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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 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: Connecticut (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)

Patricia Wilson-Coker, Commissioner, CT. Department of Social Services, December 1, 2009

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: Mark Schaefer Position/Title: Acting Director, Medical Care Administration Name: Position/Title: Director, HUSKY Programs Name: Lee Voghel Position/Title: Director, Fiscal Analysis

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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 as of 10/1/02 (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 through 9/30/02. Effective 10/1/02, the Medicaid expansion was phased out.

1.2. Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

The state will not claim expenditures for child health assistance prior to the time that the state has legislative authority to operate the state plan amendments as approved by CMS.

1.3. Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

The state complies with all applicable civil rights requirements, including but not necessarily limited to, Title VI of the Civil Rights Act of 1964, Title II of the American 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.

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):

Date Plan Submitted: January 15, 1998 Date Plan Approved: April 27, 1998 Effective date: HUSKY A (Medicaid Expansion) October 1, 1997 HUSKY B (Separate Child Health) January 1, 1998

Amendment #1: AI/AN Children Cost Sharing Exempt Date Submitted: January 21, 2000

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Approval Date: Date Approved: July 14, 2000 Date Effective: January 1, 2000

Amendment # 2: Compliance/Reduce Period of un-insurance from 6 to 2 months Date Submitted: July 1, 2002 Date Approved: October 25, 2005

Amendment #3: Premium Increase Date Submitted: March 25, 2004 Date Approved: June 21, 2004 Date Effective: February 1, 2004

Amendment #4: Premium Rollback Date Submitted: June 29, 2004 Date Approved: September 24, 2004 Date Effective: February 1, 2004

Amendment #5: Behavioral Health Carve Out & Eliminates Self-declaration of Income Date Submitted: May 8, 2006 Date Approved: August 1, 2006 Date Effective: July 18, 2005 and January 1, 2006

Amendment #6: Change from MCOs to PIHPs, four months newborn premium waiving, pharmacy carve-out, expedited newborn application processing, dental carve-out, change from PIHPs to MCOs. Date Submitted: 6/30/2008 Date Approved: 8/18/2009 Date Effective: 1/01/2008, 2/01/2008, 6/11/2008, 8/01/2008, 9/01/2008

Amendment #7: Coverage for children under the age of 19 who are qualified aliens and lawfully residing in the United States, regardless of their date of entry into the country. Revision of Appendix 3.1 (HUSKY Plus Physical) to reflect elimination of steering committee. Date Submitted: 6/30/2009 Date Approved: 12/08/2009 Date Effective: 4/01/2009

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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))

The state can measure the number of children with creditable health coverage to the extent that they are enrolled in either the HUSKY A or HUSKY B program. Since the start of the HUSKY program and combined HUSKY A and B marketing in July 1998 an additional 51,090 children enrolled in the Medicaid program resulting in their access to creditable health coverage. The increased Medicaid enrollment in addition to the 13,086 HUSKY B members means that an additional 51,090 children now have creditable health coverage in comparison to July 1998.

Please see Appendix 2.1 for a breakdown of HUSKY A (Medicaid & MCHIP) and HUSKY B (SCHIP) enrollment by race and ethnicity; a breakdown of HUSKY A and HUSKY B enrollments by county; and HUSKY B enrollment by income band. Please note that we do not have HUSKY A enrollment data broken out by income. The income limit for HUSKY A is 185% of the FPL.

The state currently does not have public-private partnerships.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

The state currently conducts outreach activities through its contracts with FQHCs and disproportionate share hospitals that assist applicants in completing the application. (See Section 5.)

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

The state currently does not have any programs that involve a public-private partnership. The Healthy Steps program, which existed at the inception of HUSKY B, has been phased out and members of that program were made

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Approval Date: eligible for HUSKY A or B, according to their family income.

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))

Title V refers potential applicants who do not qualify for its program to HUSKY B and HUSKY Plus Physical. A department representative monitors services provided by the Connecticut Children's Medical Center, the agent responsible for HUSKY B Children with Special Health Care Needs with Title V. (See Appendix 3.1.)

HUSKY B MCOs are required to contract with school-based health clinics.

HUSKY Plus Physical and HUSKY, Part B MCOs, in conjunction with the Department, also coordinate with the Birth to Three program, which provides services to children with special health care needs.

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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))

As described in the state’s Medicaid state plan amendment, under Part A of the HUSKY Plan, the state used Title XXI funds to expand Medicaid eligibility for children 14-18 with family income up to 185% of the FPL. The Title XXI- funded expansion of Medicaid was phased out effective 10/1/02. As of 10/1/02, Title XXI funds are used only for the stand-alone SCHIP program (HUSKY B).

For children with family income over 185% FPL (Part B of the HUSKY Plan), the state contracts with managed care organizations (MCOs) to administer medical benefits and a behavioral health Administrative Services Organization (ASO) to administer behavioral health services. Effective 2/1/08, pharmacy services are provided through the Department’s Medicaid network. Effective 9/1/08, dental services will be provided by an ASO. The state selects the MCOs and ASOs through a competitive bidding process. The state issues an RFP that establishes operational and financial requirements and requires bidders to provide evidence of their ability to meet the requirements. The requirements include but are not limited to: access to care, provider network, member services, utilization management, claims processing, and quality assurance. The state awards the right to negotiate a contract based on a fair evaluation of all proposals submitted in response to the RFP. This method includes evaluation of the following factors: provider network for each service area, efficiency of operation, ability to provide the required services, quality management, and ability to perform the necessary administrative tasks, financial viability, and price. The ASO Contracts do not include financial requirements because the ASOs are not capitated and bear no risk.

During the period 1/1/08 through 7/31/08, the state changed its contractual relationship with the existing at-risk MCOs to non-risk pre-paid inpatient health plans (PIHPs) The state returns to at-risk MCO contracts effective 8/1/08.

In addition the state, using Title XXI funds, has established a supplemental health insurance program, known as the HUSKY Plus Physical program, for those enrollees in the state subsidized portion of Part B whose medical needs cannot be accommodated within the basic benefit package offered by the MCOs under the HUSKY Plan, Part B. The HUSKY Plus Physical program supplements MCO coverage for enrollees with intensive physical health needs. Effective 7/1/03, the physical health services are delivered through the Connecticut Children’s Medical

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The CCMC’s Center for Children with Special HealthCare Needs contracts with a network of providers for the provision of Title V and HUSKY Plus Physical medical services. Care coordination and referrals to medical services are the responsibility of the Center’s staff. Reimbursement claims for medical services are billed to and processed by CCMC. See Appendix 3.1 for additional information on the HUSKY Plus Physical Program.

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))

As with HUSKY A, the Medicaid definition of medical necessity will prevail for HUSKY B. “Medical Necessity” or “ Medically Necessary” means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring. Prior authorization decisions are based on the Medicaid definition of medical necessity and medical appropriateness. The state includes a definition of medical necessity and utilization management requirements in the RFP and the contracts with the MCOs and ASOs. The MCOs and ASOs are required to have written utilization management policies and procedures that include the appropriateness criteria for authorization and denial of payment and protocols for prior approval, hospital discharge planning, and retrospective review.

As discussed in Appendix 3.1 (summarizing HUSKY Plus Physical), utilization is managed through prior authorization based on individual care plans and medical necessity guidelines.

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Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan: Statewide 4.1.2.

Age: Individuals must be under 19 years of age. 4.1.3.

Income: In order to receive a state subsidy under Part B, family income may not exceed 300 percent of the FPL. However, the state will apply the income disregards shown in Appendix 4.1.3. Families with income greater than 300 percent of the FPL may purchase coverage without state subsidy. 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): No asset limit. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): To be eligible for the HUSKY Plan, Part B, a child must be a resident of the State of Connecticut. 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): Measures of disability acuity will apply in HUSKY Plus Physical (See Appendix 3.1). 4.1.7.

Access to or coverage under other health coverage: Children who are eligible for Medicaid or covered under a group health plan or under health insurance coverage, and children of any state or municipal employee eligible for employer-sponsored insurance are not eligible for the HUSKY Plan, Part B. However, children of municipal employees are allowed to be eligible for HUSKY Plan, Part B “if dependent coverage was terminated due to extreme economic hardship on the part of the employee” (pursuant to section 18 of Connecticut Public Act 99-279). For other children, an application may be disapproved if it is determined that the child was covered by employer-sponsored insurance within the last two months (this may be extended to 12 months if the commissioner determines that two months is insufficient to deter applicants or employers from discontinuing employer- sponsored dependent coverage). However, an application may be approved if the reason for loss of employer-sponsored insurance is unrelated to the availability of the HUSKY Plan, Part B or otherwise exempt under section 11 of Public Act 97-1 of the October 29, 1997 Special Session. The authorizing legislation (see Appendix 4.1.3) identifies ten reasons that are unrelated to the availability of the HUSKY Plan.

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Approval Date: 4.1.8.

Duration of eligibility: A child who has been determined eligible for the HUSKY B program shall remain eligible for as long as all eligibility criteria are met. Eligibility for HUSKY B is reviewed annually. The renewal period is scheduled to coincide with the yearly anniversary of the initial eligibility determination. Renewal forms are sent during the tenth month of eligibility to allow time for the family to complete and return the form in time for the renewal to be processed before the expiration of the 12th eligible month. 4.1.9.

Other standards (identify and describe): The department, at time of initial determination and ongoing eligibility, requires the social security number for any child requesting services under the HUSKY B program. 4.1.10.

Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible individuals lawfully residing in the United States:

(1) “Qualified aliens” otherwise subject to the 5-year waiting period per section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996; (2) Citizens of a Compact of Free Association State (i.e., Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau) who have been admitted to the United States (U.S.) as non-immigrants and are permitted by the Department of Homeland Security to reside permanently or indefinitely in the U.S.; (3) Individuals described in 8 CFR 103.12(a)(4) who do not have a permanent residence in the country of their nationality and are in statuses that permit them to remain in the U.S. for an indefinite period of time pending adjustment of status. These individuals include: (a) Individuals currently in temporary resident status as Amnesty beneficiaries pursuant to section 210 or 245A of the Immigration and Nationality Act (INA); (b) Individuals currently under Temporary Protected Status pursuant to section 244 of the INA; (c) Family Unity beneficiaries pursuant to section 301 of Public Law 101-649 as amended, as well as pursuant to section 1504 of Pub. L. 106-554; (d) Individuals currently under Deferred Enforced Departure pursuant to a decision made by the President; and (e) Individuals who are the spouse or child of a U.S. citizen whose visa petition has been approved and who has a pending application for adjustment of status; and (4) Individuals in non-immigrant classifications under the INA who are permitted to remain in the U.S. for an indefinite period, including the following who are specified in section 101(a)(15) of the INA:

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Approval Date: • Parents or children of individuals with special immigrant status under section 101(a)(27) of the INA as permitted under section 101(a)(15)(N) of the INA; • Fiancées of a citizen as permitted under section 101(a)(15)(K) of the INA; • Religious workers under section 101(a)(15)(R); • Individuals assisting the Department of Justice in a criminal investigation as permitted under section 101(a)(15)(U) of the INA; • Battered aliens; and • Individuals with a petition pending for 3 years or more as permitted under section 101(a)(15)(V) of the INA.

The State elects the CHIPRA section 214 option for children up to age 19

The State elects the CHIPRA section 214 option for pregnant women through the 60-day postpartum period

4.1.10.1 The State provides assurance that for individuals whom it enrolls in CHIP under the CHIPRA section 214 option that it has verified, both 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

4.2. 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)

The state contracts with an entity to be a single point of entry servicer (SPES) for applicants and enrollees under Parts A and B of the HUSKY Plan. The SPES is

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Approval Date: responsible for making a preliminary determination of eligibility under Part A and a final determination of eligibility under Part B and enrolling eligible children under Parts A and B into an MCO. Eligibility is determined based on information collected on the application form, which includes name, address, date of birth, social security number, residency, U.S. citizenship and immigration status, family income, employment, and insurance (both current and in the previous two months). The SPES verifies address and income and whether the child is a Medicaid beneficiary. In addition, if an applicant is employed, the SPES contacts the employer for a random sample of cases (10%) for information about employer-sponsored insurance coverage. With the exception of step-parent income, income is calculated in the same manner as for poverty level children under Medicaid with the income disregards provided in section 15 of Public Act 97-1 of the October 29, 1997 Special Session or as may be amended. As described in 4.4.1 (below), as part of the eligibility process, the SPES determines whether a child may be eligible for Medicaid and, if so, sends the application and supporting documents to the Department of Social Services for final eligibility determination. Also, if a child has insurance coverage, he/she will not be enrolled in HUSKY B.

Individuals are able to initiate the application in person or by mail. The SPES uses a simplified mail-in application process. If information is incomplete, the SPES contacts the applicant (by mail or phone) to obtain missing information. If the SPES determines that a child is eligible for HUSKY B, the SPES provides information about participating MCOs. The SPES helps the family select an MCO, and then refers the child to the MCO chosen by the family. If enrolled under HUSKY B, the SPES also provides information about HUSKY Plus Physical. The SPES sends daily rosters of enrollees to the MCOs. The SPES provides choice counseling and enrollment for the HUSKY Program. Effective 6/11/08, families with a newborn child are able to initiate the application process for the newborn at a Connecticut or border hospital. The hospital will fax the application, enrollment form, and other supporting documents to the SPES for eligibility to be determined within one business day of receipt.

Not more than 12 months after determination and annually thereafter, the SPES shall re-determine eligibility for HUSKY B. The SPES shall mail a form to each HUSKY B family to obtain information to make the eligibility determination. Also, as noted in 4.1.8, applicants will be required to notify the SPES of any change in circumstance that could affect continued eligibility for coverage e.g., attaining age 19, moving out of state, change in income, U.S. citizenship and immigration status, or having obtained other insurance). If the child is no longer eligible, he/she will be disenrolled from HUSKY B.

Enrollees will be able to change enrollment during an annual open enrollment period, which will occur at the time of redetermination of eligibility.

4.3.1. Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

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

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including 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))

In accordance with Sections 2102(b)(3)(A) and 2110(b)(2)(B) and 42 CFR 457.310(b), 457.350(a)(1) and 457.80(c)(3) the State will screen HUSKY applications through the SPES. Eligibility Specialists at the SPES are trained in the Medicaid (HUSKY A) gross income limits, and applied income limits considering concepts such as, but not limited to, income disregards, and excluded income to ensure that Medicaid children who apply for HUSKY are properly identified and referred to DSS to be granted Medicaid. HUSKY applicants will also be screened by the SPES for potential Medicaid eligibility under spend-down if family income exceeds 185% of the Federal Poverty Level and unpaid medical bills for the family exist sufficient to meet the spend-down. If the family has sufficient medical bills to be eligible for Medicaid under spend-down, the SPES will refer the application to DSS for Medicaid processing. The SPES will retain all other HUSKY applications and process eligibility for HUSKY B (Title XXI). Conversely, if a family contacts DSS first to apply for HUSKY, DSS staff will screen for Medicaid eligibility as they currently do. If the child is not Medicaid eligible, including being eligible for Medicaid as a spend-down, DSS staff will refer the application to the SPES for potential processing for HUSKY B (Title XXI). DSS staff is trained in the HUSKY B (Title XXI) requirements so they can properly identify such applications.

On July 18, 2005 DSS eliminated the provision that allowed for self- declaration of income for both HUSKY A and HUSKY B application and renewal processing. Eligibility workers at DSS and the SPES are required to verify income with paycheck stubs, employer statements, or self-employment records such as tax returns. DSS and the SPES eligibility staff can still use Bendex, Social Security Income (SDX), Department of Labor (DOL) and Unemployment Compensation Benefit (UCB) files to check the unearned income information stated on the application/renewal form. The same screen and refer or screen and enroll process as identified above for a new application is also used at the time of annual renewal.

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

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Approval Date: 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

As noted in 4.4.1, if the SPES makes a preliminary determination that a child is eligible for Medicaid, the SPES sends the application and supporting documents to the Department of Social Services for final determination of eligibility.

