Street, 8th Floor Dallas, TX 75202 Region 7- Kansas City Iowa Kansas Missouri Nebraska

James G. Scott james.scott1@cms.hhs.gov Richard Bulling Federal Bldg. 601 East 12 Street, Room 235 Kansas City, MO 64106-2808 Region 8- Denver Colorado Montana North Dakota South Dakota Utah Wyoming Richard Allen richard.allen@cms.hhs.gov Federal Office Building, Room 522 1961 Stout Street Denver, CO 80294-3538 Region 9- San Francisco

Arizona California Hawaii Nevada American Samoa Guam Northern Mariana Islands Gloria Nagle gloria.nagle@cms.hhs.gov 90 Seventh Street Suite 5-300 San Francisco Federal Building San Francisco, CA 94103

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Region 10- Seattle

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

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77 GLOSSARY Adapted directly from SEC. 2110. DEFINITIONS. CHILD HEALTH ASSISTANCE- For purposes of this title, the term `child health assistance' means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in Section 2105(a)(2)(A), payment for part or all of the cost of providing any of the following), as specified under the State plan: 1. Inpatient hospital services. 2. Outpatient hospital services. 3. Physician services. 4. Surgical services. 5. Clinic services (including health center services) and other ambulatory health care services. 6. Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person. 7. Over-the-counter medications. 8. Laboratory and radiological services. 9. Prenatal care and prepregnancy family planning services and supplies. 10. Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services. 11. Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services. 12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). 13. Disposable medical supplies. 14. Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home). 15. Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting. 16. Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. 17. Dental services. 18. Inpatient substance abuse treatment services and residential substance abuse treatment services. 19. Outpatient substance abuse treatment services. 20. Case management services. 21. Care coordination services. 22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. 23. Hospice care.

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78 24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is-- a. prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law, b. performed under the general supervision or at the direction of a physician, or c. furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license. 25. Premiums for private health care insurance coverage. 26. Medical transportation. 27. Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals. 28. Any other health care services or items specified by the Secretary and not excluded under this section.

TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title-- 1. IN GENERAL- Subject to paragraph (2), the term `targeted low-income child' means a child-- a. who has been determined eligible by the State for child health assistance under the State plan; b. (i) who is a low-income child, or (ii) is a child whose family income (as determined under the State child health plan) exceeds the Medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the Medicaid applicable income level; and c. who is not found to be eligible for medical assistance under title XIX or covered under a group health plan or under health insurance coverage (as such terms are defined in Section 2791 of the Public Health Service Act). 2. CHILDREN EXCLUDED- Such term does not include-- a. a child who is a resident of a public institution or a patient in an institution for mental diseases; or b. a child who is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State. 3. SPECIAL RULE- A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program's operation. 4. MEDICAID APPLICABLE INCOME LEVEL- The term `Medicaid applicable income level' means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under title XIX (including under a waiver authorized by the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical assistance under Section 1902(l)(2) for the age of such child. 5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‘targeted low-income pregnant

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79 woman’ means an individual—‘‘(A) during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; ‘‘(B) whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this title for a targeted low-income child; and ‘‘(C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of Section 2110(b) in the same manner as a child applying for child health assistance would have to satisfy such requirements.

ADDITIONAL DEFINITIONS- For purposes of this title: 1. CHILD- The term `child' means an individual under 19 years of age. 2. CREDITABLE HEALTH COVERAGE- The term `creditable health coverage' has the meaning given the term `creditable coverage' under Section 2701(c) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to a targeted low-income child under this title or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service waiver). 3. GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The terms `group health plan', `group health insurance coverage', and `health insurance coverage' have the meanings given such terms in Section 2191 of the Public Health Service Act. 4. LOW-INCOME CHILD - The term `low-income child' means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved. 5. POVERTY LINE DEFINED- The term `poverty line' has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. 6. PREEXISTING CONDITION EXCLUSION- The term `preexisting condition exclusion' has the meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(b)(1)(A)). 7. STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires, the terms `State child health plan' and `plan' mean a State child health plan approved under Section 2106. 8. UNINSURED CHILD- The term `uninsured child' means a child that does not have creditable health coverage.

(spa-index)(p01)Colorado CHIP state plan amendments on medicaid.gov: SPA index page 1 of 1#

(spa-index)(p01)(block-1)CHIP State Plan Amendments#

Through this SPA, Colorado demonstrates compliance with section 205 of the Consolidated Appropriations Act, 2024 (CAA, 2024) by modifying CHIP eligibility requirements for the treatment of incarcerated pregnant women.

Approval Package

Through this SPA, the state implements four additional Health Services Initiatives.

Approval Package

Through this SPA, the state demonstrates compliance with section 5121 of the Consolidated Appropriations Act, 2023 (CAA, 2023) by modifying CHIP eligibility requirements for the treatment of incarcerated youth and providing pre-release services to eligible juveniles.

Approval Package

Through this SPA, the state removes outdated CHIP state plan language to ensure that the plan reflects the state’s approved program policies.

Approval Package

Through this SPA, the state amends it's existing Continuing Care Services benefit requires that a demonstrate that a CHP+ member receives continued care with the member’s same health care provider or health care facility under the member’s new MCO plan as if the provider or facility are in network, for up to ninety days.

Approval Package

Through this SPA, the state has demonstrated compliance with the Inflation Reduction Act (IRA) section 11405(b)(1) to cover adult vaccines, without cost sharing. Additionally, this SPA documents the state’s compliance with the longstanding requirement to cover children’s vaccines under current regulations at 42 CFR §§ 457.410(b)(2) and 457.520(b)(4), which requires states to cover age-appropriate vaccines in accordance with the recommendations of the ACIP without cost sharing.

Approval Package

Through this SPA the state has the authority to make the temporary policy adjustments for its CHIP program during any future state or federally-declared emergency upon notification to CMS.

Approval Package

Through this SPA, Colorado permanently removes enrollment fees for all CHIP beneficiaries.

Approval Package

This SPA demonstrates the state’s compliance with section 5022 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act.

Approval Package

Current State Plan

Approval Package

Factsheet

Current State Plan

Pending State Plan