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))

Applications for children who are determined to be ineligible for Medicaid, due to income, at time of application or renewal are referred to the SPES by DSS staff for HUSKY B eligibility processing. (See Section 4.4.1 above.) Additionally, Medicaid discontinuance notices include a reminder to families so that families may follow-up directly with the SPES to enroll their children in SCHIP. Connecticut and border hospitals are collaborating to identify uninsured newborns. Hospitals will assist families to complete the HUSKY application and fax them to the SPES for expedited eligibility processing. A family with a newborn who appears eligible for HUSKY B will be granted coverage within one business day of receipt of the application. Newborns with family income over 235% FPL will not be required to pay premiums for the first 4 months of coverage.

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.

A two-month crowd-out period is used to discourage families from dropping employer-sponsored insurance for the purposes of qualifying for HUSKY B. The SPES tracks the number of application denials for children whose coverage was dropped within two months from the application date.

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.

See answer to 4.4.4.1.

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.

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See answer to 4.4.4.1.

4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

The cost-effectiveness determination.

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))

In accordance with Section 2102(b)(3)(D), 42 CFR 457.125(a) the Department met with representatives from both of Connecticut’s federally recognized Indian tribes in 1998, during the design phase of the HUSKY plan. The program design was discussed with the tribal representatives and their comments and suggestions were considered in the final design and ongoing operations of the program. In 2000 both tribes provided the Department information required to exempt them from cost sharing. The tribal members provided the Department with the information we need to request of American Indians in order to exempt them from cost sharing.

The Department will continue to meet with the tribes on an annual basis or more often if necessary to discuss programmatic changes to HUSKY and to consider the issues or concerns of the tribal members. The Department also provides supplies of HUSKY informational materials and applications for distribution to tribal members. HUSKY information has also been available to tribal members via media (Public Service Announcements, T.V. and radio ads and ads in local newspapers) and other outreach efforts.

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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)

The Department of Social Services, in partnership with statewide, regional and local health and social service organizations, within available appropriations, regularly conducts public outreach and education to reach families of children likely to be eligible for the HUSKY Plan.

The Department’s HUSKY Outreach program includes:

Funding HUSKY InfoLine (HIL) – HIL operates a toll free information and referral service for HUSKY applicants and individuals needing information about HUSKY. HIL care coordinators instruct callers on how to apply for HUSKY, provide over the phone application assistance and follow-up to ensure that application process was completed;

School based outreach efforts – HUSKY information provided through the free- and reduced-price lunch program in cooperation with the CT Department of Education and school food service directors. HUSKY information and applications are also available through the school nurses and the school-based health centers;

Participation in the CT Department of Labor’s Rapid Response Team – provision of HUSKY information and application assistance to laid-off workers;

MCO community- based outreach – HUSKY participating plans provide information and application assistance at various community events including school health promotional fairs; craft shows; country fairs, etc;

Collaboration with Child Support Services;

Collaboration with CT’s Covering Kids and Families (CCKF) initiative –C CKF is a Robert Wood Johnson Foundation funded initiative, with Connecticut Voices for Children acting as the lead agency for Connecticut. CCKF funds several local HUSKY outreach projects throughout the state. The initiative supports statewide interventions and supports local projects in Bridgeport and Stratford, Stamford, and in a nine-town area East of the River (Manchester, East Hartford, Vernon, Hebron, Glastonbury, Mansfield, Willington, Coventry and Columbia). The local projects work in their communities to provide application assistance to families and help families through the renewal process, train community-based organizations on HUSKY, build relationships with local DSS offices, train parents and high school students to

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Approval Date: promote the HUSKY program, develop model projects to enroll immigrant children and families, and work with schools, local businesses and health care providers. All three local projects use an automated tracking system to track their own activities and to identify enrollment and renewal barriers. Statewide initiatives include the coordination and provision of outreach through established groups such as schools, child care providers, pediatric care providers, the business community, and social service providers; and

HUSKY (www.huskyhealth.com) website featuring downloadable application.

Multi-level campaign The crux of this campaign has been grass roots, community-based outreach through schools, health centers, community meetings, fairs, events, worksites, and other venues identified by DSS, statewide partners and community contractors. Just as often, HUSKY outreach brings the message to professionals who work with parents through a 'key informant' model--these are the known and trusted people in health, education, human services and other fields who are already in the community and who can vouch for the program and provide follow-up assistance. The emphasis on grass roots, community-based outreach has been acknowledged as especially important in reaching minority communities and newcomer/immigrant populations.

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Approval Date:

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 Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage

Please note that the HUSKY Part B benefits combine the most

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Approval Date: generous benefits offered at the inception of the HUSKY, Part B plan under three state employee options available in 1998 (Blue Cross, MD Health Plan, and Kaiser Permanente), in addition to covered services mandated by the Federal SCHIP regulations. In addition, HUSKY B benefits also include the HUSKY Plus Physical benefit package for Children with Special Health Care Needs, which is not available to state employees. (See Appendices 3.1 and 6.1)

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)

6.2.1.

Inpatient services (Section 2110(a)(1)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.

Inpatient mental health services, other than services described in 6.2.18, but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

100% except for the following conditions: • Mental retardation; • Learning, motor skills, communication and caffeine-related disorders; • Relational problems; • Other conditions that may be the focus of clinical attention that are not

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Approval Date: • defined as mental disorders by the American Psychiatric Association in its • “Diagnostic & Statistical Manual of Mental Disorders.”

For these above stated conditions, the following applies: Inpatient hospital benefits will be available for conversion to outpatient services. Up to 35 days may be converted; 25 days will remain as a hospital reserve (they will not be available for conversion). The conversion will be available according to the following schedule: • 1 inpatient hospital day = 1 sub-acute day • 1 inpatient hospital day = 2 partial hospitalization services • 1 inpatient hospital day = 2 intensive outpatient visits • 1 inpatient hospital day – 3 outpatient visits • Maximum of 60 days per year.

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)

Includes emergency mobile psychiatric and home-based psychiatric services. 100% except for the following conditions: • Mental retardation; • Learning, motor skills, communication and caffeine-related disorders; • Relational problems; • Other conditions that may be the focus of clinical attention that are not • defined as mental disorders by the American Psychiatric Association in its “Diagnostic & Statistical Manual of Mental Disorders.”

For these above stated conditions, the following applies: • Maximum of 30 visits per year (in addition to allowable substitution of inpatient days-

6.2.12.

Durable medical equipment and other medically related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

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

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

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

Inpatient substance abuse treatment services and residential

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Approval Date: substance abuse treatment services (Section 2110(a)(18))

100% except for the following conditions: • Mental retardation; • Learning, motor skills, communication and caffeine-related disorders; • Relational problems; • Other conditions that may be the focus of clinical attention that are not • defined as mental disorders by the American Psychiatric Association in its • “Diagnostic & Statistical Manual of Mental Disorders.” • For these above stated conditions, the following applies: • Maximum of 60 days per calendar year for drug abuse and 45 days per • year for alcohol abuse.

6.2.19.

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

100% except for the following conditions: • Mental retardation; • Learning, motor skills, communication and caffeine-related disorders; • Relational problems; • Other conditions that may be the focus of clinical attention that are not • defined as mental disorders by the American Psychiatric Association in its • “Diagnostic & Statistical Manual of Mental Disorders.” • For these above stated conditions, the following applies: • Maximum of 60 visits per year with supplemental coverage available.

6.2.20.

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

Case management will be available through HUSKY Plus Physical. (See Appendix 3.1 for additional information on HUSKY Plus Physical.

6.2.21.

Care coordination services (Section 2110(a)(21)) Care coordination will be available through HUSKY Plus Physical. (See Appendix 3.1 for additional information on HUSKY Plus Physical.)

6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) Long-term coverage will be available through HUSKY Plus. (See Appendix 3.1 for additional information on HUSKY Plus Physical.)

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Approval Date: 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)) Services of nurse midwives, nurse practitioners, podiatrists, chiropractors, and naturopaths will be covered. 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) Transportation by ambulance will be covered but non-emergency transportation will not. Limited non-emergency transportation will be covered by HUSKY Plus Physical. (See Appendix 3.1 for information on HUSKY Plus Physical.) 6.2.27.

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

Translation and outreach services will be available through the ASO, MCOs and HUSKY Plus. All printed materials must be in English and Spanish and any other languages if more than five percent of the ASO or MCO’s enrollees speak the alternative language. The ASO, MCOs and HUSKY Plus Physical program must provide translation services. (See Appendix 3.1 for information on HUSKY Plus Physical.) 6.2.28.

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

See Appendices 3.1 and 6.1: HUSKY Plus Physical Benefits and HUSKY Part B Benefits

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

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Approval Date: 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above. Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community- based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

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))

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Approval Date: 6.4.2.3. The state assures that the coverage for the family otherwise meet title XXI requirements. (42CFR 457.1010(c))

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Approval Date:

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))

The methods that are used to assure quality and appropriateness of care include contracting standards, licensing, reporting requirements, external reviews, and onsite reviews.

The MCO contracts include specific standards for quality of care, including the provision of well-baby care, well-child care, and immunizations. MCOs are required to arrange for immunizations and comprehensive screens (and any needed interperiodic screens) in accordance with the schedules recommended by the American Academy of Pediatrics. As described below, MCOs are required to submit semi-annual reports on well-baby care, childcare visits and immunizations. The state has a statewide immunization registry (Connecticut Immunization Registry and Tracking System), and the MCOs are required to report to that registry and use that information to complete their immunization reports to DSS.

The ASO contracts will include specific standards for quality of care, including the provision of behavioral health and dental health intensive care management and service coordination. In addition, the ASOs will be required to submit to the Department periodic reports on utilization of dental health services and behavioral health services, including inpatient and outpatient services.

MCOs and the ASOs are required to meet all standards for quality of care as specified in their contracts with the state. In addition, each MCO must be licensed by the state as a Health Maintenance Organization (HMO) or operate as a Managed Care Organization based on Federally Qualified Health Centers and certified by the Department to participate in the Medicaid Managed Care Program. As an HMO, the MCOs must comply with the managed care bill of 1997, which contains various quality/consumer protection requirements (See Appendix 7.1 for a summary of this bill). The ASOs must be licensed by the State Department of Insurance (DOI) to operate as a utilization review company. The State Department of Insurance (DOI) continuously monitors quality through various mechanisms, including reporting, external reviews, and onsite reviews.

Reporting will include a report on the MCO’s and ASO’s quality assurance plan (QAP), as required by the Managed Care Bill (Appendix 7.1), which includes information on complaints, prior authorization denials, utilization review (UR) denials, and all data required for HEDIS (or equivalent data for non-NCQA accredited plans).

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Approval Date: Under the managed care bill, if a plan is NCQA accredited for at least one year, it only needs to submit proof of accreditation and HEDIS. However, DSS requires NCQA accredited plans to submit a report on their QAPs, which must comply with Section 7.1.4. In addition, DSS requires semi-annual reports on compliance with the well-child periodicity schedule and on immunizations, similar to the reports currently prepared by Medicaid MCOs and quarterly provider network reports. The functions of the external quality review organization are described in 7.1.1 In addition, the state conducts periodic onsite reviews to determine ongoing compliance with contract requirements.

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

The state contracts for an external quality review of the HUSKY Plan, Part B. The review includes, but is not limited to, an evaluation of access to care, a satisfaction survey, medical record standards, provider credentialing, and individual care review (see 7.1.3)

7.1.2.

Performance measurement

The state requires MCOs and the ASOs to submit HEDIS reporting measures or equivalent data (which is likely to be HEDIS or a modified version of HEDIS) and semi-annual reports on immunizations and compliance with the well-child periodicity schedule. In addition, as noted in Section 9.7, the state will comply with any national quality measures.

7.1.3.

Information strategies

The SPES, MCOs and ASOs are required to educate enrollees about their benefits, rights and responsibilities under the HUSKY Plan, Parts A and B, including HUSKY Plus. The MCOs and ASOs also educate enrollees about the importance of preventive services including medical and dental services, health promotion activities, and visiting their primary care provider instead of an emergency room.

7.1.4.

Quality improvement strategies

The state includes specific standards for quality of care in the contracts with the MCOs and ASOs. These standards are monitored by the state through reporting requirements, onsite reviews, and external reviews.

In particular, MCOs and ASOs are required to establish an internal QAP, which will be in writing and available to the public. The written description shall include detailed goals and annually developed objectives; address the quality of clinical care and non-clinical aspects of services for the entire range of care

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Approval Date: provided by the MCO or ASO; specify quality of care studies and related activities; provide for continuous performance of activities, including tracking of issues over time; and provide for review and feedback by physicians and other health professionals.

7.2. Describe the methods used, including monitoring, to assure: (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 state requires MCOs to submit semi-annual reports on immunizations, and compliance with the well-child periodicity schedule.

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))

MCOs are required to ensure that their provider networks provide access to primary care providers (PCPs) within 15 miles of its members’ towns of residence. MCOs and ASOs must ensure access to emergency services on a 24-hour, seven day-a-week basis. Emergency cases must be seen immediately, urgent cases within 48 hours and routine cases within 10 days. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any body organ or part. The state monitors access requirements through reporting and member satisfaction surveys. For behavioral health services, the ASO will rely on the Connecticut Medical Assistance Program (CMAP) provider network to assure access to covered services.

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))

The state requires each MCO to contract with a sufficient number and mix of specialists so that the Member population’s anticipated specialty care needs can be substantially met within the MCO’s network of providers. The MCO is required to have a system to refer Members to out-of-network specialists if appropriate participating specialists are not available. The MCO will make specialist referrals available to its Members when it is medically necessary

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Approval Date: and medically appropriate and will assume all financial responsibility for such referrals whether they are in-network or out-of-network. The MCO must have policies and written procedures for the coordination of care and the arrangement, tracking and documentation of all referrals to specialty providers.

Behavioral health and dental services are provided through the Department’s Medicaid network. HUSKY B members have access to all of the same providers as Medicaid recipients. The behavioral health and dental ASOs manage the Department’s network, but does not contract with network providers. Behavioral health and dental claims are processed by the Department’s Medicaid management information system.

Pharmacy services are provided utilizing the Department’s Preferred Drug List (PDL).

For Members enrolled in HUSKY Plus Physical, the MCO is required to coordinate the specialty care services and specialty provider referral process with the HUSKY Plus Physical program to ensure access to care (See Appendix 3.1).

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))

Prior authorization of services covered in the HUSKY, Part B benefit package shall be determined by the MCO or the ASO based on individual care plans, medical necessity and medical appropriateness and in accordance with state law. However, the following services in the benefit package shall not require prior authorization: (1) Preventative care, including:

(a) Periodic and well-child visits; (b) Immunizations; and (c) Prenatal care;

(2) Preventive family planning services, including:

(a) Reproductive health exams; (b) Member counseling; (c) Member education; (d) Lab tests to detect the presence of conditions affecting reproductive health; and (e) Screening, testing and treatment of pre and post-test counseling for sexually transmitted diseases and HIV, and (3) Emergency ambulance services or emergency care.

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Approval Date:

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, with the exception of low-income children in the state who are American Indians and Alaska Natives (AI/NA) who are members of a federally recognized tribe. (As defined in section 4 (c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c). These AI/NA children will be exempt from any cost sharing (e.g., copayments and premiums).

8.1.2. NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1. Premiums:

Effective February 1, 2004, children with family income up to 235 percent of the FPL will not be required to pay a premium. Children with family income that exceeds 235 percent of the FPL but which does not exceed 300 percent of the FPL will be required to pay a premium of $30.00 per child per month, up to a maximum of $50.00 per family per month. Children with family income over 300 percent of the FPL will be required to contribute the entire premium. Effective January 1, 2008, newborns with family income over 235% FPL will not be required to pay premiums for the first four months of coverage, provided they were born in a Connecticut hospital or designated border hospital. Note enrollment of children with family income over 300 percent of the FPL does not come under Title XXI funding as it is offered as a full buy-in program. Private organizations may subsidize premiums.

8.2.2. Deductibles: Not applicable

8.2.3. Coinsurance or copayments: Coinsurance is not applicable.

Copayments: For children in families with income over 185 percent of FPL, the state has established a schedule of reasonable copayments for services other than the following: preventive care and services, inpatient physician and hospital, outpatient surgical, ambulance, skilled nursing, home health, hospice and short-term rehabilitation and physical therapy, occupational and speech

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Approval Date: therapies, lab and X-ray, preadmission testing, prosthetics, durable medical equipment, behavioral health services, and dental exams (See Appendix 6.1). There are no co-payment requirements for children enrolled in HUSKY Plus Physical.

8.2.4. Other:

The maximum annual aggregate cost sharing (premiums and copayments) for a family with income that exceeds 185 percent of the FPL (before disregards) but does not exceed 235 percent will be no more than $760.00. The $760.00 represents the maximum amount of co-payments that a family in this income range will be required to contribute. The $760.00 also represents the maximum cost sharing, as there is no premium requirement, for families whose income does not exceed 235% FPL. The maximum annual aggregate cost sharing for a family whose income exceeds 235 percent of the FPL but does not exceed 300 percent will be no more than $1,360. The $1,360.00 is composed of the annual co-payment maximum of $760.00 plus an annual premium maximum of $600.00 ($50.00/month X 12 months). Annual cost sharing, including premiums, deductibles, and co-payments cannot exceed 5% of the family’s gross income.

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))

Information about cost sharing is included in the outreach materials and both the SPES and the MCO provide information on cost sharing requirements. The MCO provides information on cost sharing requirements through the introductory Welcome Call as well as in the Member Handbook, in which the MCO is required to include a summary of the cost sharing requirements end maximum. The information is also available via MCO Member Services Departments and through outreach materials such as newsletters. The SPES makes information about cost sharing available through its toll free phone number (1-877-CT-HUSKY), a variety of outreach materials, and through letters sent to the applicant that provide notification of eligibility for HUSKY B. Enrollees and providers are informed by the MCO when a client has reached the maximum annual aggregate cost sharing limit for copayments so that the client is not charged for further copayments by the provider.

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

8.4.1.

Cost sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3.

No additional cost sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A))

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Approval Date: (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))

The family share of premium payments and co-payment caps were calculated to not exceed 5% of the lowest qualifying family income within each of the two income bands for subsidized benefits (e.g. 5% of 185% FPL and 5% of 235% FPL). Copayments are tracked by the MCOs and ASOs as applicable and reported to the SPES. The SPES is required to ensure that the co-pays do not exceed $760 per year. If a family exceeds $760 per year in copayments, the MCOs and ASOs are required to reimburse the excess above $760 to the family. There is no premium requirement for families in Income Band 1. And copayments are capped at $760 per year, therefore the maximum cost share for which a family in Income Band 1 can be liable is $760, which is less than 5% of the 185% FPL. The maximum premium, which can be paid by a family in Income Band 2, is $600 ($50 per month x 12 months). Copayments are capped at $760 per year; therefore the maximum cost share for which a family in Income Band 2 can be liable is $1,360, which is less than 5% of 235% FPL.

It is the responsibility of the SPES to review the Member accounts at a minimum on a quarterly basis to determine which families have reached their maximum annual cost sharing limit for copayments. The review must be completed no later than 15 days after the end of each review period. If, due to claims’ time-lag, the family has paid more than the allowed limits for copayments, it is the responsibility of the MCOs and ASOs to repay the overpayment to the family within three months of the SPES’s determination that the maximum annual aggregate cost sharing limit for copayments had been met. The SPES is required to establish and maintain a system to track the copayments incurred by each family in Income Bands 1 and 2 in order to adhere to the requirements of the maximum annual aggregate cost sharing limit for copayments. The MCOs and ASOs also must require their providers and subcontractors to verify whether a family has reached the maximum annual aggregate cost sharing limit for copayments before charging a co-payment.

When a family reaches the maximum annual aggregate cost-sharing limit for copayments, the SPES will inform the MCOs and ASOs. The MCOs and ASOs will inform the providers, subcontractors and family that the co-payment limit has been met, that the providers and subcontractors cannot charge further copayments within the annual period, and the date when the annual period ends.

If the family believes it has reached the maximum annual aggregate cost sharing limit for copayments, it may request, in writing, that the SPES review the copayments that have been paid by the family. The MCO will then review the copayments made

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Approval Date: by the family and respond to the family, in writing, within three weeks of the date of the family’s written request. If the family disagrees with the SPES’s determination, the family may request, in writing, a review by the DEPARTMENT. The MCOs are required to include a summary of this right and the appropriate procedures to request the review in its Member Handbook.

There is no cost sharing requirements for children enrolled in HUSKY Plus Physical.

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)

Families of American Indian/Alaskan Native (AI/AN) children who are members of a federally organized tribe and who are in Income Band 1 or 2 are exempted from paying HUSKY, Part B premiums or copayments. Income Band 1 represents those enrollees whose income falls between 185 percent and 235 percent of the federal poverty level. Income Band 2 represents those enrollees whose income falls between 235 percent and 300 percent of the federal poverty level.

The Department of Social Services staff informed representatives of the Mashantucket Pequots and the Mohegans, the two federally recognized tribes within the State of Connecticut, that federal requirements do not permit cost sharing for AI/AN children in the HUSKY B program. Staff also consulted with them about the best way to identify AI/AN children.

Based on recommendations made by both tribes, it was decided that applicants would be asked to verify their tribal membership at time of application. The HUSKY application was modified to ask if the child for whom application is made is a member of a federally recognized tribe. If the answer is “yes”, the applicant will need to provide the name of the tribe and verification of membership. HUSKY informational materials were also revised to include information about the cost sharing exemption for AI/AN children. The SPES, under contract with the Department to determine eligibility for HUSKY B applicants, will notify the MCO when a new enrollee is qualified for exemption from cost sharing due to AI/AN status. The MCO will not charge the family for any partial premium payment and will issue the enrollee a membership card that specifies “no copayments”

American Indian/Alaskan Native children enrolled in HUSKY Plus Physical will not be charged premiums or copayments as there are no cost sharing requirements for any children enrolled in HUSKY Plus Physical.

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))

Nonpayment of premiums results in a disenrollment effective the end of the month for which the premium was not paid, and a three-month lockout period.

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Approval Date: 8.7.1.

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

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

Reminder notices are sent to enrollees, prior to disenrollment, which inform enrollees of the consequences of nonpayment and instruct them to call the SPES if their family income has decreased so that eligibility can be reevaluated. Based on the reduced family income the SPES will either refer the children to Medicaid or transfer HUSKY B eligibility to Income Band 1 for which there is no premium requirement. If an enrollee becomes disenrolled due to nonpayment of premiums, they may appeal through the Department’s administrative hearing division. Enrollment will continue during the appeal process for individuals who have filed their appeal within the allowable timeframe. Please see section 12.1 for more information.

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 would 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))

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Approval Date: 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)

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Approval Date:

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))

9.1.1. To increase the number of children in Connecticut with health insurance through the expansion of the HUSKY program.

9.1.2. To maximize participation in HUSKY, Parts A and B through outreach, a single point of entry servicer (SPES), a simplified application process.

9.1.3. To promote the health of children through an improved health benefit package tailored to the health care needs of children, which includes comprehensive preventive services.

9.1.4. To assist those children enrolled in HUSKY, Part B who have special physical health care needs, to receive appropriate care through a supplemental plan (HUSKY Plus Physical).

9.1.5. To maximize coordination between HUSKY Part B managed care plans HUSKY Plus Physical by integrating basic health care needs into the care provided for intensive health care needs, and, whenever possible, building upon existing therapeutic relationships with Title V providers.

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

9.2.1. To increase the number of children covered by health insurance within Connecticut.

9.2.2. To maximize participation in HUSKY Parts A & B.

• Expand Medicaid (HUSKY Part A) enrollment of uninsured children 18 years old who are under 185% of the FPL. • Increase the number of insured children 18 or under who are between 185% and 300% of the federal poverty level.

9.2.3. To promote the health of children through a comprehensive health benefits package.

• Match or exceed the statewide average of the percentage of children in HUSKY Parts A and B who receive immunizations by age two, meet or exceed state standards for well-child care, with a goal of at least 80% of children receiving all recommended well-child visits.

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Approval Date:

9.2.4. To assist children with special physical health needs through HUSKY Plus Physical.

• Ninety percent of referrals to HUSKY Plus Physical will have eligibility determination made within 21 days. • Track the percentage of referrals to HUSKY Plus Physical accepted or denied. • 100% of children with the following conditions will receive care according to individual needs and professional guidelines: o Children with intensive physical needs with a diagnosis of cystic fibrosis under ICD 9 CM 277.0. o Children with intensive physical needs with a diagnosis of cerebral palsy under ICD 9 CM 343.

9.2.5. To maximize coordination between HUSKY Part B and HUSKY Plus Physical

• 100% of children in HUSKY Plus Physical have an assigned HUSKY B case manager/liaison within 30 days of their enrollment into HUSKY Plus Physical. • 100% of children in HUSKY Plus Physical have an assigned HUSKY Plus Physical case manager/coordinator. • 85% of children in HUSKY Plus have a global plan of care within 30 days of enrollment • 85% of children in HUSKY Plus Physical have a revised global plan of care at least semi-annually. • 85% of children in HUSKY Plus Physical have had evidence of coordination between HUSKY B, and HUSKY Plus Physical at least quarterly as documented in the progress notes, and if additional revision is indicated, in the Global Plan of Care.

9.2.6. To assure that children with behavioral health needs receive appropriate care

• 70% of children who are discharged from inpatient care for mental health or substance abuse will receive follow-up care 30 days following discharge. • 75% of children will receive a clinical assessment within14 days following referral for treatment

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))

The state, through a contract with an external quality review entity, with the exception of calendar year 2003, conducts an annual evaluation based on an analysis of the

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Approval Date: program measures and a patient satisfaction survey.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. Or modified measures that are based on HEDIS. 9.3.6.

Other child appropriate measurement set. List or describe the set used. Well-child periodicity compliance. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well childcare 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: • Ambulatory Services • Follow-up After Mental Health Hospitalization • Follow-up After Chemical Dependency Hospitalization

See Appendix 9.3 for complete listing of reporting measures.

9.3.8. Performance measures for special targeted populations.

See Appendix 9.3 for complete listing of reporting measures.

9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

The State, through a contract with an external quality review entity and through the use of internal eligibility and enrollment data and utilization reporting from the MCOs and the ASO, will conduct an annual evaluation

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Approval Date: based on an analysis of the program measure. The analysis will include a sampling of patient charts, utilization data and a patient satisfaction survey. Please note that with the exception of calendar year 2003, the report will include the findings from the audit conducted by an external quality review entity.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8.

The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

The Medicaid Managed Care Council (MMCC) plays an advisory role to the Department for both the HUSKY A and HUSKY B programs. The council is comprised of legislators, clients and representatives from the managed care organizations, the medical provider community, advocacy groups, the Department of Social Services and other State agencies such as the Departments of Children and Families and Public Health. The council meets once a month during which time the Department provides program updates. The council also has several subcommittees which act as workgroups for important issues that require additional study and follow- up. The subcommittees are as follows: Public Health; Quality Assurance; Behavioral Health and Consumer Access. Additionally public input is obtained through a public notice process whereby proposed changes are published in the Connecticut Law Journal and the Department’s website and undergo a 15 day public comment period.

The Behavioral Health Partnership Oversight Council (BHPOC) serves in an advisory role to the Department for the behavioral health services as managed by the ASO. The BHPOC is comprised of legislators, clients, advocacy groups, the Department of Social Services and other state agencies such as the Department of Children and Families and the Department of Mental Health and Addiction Services. The BHPOC meets once a month during which time the Department provides program updates.

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Approval Date: The BHPOC also has several subcommittees that provide a forum for important issues to assure the viability of the behavioral health service delivery system. The subcommittees include: Transition, Provider Advisory, Quality Management and Access, and the Department of Children and Families Subcommittee.

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))

In accordance with 42 CFR 457.125, Section 2107 (c) and 42 CFR 457.120 (c) The Department met with representatives from both of Connecticut’s federally recognized Indian tribes, during the design phase of the HUSKY plan. The program design was discussed with the tribal representatives and their comments and suggestions were considered in the final design and ongoing operations of the program. The Department met with both tribes again in 2000 to discuss American Indian’s being exempt from cost sharing. The tribal members provided the Department with the information needed to request of American Indians in order to exempt them from cost sharing.

The Department continues to consult with both tribes on an annual basis to discuss any changes to the HUSKY Plan as well as address any concerns or questions the tribal representatives may have. The consultation will either be conducted by phone or in person depending on the issues to be discussed.

9.9.2. For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65 (b) through (d).

Amendments relating to either eligibility, such as the reduction of the crowd- out period from six to two months, or benefits, such as mental health parity or the carve-out of behavioral health services to the ASO, have been the result of legislative changes; therefore the prior public notice requirement was provided through the legislative process. Based on additional comments received subsequent to the 2/1/04 implementation from clients, advocates and other stakeholders, it was decided to repeal the premium increases, retroactive to the 2/1/04 implementation. The copayment maximum remains at $760.00.

The amendment relating to the change from at-risk MCO contracts to non-risk PIHPs was due to a directive from the Governor. The amendment relating to expediting eligibility processing and waiving premium payments for the first four months of managed care enrollment for a newborn child born in a Connecticut or designated border hospital with family income greater than 235% FPL was a result of a legislative change. In addition, the amendments relating to the carve-out of dental and pharmacy services as well as the return to at-risk MCO contracts were also a result of legislative changes. The prior public notice requirement was provided through the legislative process.

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Approval Date:

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

• Planned use of funds, including -- o Projected amount to be spent on health services; o Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and o Assumptions on which the budget is based, including cost per child and expected enrollment.

• Projected sources of non-Federal plan expenditures, including any requirements for cost sharing by enrollees.

The SCHIP budget, as provided in Appendix 9.10

is based upon the following assumptions: • Total CHIP Benefit costs for FFY 2009 are estimated at $35,315,091. Total FFY 2009 CHIP administrative costs are estimated at $2,869,552. Total CHIP Program FFY 2009 costs are therefore estimated at $38,184,643. • Both CHIP Pharmacy and Dental Carve-outs are estimated to be cost neutral in FFY 2009. • The estimated CHIP expense for Expedited Eligibility / Premium Waiver for HUSKY newborns for the first 4-months of life for FFY 2009 is $147,428. • The estimated CHIP FFY 2009 expense to cover legal immigrant children who have been residing in the U.S for less than 5 years is $238,046. Note that these are not new expenditures for the State. This service has been historically State funded. CHIPRA legislation provides new Federal matching funds for these expenditures, estimated at $154,730 FFP for FFY 2009. • For FFY 2009, the estimated average CHIP Band 1 and Band 2 Managed Care pmpm cost is $142.26 (including premium payments by Band 2 clients), and $133.82 (net of premium payments). • For FFY 2009, the estimated average CHIP Band 1 and Band 2 Fee for Service pmpm is $69.66. • For FFY 2009, CHIP Band 1 and Band 2 enrollment is estimated at 173,553. • Offsetting Beneficiary costs (Band 2 premiums) for FFY 2009 are estimated at $1,464,914.

The non-Federal share of the budget is funded through appropriations from the State’s general fund.

The non-Federal share of the budget is funded through appropriations from the State’s general fund. Please see attached Appendix 9.11, which includes the budget for FFY 2008 and FFY 2009.

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Approval Date:

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.

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Approval Date:

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)

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Approval Date:

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.

In accordance with 42CFR Sec 457 part(s), 1120, 1130(a), 1130(c), 1140, 1150(a), 1160(a), 1170 and 1180, an applicant has the right to request an administrative review of eligibility and enrollment decisions described below. However, the State will not provide an opportunity for review of a matter if the sole basis for the decision is a provision in this plan or in federal or State law requiring automatic change in eligibility or enrollment that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances. The Department has a two level process to review appeals related to HUSKY B eligibility and enrollment. The level one review is conducted by the Department’s agent (SPES) and the Department’s Administrative Review Unit conducts the level two review.

The State ensures that all enrollees and applicants receive timely written notice of any eligibility or enrollment decisions subject to review, as outlined below. All notices issued during the appeals process include the reasons for the determination, an explanation of applicable rights to review of that determination, the standard and expedited time frames (if any) for review, the manner in which a review can be requested, and the circumstances under which enrollment may continue pending review. Additionally, the State will ensure that applicants and enrollees have opportunities to represent themselves or have representatives of their choosing in the review process, to timely review their files and other applicable information relevant to the review of the decision, and to fully participate in the review process.

Eligibility Eligibility decisions, which can be appealed, include denials, failure to make a timely determination of eligibility, discontinuances and premium band changes. When HUSKY B eligibility is denied, terminated, transferred to a higher premium band, or the State fails to make a timely determination of eligibility, a notice, described above, is sent to the applicant informing him of this decision. The notice also informs the applicant of his right to request an administrative review of this decision within ten business days from the date the notice was sent to the applicant. A supervisory level employee, who was not involved in the original decision, conducts the level one administrative review of the initial eligibility decision.

The SPES notifies the applicant in writing of its level one review decision not more than ten business days from receipt of a request for administrative level one review.

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Approval Date: Decisions related to expedited requests shall be made within five business days.

If the applicant is not satisfied with the SPES’ level one review decision, the applicant may request a level two administrative review within ten business days following the date on the notice of the level one decision. The level one decision notice contains information on how to request a second level review and information related to expedited review.

At the second level review, the DSS administrative reviewer, who was not involved in the prior decisions, evaluates all factors related to the SPES’ eligibility decision or failure to make a timely decision of eligibility. The level two review is a desk review unless the applicant requests a personal conference with the administrative reviewer as part of the review process. The personal conference may be conducted in person, by telephone or video conferencing.

The DSS administrative reviewer renders a decision in writing to the applicant not more than 45 calendar days following the date of receipt of the applicant’s written request for the level two administrative review. Decisions related to expedited requests shall be made within 20 days.

The Commissioner may waive any of the time limits as provided for above as may become necessary.

To the extent that an applicant has coverage, coverage continues pending both levels of review and final decision from the level two appeal.

Enrollment Enrollment decisions, which can be appealed, include any suspension or termination of enrollment, such as disenrollment due to non-payment of premiums, denial of good cause for early re-enrollment, and denial of plan change.

When a HUSKY B client’s enrollment is suspended or terminated, a notice, described above, is sent to the client informing him of this decision. The denial notice also informs the client of his right to request an administrative review of the decision within ten business days from the date the denial notice was sent by the SPES.

An agent at the SPES, who was not involved in the original decision, conducts the initial level one administrative review and notifies the applicant in writing of its level one review decision not more than ten business days from receipt of a request for administrative level one review.

If the applicant is not satisfied with the level one review decision, the applicant may request a level two administrative review within ten business days following the date on the notice of the level one administrative decision.

The Department’s administrative reviewer, who was not involved in the previous

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Approval Date: decisions, shall evaluate all factors related to the agent’s enrollment decision and shall offer the applicant the opportunity to have a personal conference with the administrative reviewer as part of the review process. Such personal conference maybe conducted in person, by telephone or video conferencing.

Enrollment continues pending both levels of review and final decision from the level two appeal. Enrollment decisions are not subject to expedited appeals.

Health Services Matters 12.2. Please describe the review process for health services matters that complies with 42 CFR §457.1120.

The State, pursuant to 42 CFR 457.1120(a)(2) has elected to comply with existing grievance and appeal requirements in effect for the MCOs with which it contracts. The same or more stringent requirements will be imposed on the ASOs for decisions related to denial of behavioral health services or dental health services. These existing requirements provide, in accordance with applicable state law, for internal reviews within the MCO and the ASOs and external reviews with the State of Connecticut, Department of Insurance (“DOI”), the state agency that regulates MCOs. In addition, pursuant to the Department’s contract with the MCO and the ASOs, the MCO’s and ASO’s internal appeals process for HUSKY B Enrollees must allow for expedited review in certain circumstances described below.

In the State of Connecticut, MCOs, as HMOs must comply with various quality consumer protection requirements by state law. (see appendix 7.1 for a summary or this law.)

The MCO and ASO must clearly specify in its Enrollee handbook/packet(s) the procedural steps and timeframes for each level of its internal appeals process and for filing an external appeal through the DOI. The enrollee handbook that describes the appeals process and enrollee rights is provided to enrollees at the time of enrollment and at least annually thereafter. An independent external review is conducted as part of this appeals process which is the statewide standard review, and also complies with the State review requirements in place for all health insurance companies.

When a requested good or service is denied, the MCO or ASO must provide a written denial notice to the Enrollee, which includes the MCO’s or ASO’s denial decision as well as notice of the Enrollee’s appeal rights. The notice must clearly state or explain what goods and/or services are being denied; the reasons for the denial; the contract section that supports the denial; the address and toll-free number of their Member Services Department; the Enrollee’s right to challenge the denial by filing an internal appeal with the MCO or ASO; the procedure and timeframe for commencing each level of the MCO’s or ASO’s internal appeals process, including the address to which any written request for appeal may be mailed; the availability of expedited internal appeals; specifications and assistance as to the format in which the Enrollee may request an internal appeal; that the Enrollee will lose his or her right to challenge the

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46 Effective Date:

Approval Date: denial with the MCO or ASO within 60 days from the date the MCO mailed the denial notice; that for each level of its appeals process, the MCO or ASO must issue a decision regarding an appeal no more than 30 days following the date that the MCO receives the request for review; that the MCO or ASO must be responsive to questions which the Enrollee may have about the denial; that the Enrollee may submit additional documentation or written material for the MCO’s or ASO’s consideration; and that the MCO’s or ASO’s review may be based solely on information available to the MCO or ASO and its providers, unless the Member requests a meeting or the opportunity to submit additional information.

Internal appeal process Enrollees must have the opportunity to request an internal appeal with the MCO or ASO of a decision made by the MCO or ASO regarding the denial of goods and services covered in the basic benefit package. The MCO is required to have a timely and organized internal appeal process for receiving and acting upon these requests. This internal appeals process, may, at the MCO’s or ASO’s option, consist of more than one level of review. The internal appeals process shall be available for resolution of disputes between the MCO/ASO or MCO/ASO subcontractors and Enrollees concerning the denial of a request for goods and services covered under the HUSKY B benefit package. The MCO/ASO is responsible for ensuring compliance with the internal appeals process, whether the MCO or one of its subcontractors denies the goods or services.

The MCO and the ASO must develop and make available to Enrollees and potential Enrollees appropriate alternative language versions of internal appeal materials, including but not limited to, the standard information contained in denial notices. Such materials shall be made available in Spanish, English and any other language(s) if more than five percent of the MCO’s or ASO’s Enrollees in the State of Connecticut served by the MCO or ASO speak the alternative language. The MCO/ASO must submit such alternative language materials to the DEPARTMENT and the DEPARTMENT must approve any such materials in writing prior to use by the MCO or ASO.

The MCO and ASO must develop written policies and procedures for each component of its internal appeals process, which must be approved by the Department in writing. The MCO and the ASO are required to maintain a record keeping system for each level of its appeal process, which shall include a copy of the Enrollee’s request for review, the response, and the resolution, which the MCO or ASO shall make available to the Department upon request.

An individual or individuals having final decision-making authority shall conduct the final level of the MCO’s or ASO’s review. One or more physicians who were not involved in the denial determination must decide any appeal arising from an action based on a determination of medical necessity.

The MCO and ASO may decide an appeal on the basis of written documentation

Connecticut Title XXI State Plan

47 Effective Date:

Approval Date: available to the MCO or ASO at the time of the request, unless the Enrollee requests an opportunity to meet with the individual or individuals conducting the internal appeal on behalf of the MCO or ASO and/or requests the opportunity to submit additional written documentation or other written material. The MCO/ASO shall inform the Enrollee that the MCO’s or ASO’s review may be based solely on information available to the MCO or ASO and its providers, unless the Enrollee requests a meeting or the opportunity to submit additional information.

The MCO or ASO shall issue a written decision for each level of its internal appeals process. Each decision shall be sent to the Member by certified mail. The MCO/ASO shall send a copy of each decision to the DEPARTMENT. The appeal decision shall be sent no later than 30 days from the date on which the MCO or ASO received the appeal.

If the MCO or ASO fails to issue a decision within 30 days, the DEPARTMENT will deem the decision to be a denial and the Enrollee may file an external appeal with the DOI.

The MCO’s and ASO’s written decision must include the Member’s name and address; the provider’s name and address; the MCO or ASO name and address; a complete statement of the MCO’s or ASO’s findings and conclusions, including the section number and text of any statute or regulation that supports the decision; a clear statement of the MCO’s or ASO’s disposition of the appeal; a statement that the Member has exhausted the MCO’s/ASO’s internal appeal procedure concerning the denial at issue; and relevant information concerning the external appeals process available through the DOI.

The MCO and the ASO shall have also an internal appeal process through which a health care provider may grieve the MCO or ASO decision on behalf of a Member. The MCO/ASO shall provide information on the availability of this process to the providers in the MCO’s or ASO’s network. The health care provider appeal process does not include any appeal rights to the DEPARTMENT or any rights to an external appeal through the DOI.

Expedited internal appeal process Pursuant to the Department’s contract with the MCO’s and ASO, the MCO’s/ASO’s internal appeals process for HUSKY B Enrollees must allow for expedited review. If an Enrollee requests an expedited review, the MCO or ASO must determine within one business day of receipt of the request, whether to expedite the review or whether to perform the review according to the standard timeframes.

The MCO and the ASO must include the following information concerning the DOI external appeal process in the Enrollee’s member handbook: that if the Member has exhausted the MCO’s or ASO’s internal appeals process and has received a final written decision from the MCO or ASO upholding the MCO’s/ASO’s original denial of the good or service, the Member may file an external appeal with the DOI within 30

Connecticut Title XXI State Plan

48 Effective Date:

Approval Date: days of receiving the final written appeal decision; that the Member may be required to pay a filing fee for the DOI appeal; that the Enrollee will be asked to submit certain information in support of the appeal request, including a copy of his or her HUSKY B enrollment card and a release of medical records; that the DOI will assign the appeal to an outside, independent entity, which will conduct a preliminary review and determine whether the appeal meets eligibility for review; that the Enrollee will be notified within five business days of the DOI’s receipt of the request whether the appeal has been accepted or denied for full review; and that Enrollees may obtain information about the external review process and request a form from the DOI and provide the DOI’s address and phone number; a copy of the DOI External Appeal Consumer Guide; and that the MCO or ASO shall be bound by the DOI’s external appeal decision.

The DEPARTMENT shall pay the filing fee on behalf of any Enrollee whose family income exceeds 185 percent of the federal poverty level but does not exceed 300 percent of the federal poverty level (Members in Income Bands 1 and 2).

HUSKY PLUS: The HUSKY Plus Physical program has its own separate appeals process that addresses issues specific to the services covered by HUSKY Plus Physical. The HUSKY Plus Physical appeals process has three levels. The first level is an informal appeal that is addressed by the participating HUSKY Plus Center. If the enrollee wishes to pursue the matter further, a written request is submitted to the HUSKY Plus Appeals Subcommittee. The subcommittee in HUSKY Plus Physical consists of impartial representatives from the Department of Social Services, the Department of Public Health, and each of the contracting Title V Centers. The appeals subcommittee hears appeals for both HPP and Title V. If the enrollee is still dissatisfied, the appeal subcommittee’s decision may be further appealed through the Commissioner of the Department of Social Services. A detailed description of this appeals process is included in Appendix 3.1.

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.

CONNECTICUT TITLE XXI STATE PLAN 0BFACT SHEET

1BName of Plan: HUSKY Plan

Date Plan Submitted:

January 15, 1998 Date Plan Approved:

April 27, 1998 Effective Date:

October 1, 1997 (HUSKY A) (ended 0/1/02)

January 1, 1998 (HUSKY B)

Date Amendment #1 Submitted:

January 21, 2000 Date Amendment #1 Approved:

July 14, 2000 Date Amendment #1 Effective:

January 1, 2000

Date Amendment #2 Submitted:

July 1, 2002 Date Amendment #2 Approved:

October 25, 2005

Date Amendment #3 Submitted:

March 25, 2004 Date Amendment #3 Approved:

June 21, 2004 Date Amendment #3 Effective:

February 1, 2004

Date Amendment #4 Submitted:

June 29, 2004 Date Amendment #4 Approved:

September 24, 2004 Date Amendment #4 Effective:

February 1, 2004

Date Amendment #5 Submitted:

May 8, 2006 Date Amendment #5 Approved:

August 1, 2006 Date Amendment #5 Effective:

July 18, 2005 and January 1, 2006

Date Amendment #6 Submitted:

June 30, 2008 Date Amendment #6 Approved:

August 18, 2009 Date Amendment #6 Effective:

January 1, 2008 (newborn waiver) January 1, 2008 (PIHP contracts) February 1, 2008 (Pharmacy carve-out) June 11, 2008 (Expedited Newborn applications) August 1, 2008 (Managed Care Contracts) September 1, 2008 (Dental Carve-out)

Date Amendment #7 Submitted:

June 30, 2009 Date Amendment #7 Approved:

December 18, 2009 Date Amendment #7 Effective:

April 1, 2009

2

1BBackground

• On January 15, 1998, Connecticut submitted a title XXI State Plan to expand its Medicaid program and create a separate child health program. Connecticut’s Medicaid expansion (HUSKY A) covers uninsured children age 14 through 18 in families with incomes up to 185 percent of the Federal Poverty Level (FPL). The State’s separate child health program (HUSKY B) covers uninsured children whose family incomes are at or below 300 percent of the FPL. The Medicaid expansion phased out on September 30, 2002.

• Children who are eligible for HUSKY B and who require intensive physical health services receive medically necessary services under HUSKY Plus.

• The State also has a buy-in option available to uninsured children in families with incomes above 300 percent of the FPL with no State or Federal subsidy.

2BAmendments

• On January 21, 2000, Connecticut submitted a State plan amendment to incorporate the following provisions to eliminate cost sharing for American Indian/Alaska Native children, implement full mental health parity, remove all limitations imposed on inpatient and outpatient treatment of DSM IV mental health conditions or substance abuse, provide HUSKY Part B coverage to children of municipal employees in certain situations, and remove children of Federal employees from the list of children ineligible for HUSKY Part B.

• On July 1, 2002, Connecticut submitted a State plan amendment to indicate the State’s compliance with the final CHIP regulations and to update program descriptions and to reduce the period of uninsurance prior to enrolling in CHIP from 6 months to 2 months.

• On March 25, 2004, Connecticut submitted a State plan amendment to impose new monthly premiums on families with incomes from above 185 to 235 percent of the FPL of $30 per child with a monthly family cap of $50. This amendment also increases monthly premiums for families with incomes from above 235 to 300 percent of the FPL from $30 to $50 per child with a monthly family cap of $75.

• On June 29, 2004, Connecticut submitted a State plan amendment to rollback the monthly premiums effective February 1, 2004. Children with family income up to including 235 percent of the FPL are not required to pay a premium. Children with family income that exceeds 235 percent of the FPL but which does not exceed 300 percent of the FPL are required to pay $30 per child per month, and the cap decreases from $75 to $50 per family per month.

• On May 8, 2006, Connecticut submitted a State plan amendment to carve out behavioral health services from the capitation portion of the HUSKY B (CHIP) program and to provide these services on a fee-for-service basis managed by an Administrative Services Organization (ASO) under contract with the Department of Social Services and the

3

Department of Children and Families. This SPA also eliminates self-declaration of income for families when applying for CHIP.

• On June 30, 2008, Connecticut submitted a State plan amendment to: 1) Newborn Premium Waiver, families with income over 235 percent of the Federal poverty level (FPL) will not be required to pay premiums for a newborn during the first 4 months of coverage, provided the newborn is born is a Connecticut hospital or designated border hospital; 2) Pre-Paid Inpatient Health Plan (PIHP) contracts – due to the inability of some managed care organizations (MCOs) to comply with freedom of information requirements to make public certain company documents, the State terminated its at-risk contracts with the four HUSKY MCOs and re-contracted with them as PIHPs in non-risk arrangements; 3) Pharmacy Carve-out, pharmacy services no longer offered through the PIHPs. Pharmacy services are provided through the fee-for service pharmacy program; 4) Expedited Newborn Applications – HUSKY applications containing a newborn will be processed within one business day of receipt of the application; 5) Managed Care Contracts – the State intends to contract with successful bidders in at-risk MCO arrangements to serve the HUSKY population; 6) Dental Carve-out – the State will carve-out dental services from its contracts with MCO companies and will contract with an Administrative Service Organization (ASO) in order to improve access to dental care.

• On June 30, 2009, Connecticut submitted a State plan amendment to cover children under the age of 19 who are qualified aliens and lawfully residing in the United States, regardless of their date of entry into the country. Also, eliminates steering committee for HUSKY Plus Physical program (Appendix 3.1 of the State plan).

4BChildren Covered Under the Program

• The State reported that 22,270 children were ever enrolled in CHIP in Federal fiscal year (FFY) 2008.

5BAdministration

• Connecticut’s Department of Social Services administers the CHIP program.

6BHealth Care Delivery System

• HUSKY Part B is administered through State contracts with managed care plans through a competitive bidding process.

• Behavioral health services are carved out from the capitation portion of the HUSKY B (CHIP) program. These services are provided on a fee-for-service basis managed by an ASO under contract with the Department of Social Services and the Department of Children and Families.

• HUSKY Plus is for children with special physical health needs. The plan is responsible for all aspects of benefit management under HUSKY Plus, including the direct reimbursement of

4

HUSKY Plus providers through contractual arrangements including, but not limited to, fee for service reimbursement.

• Dental Carve-out – the State carves-out dental services from its contracts with MCO companies and contracts with an Administrative Service Organization (ASO) in order to improve access to dental care.

• Pharmacy Carve-out - pharmacy services no longer offered through the PIHPs. Pharmacy services are provided through the fee-for service pharmacy program.

7BBenefit Package

• The benefits package is benchmark coverage plus additional coverage, which is Secretary- approved coverage. The benchmark benefit package is based on the state employee coverage. The coverage combines the most generous benefits offered under the three state employee options (Blue Cross, MD Health Plan, and Kaiser Permanente) in addition to covered services mandated by the Federal CHIP regulations. The HUSKY Plus benefit package offers additional for Children with Special Health Care Needs. Behavioral health services are provided on a fee-for-service basis. Pharmacy services are provided through the fee-for service pharmacy program. Dental services are contracted with an Administrative Service Organization (ASO).

Cost Sharing

• Families with incomes from above 185 to 235 percent of the FPL, pay no monthly premiums.

• Families with incomes from above 235 to 300 percent of the FPL pay monthly premiums of $30 per child with a monthly family cap of $50.

• Families with incomes above 185 percent of the FPL pay the following copayments: $5 for office visits, $3 for generic drugs, $5 for oral contraceptives, $6 for brand name drugs, $5 for outpatient mental health, $25 for emergency room visits unless the patient is admitted to the hospital, $5 for eye and hearing exams, and $5 for nurse midwives (except preventative), nurse practitioners (except preventative), podiatrists, chiropractors, and naturopaths.

Coordination between Separate Child Health Program and Medicaid

• The State screens all HUSKY applications through the single point of entry system (SPES). The Eligibility Specialists at the SPES are trained in Medicaid and CHIP eligibility and screen all applications for potential eligibility for both programs.

8BCrowd-Out Strategy

A child is ineligible for HUSKY Part B if they have been covered by employer-sponsored insurance within the last two months. This may be extended to 12 months if the Commissioner determines that two months is insufficient to deter applicants or employers

5

from discontinuing employer-sponsored dependent coverage. However, an application may be approved if the reason for loss of employer-sponsored insurance is unrelated to the availability of the HUSKY Plan or any of ten other reasons, which include the loss of employment.

9BOutreach Activities

• The State works with the Children’s Health Council, Medicaid Managed Care Council, Infoline of CT and local CAP agencies to develop outreach mechanisms. Outreach includes radio and TV ads, direct-mail campaign, brochures/flyers, video, toll-free number, web sites, State presentations and mail-in applications.

• The Department’s HUSKY Outreach program includes:

o Funding HUSKY Info Line (HIL) – HIL operates a toll free information and referral service for HUSKY applicants and individuals needing information about HUSKY. HIL care coordinators instruct callers on how to apply for HUSKY, provide over the phone application assistance and follow-up to ensure that application process was completed; o School based outreach efforts – HUSKY information provided through the free- and reduced-price lunch program in cooperation with the CT Department of Education and school food service directors. HUSKY information and applications are also available through the school nurses and the school-based health centers; o Participation in the CT Department of Labor’s Rapid Response Team – provision of HUSKY information and application assistance to laid-off workers; o MCO community- based outreach – HUSKY participating plans provide information and application assistance at various community events including school health promotional fairs; craft shows; country fairs, etc; o Collaboration with Child Support Services; o Collaboration with CT Covering Kids and Families (CCKF) initiative – CKF is a Robert Wood Johnson Foundation initiative, with Connecticut Voices for Children acting as the lead agency for Connecticut. CCKF funds several local HUSKY outreach projects throughout the state; and o HUSKY (Hwww.huskyhealth.comH) website featuring downloadable application.

3BFinancial Information

Total FFY 2009 SCHIP Allotment: $45,644,506 FFY 2009 Enhanced Federal Matching Rate: 65%

Date Last Updated: CMS, CMSO, DSCHI: December 08, 2009

_____________________________________________________________________________ Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT-14-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Connecticut 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: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services “CMSs

7500 Security Boulevard, Mail Stop: S2-01-16 Ss (CENTERS FOR MEDICARE & MEDICAID SERVICES

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

SEP 2 2 2014

Kate McEvoy, Esq.

Director, Division of Health Services

State of Connecticut Department of Social Services

55 Farmington Avenue ‘ Hartford, CT 06106

Dear Ms. McEvoy:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number CT-14-0003 submitted on June 26, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number CT-14-0003 describes the state’s plan to provide coverage in its separate CHIP, for children subject to section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under section 4.1 of Connecticut’s approved CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment and other CHIP-related issues. Mr. Burian’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) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, MA 02203

Page 2 — Ms. Kate McEvoy

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. Kelly Whitener, Director, Division of State Coverage Programs at

(410) 786-0719.

Sincerely, Eliot Fishman Director

Enclosure

ce:

Mr. Richard McGreal, ARA, CMS Region I, Boston

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility CT.1129.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Connecticut State Funds: $ Federal Funds: $ 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. CT-14-0003 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion  ish 2101(f) Gr Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page

Submitted By: Patricia McCooey Last Revision Date: Sep 5, 2014 Submit Date: Jun 27, 2014 Character Count:552 out of 2000   In order to comply with section 2101(f) of the ACA, Connecticut seeks to amend its CHIP plan to assure that it will treat any children determined ineligible under the state's Medicaid plan as a result of the elimination of the application of income disregards under section 1902(e)(14) of the Social Security Act (MAGI b d i th d l i ) t t d l i Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov 02/05/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

cCmMS CHIP Eligibility

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

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

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

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to

Section 2101(f) such that no child in the state will be subject to this provision.

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

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

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

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

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

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

% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

SPA# CT-14-0003 Approval Date: Effective Date: January 1, 2014

ccmMs CHIP Eligibility

(@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

V.20130917

SEP 2 2 2014

SPA# CT-14-0003 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT-14-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Connecticut 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: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

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

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

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

FEB 2 4 2015

Kate McEvoy, Esq.

Director, Division of Health Services

State of Connecticut Department of Social Services 55 Farmington Avenue

Hartford, CT 06106

Dear Ms. McEvoy:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XX] Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number CT-14-0005, submitted on June 17, 2014. This SPA is related to Modified Adjusted Gross Income (MAGI)

Eligibility and has an effective date of January 1, 2014.

The SPA number CT-14-0005 describes the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, non-payment of premiums and presumptive eligibility. Copies of the approved state plan pages are attached, and these approved pages supersede sections of Connecticut’s current state plan as detailed below:

New State Plan Page Impact on Current State Plan Section CS17: Non-Financial Eligibility — Residency Section 4.1.5 CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR

Number

CS19: Non-Financial Eligibility — Social Security | Section 4.1.9.1

Coverage

CS20: Non-Financial Eligibility — Substitution of | Section 4.4.4

Premiums

CS21: Non-Financial Eligibility - Non-Payment of | Section 8.7

for Children

CS28: General Eligibility - Presumptive Eligibility | Section 4.3.2

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’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) 786-3246

Page 2 — Ms. Kate McEvoy

Facsimile: (410) 786-5882 E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator in our Boston Regional Office. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 New Sudbury St, Room 2325

Boston, MA 02203-0003

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.

Sincerely,

1ot Fis) Director

Enclosures

ce: Richard McGreal, Associate Regional Administrator, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility CT.1082.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Connecticut Transmittal Number: CT-14-0005 Children's Health Insurance Program Eligibility: General Information General Information: Submission Title: short (under 100 characters) label used to identify this submission in the web application Non-Financial Eligibility FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 1 of 1 Children's Health Insurance Program Eligibility: General Infor...

coms. CHIP Eligibility

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

CS17

Separate Ch Non-Financial

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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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OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS18

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens. including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship. national status or satisfactory immigration status.

[B] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

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

Who have declared themselves to be citizens or nationals of the United States. or an individual having satisfactory immigration status. during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

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

The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

(# Other date, as described:

The date on which CHIP benefits would have otherwise been furnished had the inconsistency not arisen.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009. P.L. 111-3). °

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. Cid and is Os FED 2% CUld

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coms CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

No

ry An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

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

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

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

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

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

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

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

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

(i) Has been granted employment authorization; or

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

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

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10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum. shall not

be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

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

cSsi9

Separate Ch th Insu Non-Financial Eligibility -

42 CFR 457.340(b)

Social Security Number As a condition of eligibility. the CHIP Agency must require individuals who have a social security number or are eligible for one as

determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals. as a condition of eligibility, to furnish their social security number(s). with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections. or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

ry The CHIP Agency assists individuals, who are required to provide their SSN. to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[m] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN. The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their es SSN. .

When requesting an SSN for non-applicant household members, the state assures that:

ia At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

i The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

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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.

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

Transmittal Number: CT - 14 - 0005 Expiration date: 10/31/2014 Separate Child Health Insurance Program Non-Financial Eligibility - Substitution of Coverage

CS20

Section 2102(b)\3)(C) of the SSA and 42 CFR 457.340(d)(3). 457.350(i), and 457.805

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[M] Substitution of coverage prevention strategy:

Name of policy Description

Substitution Monitoring Applicants may not be covered by other

comprehensive health insurance. The application used by the CHIP agency and the state-based marketplace asks applicants to report other health insurance coverage. If a household reports creditable coverage. any child in the household will be found ineligible for CHIP. To determine the percent of enrollees who dropped group health

+ insurance without good cause in order to gain eligibility for HUSKY. 4 the Department will generate quarterly reports to compare the number

of individuals under age 19 that were denied due to other insurance and then reapplied within a six (6) month time frame. The report will monitor the percentage of such applicants who are subsequently approved for HUSKY, but no longer report other insurance. If substitution exceeds ten (10) percent, the Department will collaborate with CMS to identify an alternative strategy to reduce substitution.

A waiting period during which an individual is ineligible due to having dropped group health coverage. No

If the state elects to offer dental only supplemental coverage. the following assurances apply:

o The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

(F] The waiting period does not apply to children eligible for dental only supplemental coverage.

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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State Name:|Connecticut

Transmittal Number: CT - 14 - 0005

OMB Control Number: (938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance cent

Non-Financial Eligibility

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? No

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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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CHIP Eligibility

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

CS28

42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. | Yes

[Ml] Describe the population of children to whom presumptive eligibility applies:

All children, from birth to the age of nineteen, with incomes above 196% of the FPL and up to and including 318% of the FPL.

[W] Describe the duration of the presumptive eligibility period and any limitations:

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

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

No more than two periods within a calendar year.

[Ml] Describe the application process and eligibility determination factors used:

Qualified entities may use either an online portal for presumptive eligibility applications or a simplified, one page presumptive eligibility paper application.

[i] The CHIP Agency uses qualified entities, as defined in section 1920A, to determine eligibility presumptively for children.

Se

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

x Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan

Is authorized to determine a child’s eligibility to participate in a Head Start program under the Head Start

SZ

bs Act

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

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food

XS

Program for Women, Infants, and Children (WIC) under section 17 of the Child Nutrition Act of 1966

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

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

Is an elementary or secondary school operated or supported by the Bureau of Indian A ffairs ([] Isa state or Tribal child support enforcement agency under title IV-D of the Act

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

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

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

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

(1 Any other entity the state so deems, as approved by the Secretary The CHIP Agency assures that it has communicated the requirements for qualified entities, at 1920A(b)(3)

of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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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_____________________________________________________________________________ Table of Contents State/Territory Name: Connecticut State Plan Amendments (SPA) #: CT-17-0010-CHIP This file contains the following documents in the order listed: 1) 1) Approval Letter 2) Final Approved State Plan 3) State Plan Attachments

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-0"1-16 Baltinrore, MD 21244-1850 clvts ctNttRS fon MtDtc¡R[ & MfDtcAtD sfRvtcas CCNTTR fOR MEDICAID & CHIP SENVICE9 Children and Adults Health Grouo Nov I 5 2017 Kate McEvoy, Esq. Director, Division of Health Services Connecticut Department of Social Services 55 Farmington Avenue Hartford, CT 06106 Dear Ms. McEvoy: I am writing to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children's Health Insurance Program (CHIP) state plan amenrdment (SPA) number CT-17-001O-CHIP, submitted on October 13,2017. This SPA makes two changes effective July l, 2017. The first permits Connecticut to add coverage of gender dysphoria treatment services in its CHIP program, Husky B. The second updates the state's premium bands to be consistent with Modified Adjusted Gross Income (MAGr). Your title XXI project officer is Ms. Mary (Tess) Hines. She is available to answer questions concerning this amendment and other CHIP related issues. Ms. Hines' contact information is: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop 52-05-05 Baltimore, MD 21244- I 850 Telephone: (4 I 0) 786-0435 E-mail: Marv.H s,hhs.sov Official communications regarding program matters should be sent simultaneously to Ms. Hines and to Mr. Richard McGreal, Associate Regional Administrator (ARA) in our Boston Regional Office. Mr. McGreal's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations JFK Federal Building 15 New Sudbury St, Room 2325 Boston, MA 02203-0003 If you have additional questions, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (410) 786-0721. V/e look forward to continuing to work with you and your staffon your program.

Page 2 - Ms. Kate McEvoy eõ A¡¡re Marie Costello Director Mr. Richard McGreal, ARA, CMS Region I, Boston

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:_____________Connecticut_______________________________________ (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)) Roderick L. Bremby, Commissioner, CT DSS, October 13, 2017 (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Kate McEvoy Position/Title: Director, Division of Health Services Name: Michael Gilbert Position/Title: Director, Division of Financial Services *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 (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.

2 This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: 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 state plan. The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the

3 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, 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

4 access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: o Option to Create a Separate Program- States may elect to establish a separate child health 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

5 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 a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

6 Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address:

Mary T. Hines 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

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

As of 10/1/02

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))

Through 9/30/02. Effective 10/1/02, the Medicaid expansion was phased out.

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

8 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 incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Date Plan Submitted: January 15, 1998 Date Plan Approved: April 27, 1998 Effective date: HUSKY A (Medicaid Expansion) October 1, 1997 HUSKY B (Separate Child Health) January 1, 1998

Amendment #1: AI/AN Children Cost Sharing Exempt Date Submitted: January 21, 2000 Date Approved: July 14, 2000 Date Effective: January 1, 2000

Amendment # 2: Compliance/Reduce Period of un-insurance from 6 to 2 months Date Submitted: July 1, 2002 Date Approved: October 25, 2005

Amendment #3: Premium Increase Date Submitted: March 25, 2004 Date Approved: June 21, 2004 Date Effective: February 1, 2004

Amendment #4: Premium Rollback Date Submitted: June 29, 2004 Date Approved: September 24, 2004 Date Effective: February 1, 2004

9 Amendment #5: Behavioral Health Carve Out & Eliminates Self-declaration of Income Date Submitted: May 8, 2006 Date Approved: August 1, 2006 Date Effective: July 18, 2005 and January 1, 2006

Amendment #6: Change from MCOs to PIHPs, four months newborn premium waiving, pharmacy carve-out, expedited newborn application processing, dental carve-out, change from PIHPs to MCOs. Date Submitted: June 30, 2008 Date Approved: August 18, 2009 Date Effective: January 1, 2008, February 1, 2008, June 11, 2008, August 1, 2008, September 1, 2008

Amendment #7: Coverage for children under the age of 19 who are qualified aliens and lawfully residing in the United States, regardless of their date of entry into the country. Revision of Appendix 3.1 (HUSKY Plus Physical) to reflect elimination of steering committee. Date Submitted: July1, 2009 Date Approved: December 8, 2009 Date Effective: April 1, 2009

Amendment #8: Cost sharing changes and implementation of presumptive eligibility Date Submitted: April 29, 2011 Date Approved: August 21, 2015 Date Effective: March 1, 2011

Amendment #9: Technical revision using new State Plan format to the Lawfully Residing Option in accordance with section 214 of CHIPRA previously amended under SPA #7.

Implementation of the HUSKY Health medical administrative services organization (ASO) delivery system for all CHIP medical benefits and the elimination of the medical managed care delivery system model.

Cessation of the Statewide Standard Review Process available through the Connecticut Insurance Department for external appeals of health services matters. Pursuant to 42 CFR 457.1120(a)(1), the Department has developed a program specific review process in which a clinical director at the Department (Medical, Behavioral Health or Dental director) will conduct the appeal of an ASO decision concerning a health services matter.

Date Submitted: June 30, 2012 Date Approved: February 22, 2017

10 Date Effective: January 1, 2012

CT-17-0010-CHIP (Amendment #10): Describes the new premium bands following ACA/MAGI implementation, incorporates and cross-references the MAGI SPA templates, adds coverage for the coverage of gender dysphoria, and makes certain other technical corrections.

Date Submitted: October 13, 2017 Date Approved: Date Effective: Proposed Effective date: July 1, 2017

1.4 MAGI SPAs

The following MAGI Eligibility plan amendments, CT-14-0001, 14-0003, 14-0004 and 14-0005, replace and supersede the following plan sections, as noted below. Please see Appendix 1.4 for the plan amendments and supporting templates/PDFs. Please note that the effective date for the MAGI eligibility changes was January 1, 2014.

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) CT-14-0001

Effective/ Implementation Date: January 1, 2014

MAGI Eligibility & Methods CS15

CS7

CS10

CS10 MAGI-Based Income Methodologies

Eligibility – Targeted Low Income Children

Eligibility – Children Who Have Access to Public Employee Coverage

Maintenance of Agency Contribution Incorporated within a separate subsection under section 4.3

Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Supersedes current section 4.1.7 regarding children of public employees

Appendix: Incorporate within a separate appendix CT-14-0003 Establish CS14 Children Ineligible for Incorporated within a separate

11 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s)

Effective/ Implementation Date: January 1, 2014 2101(f) Group Medicaid as a Result of the Elimination of Income Disregards subsection under section 4.1 CT-14-0004

Effective/Implementatio n Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 CT-14-0005

Effective/ Implementation Date: January 1, 2014 Non-Financial Eligibility CS17

CS18

CS19

CS20

CS21

CS28 Non-Financial Eligibility – Residency

Non-Financial Eligibility – Citizenship

Non-Financial Eligibility – Social Security Number

Non-Financial Eligibility – Substitution of Coverage

Non-Financial Eligibility – Non-Payment of Premiums

General Eligibility – Presumptive Eligibility for Children Supersedes the current section 4.1.5

Incorporated in new sections 4.1.0; supersedes the current sections 4.1.10 4.1.10.1

Incorporated in new section 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Supersedes the current sections , 4.3, 4.3.24.4.3 and 5.1.1 regardin presumptive eligibility

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.

In accordance with the Department’s tribal consultation process, the Department’s tribal leads, the Department Medical Director and Staff Attorney for Medical Care Administration, met with health services representatives of the two federally-recognized tribes on April 28, 2011 and June 6, 2011 to discuss upcoming changes to the Department’s Medical Assistance programs, including the HUSKY B/CHIP Program.

12 The tribal leads detailed the changes concerning the transition of the HUSKY B program from a managed care program to the ASO, including a discussion of the person-centered medical home concept and intensive case management.

For CT-17-0010-CHIP, the State met on October 28, 2014, with the Mashantucket Pequot Tribal Health Services Director and other staff to describe MAGI-related CHIP eligibility changes. This session permitted the Tribal health staff to ask questions on MAGI changes. In a series of emails between May and June, 2014, the State described the MAGI-related CHIP changes to the other Connecticut tribal representatives with the Mohegan Tribal Health and Human Services Department and offered to meet with them if they had any outstanding questions. The representatives were satisfied with the written information provided.

TN No: 10-21; Approval Date 3/21/2011 Effective Date 10/1/2010

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low- income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

The State can measure the number of children with creditable health coverage to the extent that they are enrolled in either the HUSKY A or HUSKY B program. Since the start of the HUSKY program and combined HUSKY A and B marketing in July 1998 an

13 additional 51,090 children enrolled in the Medicaid program resulting in their access to creditable health coverage. The increased Medicaid enrollment in addition to the 13,086 HUSKY B members means that an additional 51,090 children now have creditable health coverage in comparison to July 1998.

Please see Appendix 2.1 for a breakdown of HUSKY A (Medicaid ) and HUSKY B (CHIP) enrollment by race and ethnicity; a breakdown of HUSKY A and HUSKY B enrollments by county; and HUSKY B enrollment by income level. Please note that we do not have HUSKY A enrollment data broken out by income. The income limit for HUSKY A is 196% of the FPL.

The state currently does not have public-private partnerships.

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.

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)

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)) ; (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

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.

14 The State seeks advice from the two Connecticut federally-recognized tribes, the Mashantucket Pequot Tribal Nation and The Mohegan Tribe, through periodic meetings with tribal health representatives and by ongoing written and electronic communications.

The State tribal leads for the HUSKY and CHIP programs meet with tribal representatives at least once annually to update the representatives on developments in the Medicaid and CHIP programs. These meetings include a discussion of program changes, including, but not limited to, waivers, demonstration projects and State Plan amendments.

The process that led to the development of this State Plan Amendment included introductory meetings with tribal representatives in May 2010 to describe the State Plan Amendment process and the tribal consultation requirement. The Department’s tribal leads described the Medicaid State Plan Amendment and CHIP plan processes and discussed the method of consultation and communication that would best serve the tribal representatives’ needs. The tribal representatives agreed to an informal process in which the Department sends copies of the public notice for proposed amendments to the tribes prior to submission to CMS. If the State has not received comments or questions concerning the plan amendment within two weeks, the State determines that the tribe does not have any questions or concerns regarding the proposed amendment. In addition to this informal consultation process, for State Plan Amendments that may have a unique or particular impact on tribal members, for example, a program or plan change that exempts tribal members from some requirement, the State will also arrange for a meeting or teleconference with the tribal representatives to discuss the proposed change.

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

15 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.

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))

16 As described in the State’s Medicaid state plan amendment, under Part A of the HUSKY Plan, the State used Title XXI funds to expand Medicaid eligibility for children 14-18 with family income up to 185% of the FPL. The Title XXI- funded expansion of Medicaid was phased out effective 10/1/02. As of 10/1/02, Title XXI funds are used only for the stand-alone SCHIP program (HUSKY B).

As of 1/1/12, all medical services for Connecticut’s Medicaid and CHIP population are coordinated by the statewide HUSKY Health medical Administrative Services Organization (ASO). The State eliminated the managed care organization (MCO) service delivery model on 12/31/11. Medical services for children with family income over 185% of the FPL under the HUSKY Plan, Part B are now obtained through providers in the fee-for-service Connecticut Medical Assistance Program (CMAP) network, the same network through which Connecticut’s Medicaid recipients receive their benefits. Behavioral health services have been administered by a behavioral health ASO since 7/1/05 and a dental ASO has provided dental services since 9/1/08. Pharmacy services have been provided through CMAP network providers since 2/1/08.

The State selects ASOs through a competitive bidding process. The State issues a Request for Proposal (RFP) that establishes operational and financial requirements and requires bidders to provide evidence of their ability to meet the requirements. The requirements include but are not limited to: access to care, provider network, member services, utilization management, claims processing, and quality assurance. The State awards the right to negotiate a contract based on a fair evaluation of all proposals submitted in response to the RFP. This method includes evaluation of the following factors: provider network for each service area, efficiency of operation, ability to provide the required services, quality management, and ability to perform the necessary administrative tasks, financial viability, and price. The ASO contracts do not include financial requirements because the ASOs are not capitated and bear no risk.

During the period 1/1/08 through 7/31/08, the state changed its contractual relationship with the existing at-risk MCOs to non-risk pre-paid inpatient health plans (PIHPs). The State returned to at-risk MCO contracts effective 8/1/08.

As of 12/31/11, the Department terminated its MCO contracts.

In addition the state, using Title XXI funds, has established a supplemental health insurance program, known as the HUSKY Plus Physical program, for those enrollees in the state subsidized portion of Part B whose medical needs cannot be accommodated within the basic benefit package offered by the Department under the HUSKY Plan, Part B. The HUSKY Plus Physical program supplements HUSKY Plan, Part B coverage for enrollees with intensive physical health needs. Effective 7/1/03, the physical health services are delivered through the Connecticut Children’s Medical Center (CCMC)/ Title V network.

17

The CCMC’s Center for Children with Special HealthCare Needs contracts with a network of providers for the provision of Title V and HUSKY Plus Physical medical services. Care coordination and referrals to medical services are the responsibility of the Center’s staff. Reimbursement claims for medical services are billed to and processed by CCMC. See Appendix 3.1 for additional information on the HUSKY Plus Physical program.

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR, 457.490(b))

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 state includes a definition of medical necessity and utilization management requirements in the RFP and the contracts with its ASOs. The ASOs are required to have written utilization management policies and procedures that include the medical necessity criteria for authorization and denial of payment and protocols for prior approval. The ASOs are also required to have mechanisms to ensure consistent application of the review criteria. In addition, the MCOs and ASOs must have utilization controls to ensure that only services described in the approved state plan are provided to HUSKY B members.

As discussed in Appendix 3.1 (summarizing HUSKY Plus Physical), utilization is managed through prior authorization based on individual care plans and medical necessity guidelines.

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

18 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: 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.

See CT-14-0005, CS18, Non-Financial Eligibility - Citizenship.

The State contracts with an entity to be a single point of entry servicer (SPES) for applicants and enrollees of the HUSKY Plan, Part B. Effective 1/1/10, the SPES will require verification of U.S. citizenship and identity as a condition of HUSKY B eligibility. The Department will verify U.S. citizenship and identity by utilizing citizenship and identity information that may have already been provided by the client to the Department for another program (ex parte), partnering with the Department’s Medicaid process of utilizing a birth records match with the Department of Public Health, partnering with the Department’s Medicaid process to exchange data with the Social Security Administration, or by requiring original paper documentation of U.S. citizenship and identity as stipulated by the Deficit Reduction Act of 2005. If original documentation of citizenship and identity is needed, the Department’s regional offices and contracted state- wide out-stationed locations will receive these documents, document the originality, and forward a scanned image of the documentation to the SPES.

The SPES will attempt to obtain verification of citizenship and identity of the current HUSKY B population utilizing all electronic means before requiring paper documentation. Notices will be mailed to all clients who need to fulfill the requirement prior to redetermination.

19

4.1.1 Geographic area served by the Plan if less than Statewide: See CT-14-0001, CS7, Eligibility – Targeted Low-Income Children

4.1.2 Ages of each eligibility group, including unborn children and pregnant

women (if applicable) and the income standard for that group:

See CT-14-0001, CS7, Eligibility – Targeted Low-Income Children

Individuals must be under 19 years of age.

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):

See CT-14-0001, CS7, Eligibility – Targeted Low-Income Children

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):

No asset limit.

4.1.5 Residency (so long as residency requirement is not based on length of

time in state):

See CT-14-0005, CS 17 – Non-Financial Eligibility – Residency To be eligible for the HUSKY Plan, Part B, a child must be a resident of Connecticut.

4.1.6 Disability Status (so long as any standard relating to disability status

does not restrict eligibility): Measures of disability acuity will apply in HUSKY Plus Physical (See Appendix 3.1).

4.1.7 Access to or coverage under other health coverage:

See CT-14-0001, CS10 – Eligibility – Children Who Have Access to Public Employee Coverage

20 Children who are eligible for Medicaid or covered under a group health plan or under health insurance coverage and children of any state or municipal employee eligible for employer-sponsored insurance are not eligible for the HUSKY Plan, Part B. However, children of municipal employees are allowed to be eligible for HUSKY Plan, Part B “if dependent coverage was terminated due to extreme economic hardship on the part of the employee” (pursuant to section 18 of Connecticut Public Act 99-279). For other children, an application may be disapproved if it is determined that the child was covered by employer-sponsored insurance within the last 2 months (this may be extended to 12 months if the commissioner determines that 2 months is insufficient to deter applicants or employers from discontinuing employer-sponsored dependent coverage). However, an application may be approved if the reason for loss of employer- sponsored insurance is unrelated to the availability of the HUSKY Plan, Part B or otherwise exempt under section 11 of Public Act 97-1 of the October 29, 1997 Special Session. The authorizing legislation (see Appendix 4.1.3) identifies 10 reasons that are unrelated to the availability of the HUSKY Plan.

4.1.8 Duration of eligibility, not to exceed 12 months: A child who has been determined eligible for the HUSKY B program shall remain eligible for as long as all eligibility criteria are met. Eligibility for HUSKY B is reviewed annually. The renewal period is scheduled to coincide with the yearly anniversary of the initial eligibility determination. The initial eligibility period may include a presumptive eligibility period. Renewal forms are sent during the tenth month of eligibility to allow time for the family to complete and return the form in time for the renewal to be processed before the expiration of the twelfth eligible month. 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 States should specify whether Social Security Numbers (SSN) are required.

CT-14-0005, CS19, Non-Financial Eligibility – Social Security Number

The Department, at time of initial determination and when determining ongoing eligibility, requires the social security number for any child

21 requesting services under the HUSKY B program.

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1- PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1)“lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In 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: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641);

22 (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. Elected for children under age 19.

23 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.

4.1-ID – Income Disregards – See 14-0003, CS14, Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards.

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

24

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3 Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350)

See CT-14-0001, CS15, MAGI-Based Income Methodologies, CT-14-0004, CS24, Eligibility Process, and CT-14-0005, CS28, General Eligibility – Presumptive Eligibility for Children. The State uses a single streamline application for its non-elderly/blind/disabled Medicaid coverage groups (parent/ caretakers, single adults and pregnant women and children),CHIP applicants and applicants for Qualified Health Plans through the State Based Marketplace. The application is a variant on the federal single streamlined application. The State encourages the use of online applications, but application may also be made over the phone or on a paper application. Applications may also be made at a number of locations. Once entered, all applicants receive a real-time determination of eligibility. If not all conditions are eligibility are verified at time of application, enrollees will be given 90 days to verify this information. Verification documents are sent to a central post office box, where they are processed by a State contractor.

The SPES is responsible for making a preliminary determination of eligibility under Part A and a final determination of eligibility under Part B and enrolling eligible children under B. Eligibility is determined based on information collected on the application form, which includes name, address, date of birth, social security number, residency, U.S. citizenship and immigration status, family income, employment, and insurance (both current and in the previous two months). The SPES verifies address and income and whether the child is a Medicaid beneficiary. In addition, if an applicant is employed, the SPES contacts the employer for a random sample of cases (10%) for information about employer-sponsored insurance coverage. With the exception of step-parent income, income is calculated in the same manner as for poverty level children under Medicaid with the income disregards provided in section 15 of Public Act 97-1 of the October 29, 1997 Special Session or as may be amended. As described in 4.4.1 (below), as part of the eligibility process, the SPES determines whether a child may be eligible for Medicaid and, if so, sends the application and supporting documents to the Department for final eligibility determination. Also, if a child has insurance coverage, he/she will not be enrolled in HUSKY B.

25 Individuals are able to initiate the application in person or by mail. The SPES uses a simplified mail-in application process. If information is incomplete, the SPES contacts the applicant (by mail or phone) to obtain missing information. If enrolled under HUSKY B, the SPES also provides information about HUSKY Plus Physical. The SPES sends daily and monthly eligibility files of enrollees to the HUSKY Health medical ASO as well as the behavioral health and dental ASOs. Effective 6/11/08, families with a newborn child are able to initiate the application process for the newborn at a Connecticut or border hospital. The hospital will fax the application and other supporting documents to the SPES for eligibility to be determined within one business day of receipt. Effective 4/1/11, families may apply for HUSKY B for a child at any of our certified Qualified Entities available statewide and receive a presumptive eligibility determination. The Qualified Entity will fax the application and other supporting documents to the SPES for eligibility to be entered in the eligibility system within one business day of receipt. The Qualified Entity will provide the family with a payment voucher guaranteeing coverage and payment of services for the child for 10 days in the event there is a need for immediate access to care. The presumptive period will end when a determination for regular HUSKY B is made. Not more than 12 months after determination and annually thereafter, the SPES shall re- determine eligibility for HUSKY B. The SPES shall mail a form to each HUSKY B family to obtain information to make the eligibility determination. Also, as noted in 4.1.8, applicants will be required to notify the SPES of any change in circumstance that could affect continued eligibility for coverage e.g., attaining age 19, moving out of state, change in income, or having obtained other insurance). If the child is no longer eligible, he/she will be disenrolled from HUSKY B.

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1 Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(4)) (42CFR, 457.305(b))

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

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)

26

See 14-0005, CS28, General Eligibility – Presumptive Eligibility for Children.

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is

applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as

Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility

that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that

are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and

enrollment requirements before a child may be enrolled under

title XXI.

Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 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

27 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

a waiting period for pregnant women.

See 14-0004, CS24, Eligibility Process.

In accordance with Sections 2102(b)(3)(A) and 2110(b)(2)(B) and 42 CFR 457.310(b), 457.350(a)(1) and 457.80(c)(3) the State will screen HUSKY applications through the SPES. Eligibility Specialists at the SPES are trained in the Medicaid (HUSKY A) gross income limits, and applied income limits considering concepts such as, but not limited to, income disregards, and excluded income to ensure that Medicaid children who apply for HUSKY are properly identified and referred to the Department to be granted Medicaid. HUSKY applicants will also be screened by the SPES for potential Medicaid eligibility under spend-down if family income exceeds 185% of the Federal Poverty Level and unpaid medical bills for the family exist sufficient to meet the spend-down. If the family has sufficient medical bills to be eligible for Medicaid under spend- down, the SPES will refer the application to the Department for Medicaid processing. The SPES will retain all other HUSKY applications and process eligibility for HUSKY B (Title XXI). Conversely, if a family contacts Department first to apply for HUSKY, Department staff will screen for Medicaid eligibility as they currently do. If the child is not Medicaid eligible, including being eligible

28 for Medicaid as a spend-down, Department staff will refer the application to the SPES for potential processing for HUSKY B (Title XXI). Department staff is trained in the HUSKY B (Title XXI) requirements so they can properly identify such applications.

On July 1, 2007 the Department re-instituted self-declaration of income, with the exception of self-employment income which must be verified with tax forms or other documents. Department and SPES eligibility staff will still use Bendex, Social Security Income (SDX), Department of Labor (DOL) and Unemployment Compensation Benefit (UCB) files to check the earned and unearned income information stated on the application/renewal form to be certain there are no discrepancies with what the client reported and what the electronic records show. Any discrepancies will be clarified. The same screen and refer or screen and enroll process as identified above for a new application is also used at the time of annual renewal.

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))

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))

Applications for children who are determined to be ineligible for Medicaid, due to income, at time of application or renewal are referred to the SPES by Department staff for HUSKY B eligibility processing. (See Section 4.4.1 above.) Additionally, Medicaid discontinuance notices include a reminder to families so that families may follow up directly with the SPES to enroll their children in CHIP. Connecticut and border hospitals are collaborating to identify uninsured newborns. Hospital staff will assist families in completing HUSKY applications and then fax the applications to the SPES for expedited eligibility processing. A family with a newborn who appears eligible for HUSKY B will be granted coverage within one business day of receipt of the application. Newborns with family income over 235% of the FPL will not be required to pay premiums for the first four months of coverage. Uninsured children who are determined eligible by a Qualified Entity will be granted presumptive eligibility as defined in Sec. 2107(e)(1)(L) of the Social Security Act or 42 U.S.C. 1397gg(e)(1)(L). The presumptive period begins on the day that the preliminary determination is made and ends the day that the SPES makes a determination for regular HUSKY B coverage.

29 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))

See 14-0005, CS20, Non-Financial Eligibility – Substitution of Coverage

A two-month crowd-out period is used to discourage families from dropping employer-sponsored insurance for the purposes of qualifying for HUSKY B. The SPES tracks the number of application denials for children whose coverage was dropped within two months from the application date.

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))

In accordance with Section 2102(b)(3)(D), 42 CFR 457.125(a) the Department met with representatives from both of Connecticut’s federally recognized Indian tribes in 1998, during the design phase of the HUSKY plan. The program design was discussed with the tribal representatives and their comments and suggestions were considered in the final design and ongoing operations of the program. In 2000 both tribes provided the Department information required to exempt them from cost sharing. The tribal members provided the Department with the information we need to request of American Indians in order to exempt them from cost sharing.

The Department will continue to meet with the tribes on an annual basis or more often if necessary to discuss programmatic changes to HUSKY and to consider the issues or concerns of the tribal members. The Department also provides supplies of HUSKY informational materials and applications for distribution to tribal members. HUSKY information has also been available to tribal members via media (Public Service Announcements, T.V. and radio ads and ads in local newspapers) and other outreach efforts.

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.

30

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):

The State currently conducts outreach activities through its contracts with Federally Qualified Health Centers and disproportionate share hospitals that assist applicants in completing the application. Effective Marchl 1, 2011 the State implemented the process of presumptive eligibility in accordance with Sec. 2107(e)(1)(L) of the Social Security Act or U.S.C. 1397gg(e)(1)(L). Families may apply for HUSKY B for a child at any of our statewide certified Qualified Entities who make an immediate eligibility determination based on preliminary information provided by the family.

Guidance: The State may address the coordination between the public-private outreach and

31 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.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership:

The State currently does not have any programs that involve a public-private partnership. The Healthy Steps program, which existed at the inception of HUSKY B, has been phased out and members of that program were made eligible for HUSKY A or B, according to their family income.

Guidance: The State should describe below how it’s Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid- eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42CFR 457.80(c))

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. Section 2102(a)(3) 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.

Title V refers potential applicants who do not qualify for its program to HUSKY B and HUSKY Plus Physical. A Department representative monitors services provided by the Connecticut Children's Medical Center, the agent responsible for HUSKY B Children with Special Health Care Needs with Title V. (See Appendix 3.1.)

The Department contracts with school-based health clinics.

HUSKY Plus Physical and the HUSKY Health medical ASO, in conjunction with the Department, also coordinate with the Birth to Three program, which provides services to children with special health care needs.

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.

5.3 Strategies

32 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 Department, in partnership with statewide, regional and local health and social service organizations, within available appropriations, regularly conducts public outreach and education to reach families of children likely to be eligible for HUSKY Health, be it Medicaid or CHIP. The Department’s HUSKY Outreach program includes: Funding HUSKY InfoLine (HIL) – HIL operates a toll free information and referral service for HUSKY applicants and individuals needing information about HUSKY. HIL care coordinators instruct callers on how to apply for HUSKY, provide over the phone application assistance and follow-up to ensure that application process was completed;

School based outreach efforts – HUSKY information provided through the free- and reduced-price lunch program in cooperation with the CT Department of Education and school food service directors. HUSKY information and applications are also available through the school nurses and the school-based health centers;

Participation in the CT Department of Labor’s Rapid Response Team – provision of HUSKY information and application assistance to laid-off workers;

HUSKY Health medical ASO community-based outreach – The HUSKY Health medical ASO provides information on benefit delivery through periodic mailings, handbooks, its website, and at various community forums including school health promotional fairs; craft shows; country fairs, etc., throughout the state;

Collaboration with Child Support Services;

Collaboration with CT’s Covering Kids and Families (CCKF) initiative –C CKF is a Robert Wood Johnson Foundation funded initiative, with Connecticut Voices for Children acting as the lead agency for Connecticut. CCKF funds several local HUSKY outreach projects throughout the state. The initiative supports statewide interventions

33 and supports local projects in Bridgeport and Stratford, Stamford, and in a nine-town area East of the River (Manchester, East Hartford, Vernon, Hebron, Glastonbury, Mansfield, Willington, Coventry and Columbia). The local projects work in their communities to provide application assistance to families and help families through the renewal process, train community-based organizations on HUSKY, build relationships with local Department of Social Services (DSS) offices, train parents and high school students to promote the HUSKY program, develop model projects to enroll immigrant children and families, and work with schools, local businesses and health care providers. All three local projects use an automated tracking system to track their own activities and to identify enrollment and renewal barriers. Statewide initiatives include the coordination and provision of outreach through established groups such as schools, child care providers, pediatric care providers, the business community, and social service providers; and the HUSKY (www.huskyhealth.com) website featuring a downloadable application.

Multi-level campaign

The crux of this campaign has been grass roots, community-based outreach through schools, health centers, community meetings, fairs, events, worksites, and other venues identified by DSS, statewide partners and community contractors. Just as often, HUSKY outreach brings the message to professionals who work with parents through a 'key informant' model--these are the known and trusted people in health, education, human services and other fields who are already in the community and who can vouch for the program and provide follow-up assistance. The emphasis on grass roots, community- based outreach has been acknowledged as especially important in reaching minority communities and newcomer/immigrant populations.

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))

34 6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

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

35 the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431.

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark 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

36 for ”existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 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 coverage. 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.

See Appendix 6.1.4, updated on March 1, 2015 to reflect the addition of coverage of services for the treatment of gender dysphoria.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage

Please note that the HUSKY Part B benefits combine the most generous benefits offered at the inception of the HUSKY, Part B plan under three state employee options available in 1998 (Blue Cross, MD Health Plan, and Kaiser Permanente), in addition to covered services mandated by the Federal CHIP regulations. In

37 addition, HUSKY B benefits also include the HUSKY Plus Physical and Behavioral benefit packages for Children with Special Health Care Needs, which is not available to state employees. (See Appendices 3.1 and 6.1) 6.1.4.5.

Coverage that is the same as defined by existing comprehensive state-based coverage applicable only New York, Pennsylvania, or Florida (under 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than to coverage under one of the benchmark plans specified in 457.420, through use of a benefit-by-benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done)

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other (Describe)

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

6.2. The State elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

38 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) 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))

39 6.2.20.

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

Case management will be available through HUSKY Plus Physical. (See Appendix 3.1 for additional information on HUSKY Plus Physical. 6.2.21.

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

Care coordination will be available through HUSKY Plus Physical. (See Appendix 3.1 for additional information on HUSKY Plus Physical.)

6.2.22.

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

Long-term coverage will be available through HUSKY Plus. (See Appendix 3.1 for additional information on HUSKY Plus Physical.)

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))

Services of nurse midwives, nurse practitioners, podiatrists, chiropractors, and naturopaths will be covered.

6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) Transportation by ambulance will be covered but non-emergency transportation will not. Limited non-emergency transportation will be covered by HUSKY Plus Physical. (See Appendix 3.1 for information on HUSKY Plus Physical.)

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.

40 6.2.27.

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

Translation and outreach services will be available through the HUSKY Health ASO and the other ASOs and HUSKY Plus Physical. All printed materials must be in English and Spanish and any other languages if more than five percent of the ASO enrollees speak the alternative language. The HUSKY Health ASOs and HUSKY Plus Physical program must provide translation services. (See Appendix 3.1 for information on HUSKY Plus Physical.)

6.2.28.

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

See Appendices 3.1 and 6.1: HUSKY Plus Physical Benefits and HUSKY Part B Benefits

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) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule

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

41 Other (description attached)

6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT2 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

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

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

6.3 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

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

42 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 CFR 457.1005 and 457.1010)

6.4.1. Cost Effective Coverage- Payment may be made to a State in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low- income children and other low-income children); 3) expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The State may cross reference Section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

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

43 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

44 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).

45 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

No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool. 6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

46 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

47 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.)

The methods that are used to assure quality and appropriateness of care include contracting standards, licensing, reporting requirements, external reviews, and onsite reviews.

The HUSKY Health medical ASO contract includes specific standards for quality of care, including the provision of well-baby care, well-child care, and immunizations. The HUSKY Health medical ASO is required to arrange for immunizations and comprehensive screens (and any needed interperiodic screens) in accordance with the schedules recommended by the American Academy of Pediatrics. As described below, The HUSKY Health medical ASO is required to submit reports on well-baby care, childcare visits and immunizations. The Connecticut Department of Public Health has a

48 statewide immunization registry (Connecticut Immunization Registry and Tracking System), to which providers report directly.

The behavioral health and dental ASO contracts will include specific standards for quality of care, including the provision of behavioral health and dental health intensive care management and service coordination. In addition, the behavioral health and dental ASOs will be required to submit to the Department periodic reports on utilization of dental health services and behavioral health services, including inpatient and outpatient services.

The HUSKY Health ASOs are required to meet all standards for quality of care as specified in their contracts with the State. The ASOs must be licensed by the Connecticut Insurance Department (CID) to operate as a utilization review company. CID continuously monitors quality through various mechanisms, including reporting, external reviews, and onsite reviews.

Reporting will include a report on each ASO’s quality assurance plan (QAP), complaints, prior authorization denials, utilization review (UR) denials, and all data required for HEDIS (or equivalent data for non-NCQA accredited plans). In addition, the Department requires reports on compliance with the well-child periodicity schedule and on immunization. The State conducts periodic onsite reviews to determine ongoing compliance with contract requirements.

7.1.1.

Quality standards

The State contracts for an external quality review of the HUSKY Plan, Part B. The review includes, but is not limited to, an evaluation of access to care, a satisfaction survey, medical record standards, provider credentialing, and individual care review (see 7.1.3)

7.1.2.

Performance measurement

7.1.2 (a) CHIPRA Quality Core Set

7.1.2 (b) Other

The State requires its ASOs to submit HEDIS reporting measures or equivalent data (which is likely to be HEDIS or a modified version of HEDIS) and reports on immunizations and compliance with the well-child periodicity schedule. In addition, as noted in Section 9.7, the State will comply with any national quality measures.

The State will attempt to do full CHIPRA Quality Core Set with 2012 data in 2013.

7.1.3.

Information strategies

The HUSKY Health ASOs are required to educate enrollees about their benefits, rights

49 and responsibilities under the HUSKY Plan, Parts A and B, including HUSKY Plus Physical. The HUSKY Health ASOs also educate enrollees about the importance of preventive services including medical and dental services, health promotion activities, and visiting their primary care provider instead of an emergency room.

7.1.4.

Quality improvement strategies

The State includes specific standards for quality of care in the contracts with its ASOs. These standards are monitored by the State through reporting requirements, onsite reviews, and external reviews.

In particular, the HUSKY Health ASOs are required to establish an internal QAP, which will be in writing and available to the public. The written description shall include detailed goals and annually developed objectives; address the quality of clinical care and non-clinical aspects of services for the entire range of care provided by each ASO; specify quality of care studies and related activities; provide for continuous performance of activities, including tracking of issues over time; and provide for review and feedback by physicians and other health professionals.

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 State requires the HUSKY Health medical ASO to submit reports on immunizations, and compliance with the well-child periodicity schedule.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

The State monitors access requirements through reporting and member satisfaction surveys. For medical, dental, pharmacy, and behavioral health services, the ASO will rely on the Connecticut Medical Assistance Program (CMAP) provider network to assure access to covered services. HUSKY Health ASO is required to monitor the CMAP provider network to ensure providers who fail to reenroll do so and also to recruit additional providers to make the network more robust.

50

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))

All HUSKY Health services (medical, behavioral health and dental) are provided through the CMAP network. HUSKY B members have access to all of the same providers as Medicaid recipients. The HUSKY Health medical, behavioral health and dental ASOs assist in managing the Department’s network, but do not contract directly with network providers. All claims are processed by the Department’s MMIS.

Pharmacy services are provided utilizing the Department’s Preferred Drug List (PDL).

For members enrolled in HUSKY Plus Physical, the HUSKY Health medical ASO is required to coordinate the specialty care services and specialty provider referral process with the HUSKY Plus Physical program to ensure access to care (See Appendix 3.1).

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.

Prior authorization of services covered in the HUSKY, Part B benefit package shall be determined by the appropriate ASO based on the Department’s individual care plans, medical necessity and in accordance with State law. However, the following services in the benefit package shall not require prior authorization:

(1) Preventive care, including:

(a) Periodic and well-child visits; (b) Immunizations; and (c) Prenatal care; (2) Preventive family planning services, including: (a) Reproductive health exams; (b) Member counseling; (c) Member education; (d) Lab tests to detect the presence of conditions affecting reproductive health; and (e) Screening, testing and treatment of pre and post-test counseling for sexually transmitted diseases and HIV, and

51 (3) Emergency ambulance services or emergency care.

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

Some cost sharing applies to pregnant children under the age of 19. Prenatal visits are not subject to copayments.

With the exception of low-income children in the State who are American Indians and Alaska Natives (AI/AN) who are members of a federally recognized tribe. (As defined in section 4 (c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c). These AI/AN children will be exempt from any cost sharing (e.g., copayments and premiums).

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. 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:

52 Effective July1, 2014, children with family income up to 249% of the FPL will not be required to pay a premium. Children with family income that exceeds 250% of the FPL but which does not exceed 318% of the FPL will be required to pay a premium of $30.00 per child per month, up to a maximum of $50.00 per family per month. Effective July 1, 2014, newborns with family income over 249% of the FPL will not be required to pay premiums for the first four months of coverage, provided they were born in a Connecticut hospital or designated border hospital. . Effective August 1, 2015, pursuant to a change in state law, enrollment of children over 318% of the FPL will not be permitted. Private organizations may subsidize premiums.

8.2.2. Deductibles: Not applicable.

8.2.3. Coinsurance or copayments:

Coinsurance is only applicable for certain non-preventive dental services.

Copayments: For children in families with income over 196% of the FPL, the State has established a schedule of reasonable copayments for services other than the following: preventive care and services, inpatient physician and hospital, outpatient surgical, ambulance, skilled nursing, home health, hospice and short-term rehabilitation and physical therapy, occupational and speech therapies, lab and X-ray, preadmission testing, prosthetics, and durable medical equipment (See Appendix 6.1)

There are no co-payment requirements for covered HUSKY Plus Physical services.

8.2.4. Other:

Effective March 1, 2011, the maximum annual aggregate cost sharing (premiums, if applicable, dental co-insurance and co-payments) will be calculated using the lowest qualifying income according to income level which is based on FPL and household size. Income Level 1 includes children with family income that exceeds 196% of the FPL but does not exceed 249% of the FPL. There is no premium. Income Level 2 includes children with family income that is 250% or more of the FPL but does not exceed 318% FPL. The premium is $30 per month for one child or $50 for two or more children per month. Annual cost sharing including premiums, dental co-insurance, and co-payments cannot exceed 5% of the family’s gross income per eligibility year. Maximums will be adjusted yearly to reflect the most current FPL’s.

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

53 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:

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))

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.

Information about cost sharing is included in the outreach materials and both the SPES and the HUSKY Health ASOs provide information on cost sharing requirements. The HUSKY Health ASOs provide information on cost sharing requirements through the introductory Welcome Call as well as in the Member Handbook, in which the HUSKY Health ASOs are required to include a summary of the cost sharing requirements and maxima. The information is also available via HUSKY Health ASO Member Services Department and through outreach materials such as newsletters. The SPES makes information about cost sharing available through its toll free phone number (1-877-CT- HUSKY), the program website, a variety of outreach materials, and through letters sent to the applicant that provide notification of eligibility for HUSKY B. The HUSKY Health ASO is required to inform its members and providers when a client has reached the maximum annual aggregate cost sharing limit for copayments and co-insurance so that the client is not charged for further cost-sharing by the provider.

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

8.4.1.

Cost sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

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

8.5 Describe how the State will ensure that the annual aggregate cost sharing for a family does not

54 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 family share of premium payments, copayments and dental co-insurance payments were calculated to not exceed 5% of the lowest qualifying family income within each of the two income levels for subsidized benefits (e.g. 5% of 196% of FPL and 5% of 250% of the FPL) for the applicable household size. Cost sharing is tracked by the Department’s Medicaid Management Information System (MMIS) as applicable and reported to the SPES. The SPES compiles the cost sharing amounts with premiums it has collected and reports back to the Department’s MMIS vendor and the ASOs. When cost sharing maximums have been met, the ASOs will issue new member identification cards. If a family exceeds the maximum, the Department is required to reimburse the excess above the maximum amount to the family.

It is the responsibility of the SPES to review the member accounts at a minimum on a monthly basis to determine which families have reached their maximum annual cost sharing limit. The review must be completed no later than 15 days after the end of each review period. If, due to claims’ time-lag, the family has paid more than the allowed limits for cost sharing, it is the responsibility of the Department to repay the overpayment to the family within three months of the SPES’s determination that the maximum annual aggregate cost sharing limit for copayments had been met. The SPES is required to establish and maintain a system to track the copayments incurred by each family in Income Levels 1 and 2 in order to adhere to the requirements of the maximum annual aggregate cost sharing. The ASOs and the Department also must require their providers and subcontractors to verify whether a family has reached the maximum annual aggregate cost sharing limit for copayments and co-insurance before charging a copayment or co-insurance amount.

When a family reaches the maximum annual aggregate cost sharing limit, the SPES will inform the Department. The ASOs will inform the providers, subcontractors and family that the limit has been met, that the providers and subcontractors cannot charge further cost sharing within the annual eligibility period.

If the family believes it has reached the maximum annual aggregate cost sharing limit, it may request, in writing, that the Department review the cost sharing amounts paid by the family. The Department will then review the cost sharing amounts paid by the family and respond to the family, in writing, within three weeks of the date of the family’s written request. If the family disagrees with the determination, the family may request, in writing, a review by the Department. The ASOs are required to include a summary of this right and the appropriate procedures to request the review in their Member Handbooks.

55 There are no cost sharing requirements for covered HUSKY Plus Physical services.

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)

Families of American Indian/Alaskan Native (AI/AN) children who are members of a federally organized tribe and who are in Income Level 1 or 2 are exempted from paying HUSKY, Part B premiums or copayments. Income Level 1 represents those enrollees whose income falls between 196 percent and 249 percent of the federal poverty level. Income Level 2 represents those enrollees whose income falls between 250 percent and 318 percent of the federal poverty level.

The Department of Social Services staff informed representatives of the Mashantucket Pequots and the Mohegans, the two federally recognized tribes within the State of Connecticut, that federal requirements do not permit cost sharing for AI/AN children in the HUSKY B program. Staff also consulted with them about the best way to identify AI/AN children.

Based on recommendations made by both tribes, it was decided that applicants would be asked to verify their tribal membership at time of application. The HUSKY application was modified to ask if the child for whom application is made is a member of a federally recognized tribe. If the answer is “yes”, the applicant will need to provide the name of the tribe and verification of membership. HUSKY informational materials were also revised to include information about the cost sharing exemption for AI/AN children. The SPES, under contract with the Department to determine eligibility for HUSKY B applicants, will notify the ASOs when a new enrollee is qualified for exemption from cost- sharing due to AI/AN status. The ASOs will not charge the family for any partial premium payment and will issue the enrollee a membership card that specifies “no copayments”

American Indian/Alaskan Native children enrolled in HUSKY Plus Physical will not be charged premiums or copayments as there are no cost sharing requirements for any children enrolled in HUSKY Plus Physical.

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))

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.

56 See CT14-0005, CS21, Non-Financial Eligibility – Substitution of Coverage). Enrollees are permitted up to 90 (days) to pay their initial premium and their premium for annual re-enrollment. Failure to do so will result preclude the enrollee from receiving initial coverage or having their coverage renewed, as applicable. Once the enrollee has coverage however, as of January 1, 2014, the Department no longer disenrolls enrollees for failure to pay the monthly premium.

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

57 eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Section 9. Strategic Objectives and Performance Goals and Plan Administration Guidance: States should consider aligning its strategic objectives with those discussed in Section II of the CHIP Annual Report.

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

To increase the number of children in Connecticut with health insurance through the expansion of the HUSKY program.

To maximize participation in HUSKY, Parts A and B through outreach, a single point of entry servicer (SPES), a simplified application process

To promote the health of children through an improved health benefit package tailored to the health care needs of children, which includes comprehensive preventive services.

To assist those children enrolled in HUSKY, Part B who have special physical health care needs, to receive appropriate care through a supplemental plan (HUSKY Plus Physical).

To maximize coordination between the HUSKY Health ASOs and HUSKY Plus Physical by integrating basic health care needs into the care provided for intensive health care needs, and, whenever possible, building upon existing therapeutic relationships with Title V providers.

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))

Guidance: The State should include data sources to be used to assess each performance goal. In

58 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.

To increase the number of children covered by health insurance within Connecticut.

To maximize participation in HUSKY Parts A & B.

• Expand Medicaid (HUSKY Part A) enrollment of uninsured children 18 years old who are under 185% of the FPL.

• Increase the number of insured children 18 or under who are between 185% and 300% of the federal poverty level.

To promote the health of children through a comprehensive health benefits package.

• Match or exceed the statewide average of the percentage of children in HUSKY Parts A and B who receive immunizations by age two, meet or exceed state standards for well-child care, with a goal of at least 80% of children receiving all recommended well-child visits.

To assist children with special physical health needs through HUSKY Plus Physical.

• Ninety percent of referrals to HUSKY Plus Physical will have eligibility determination made within 21 days.

• Track the percentage of referrals to HUSKY Plus Physical accepted or denied.

59

• 100% of children with the following conditions will receive care according to individual needs and professional guidelines:

♦ Children with intensive physical needs with a diagnosis of cystic fibrosis under ICD 9 CM 277.0. ♦ Children with intensive physical needs with a diagnosis of cerebral palsy under ICD 9 CM 343.

To maximize coordination between HUSKY Part B and HUSKY Plus Physical

• 100% of children in HUSKY Plus Physical have an assigned HUSKY B case manager/liaison within 30 days of their enrollment into HUSKY Plus Physical.

• 100% of children in HUSKY Plus Physical have an assigned HUSKY Plus Physical case manager/coordinator.

• 85% of children in HUSKY Plus Physical have a global plan of care within 30 days of enrollment

• 85% of children in HUSKY Plus Physical have a revised global plan of care at least semi-annually.

• 85% of children in HUSKY Plus Physical have had evidence of coordination between HUSKY B, and HUSKY Plus Physical at least quarterly as documented in the progress notes, and if additional revision is indicated, in the Global Plan of Care.

To assure that children with behavioral health needs receive appropriate care

• 70% of children who are discharged from inpatient care for mental health or substance abuse will receive follow-up care 30 days following discharge.

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.

60 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. Or modified measures that are based on HEDIS. 9.3.6.

Other child appropriate measurement set. List or describe the set used. Well-child periodicity compliance. 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: • Ambulatory Services • Follow-up After Mental Health Hospitalization • Follow-up After Chemical Dependency Hospitalization

See Appendix 9.3 for complete listing of reporting measures.

9.3.8.

Performance measures for special targeted populations.

See Appendix 9.3 for complete listing of reporting measures

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, through the use of internal eligibility and enrollment data and utilization reporting from its MMIS, will conduct an annual evaluation based on an analysis of the program measure. The analysis will include a sampling of patient charts, utilization data and a patient satisfaction survey. Please note that with the exception of calendar year

61 2003, the report will include the findings from the audit conducted by an external quality review entity.

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))

The Medical Assistance Oversight Council (MAPOC) and the Behavioral Health Partnership Oversight Council (BHPOC) serves in an advisory role to the Department for the behavioral health services as managed by the medical and behavioral health ASOs. The MAPOC and BHPOC are comprised of legislators, clients, advocacy groups, DSS, and other state agencies such as the Department of Children and Families and the Department of Mental Health and Addiction Services. The MAPOC and BHPOC meet once a month during which time the Department provides program updates. The MAPOC and BHPOC also have several subcommittees that provide a forum for important issues

62 to assure the viability of the medical and behavioral health service delivery system. The subcommittees include: Transition, Provider Advisory, Quality Management, Consumer Access, and the Department of Children and Families Subcommittee.

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))

In accordance with 42 CFR 457.125, Section 2107 (c) and 42 CFR 457.120 (c) The Department met with representatives from both of Connecticut’s federally recognized Indian tribes, during the design phase of the HUSKY plan. The program design was discussed with the tribal representatives and their comments and suggestions were considered in the final design and ongoing operations of the program. The Department met with both tribes again in 2000 to discuss American Indian’s being exempt from cost sharing. The tribal members provided the Department with the information needed to request of American Indians in order to exempt them from cost sharing.

The Department continues to consult with both tribes on an annual basis to discuss any changes to the HUSKY Plan as well as address any concerns or questions the tribal representatives may have. The consultation will either be conducted by phone or in person depending on the issues to be discussed.

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).

9.9.2 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.

Amendments relating to either eligibility, such as the reduction of the crowd-out period from six to two months, or benefits, such as mental health parity or the carve-out of behavioral health services to the ASO, have been the result of legislative changes; therefore the prior public notice requirement was provided through the legislative process. Based on additional comments received subsequent to the 2/1/04 implementation from clients, advocates and other stakeholders, it was decided to repeal the premium increases, retroactive to the 2/1/04 implementation. The copayment maximum remained at $760.00.

The amendment relating to the change from at-risk MCO contracts to non-risk PIHPs was due to a directive from the Governor. The amendment relating to expediting eligibility processing and waiving premium payments for the first four months of

63 managed care enrollment for a newborn child born in a Connecticut or designated border hospital with family income greater than 235% FPL was a result of a legislative change. In addition, the amendments relating to the carve-out of dental and pharmacy services as well as the return to at-risk MCO contracts were also a result of legislative changes. The prior public notice requirement was provided through the legislative process.

The amendment relating to the increase in cost sharing including copayments and co- insurance effective 3/1/11 were the result of legislative change. Prior public notice was provided in the Connecticut Law Journal and on the Department’s website.

The amendment relating to the elimination of the managed care delivery service model for HUSKY B benefits effective 1/1/12 was the result of legislative change.

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 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

64

CHIP Budget STATE: FFY Budget Federal Fiscal Year 2012 State's enhanced FMAP rate

Benefit Costs

Insurance payments

Managed care1 $86,682.33 per member/per month rate See below Fee for Service $25,581,018.58 Health Services Initiatives $0.00 Cost of Proposed SPA changes

Total Benefit Costs $25,667,700.91 (Offsetting beneficiary cost sharing payments) (1,452,839.08) Net Benefit Costs $24,214,861.83

Administration Costs

Personnel $302,145.01 General administration $193,121,.83 Contractors/Brokers $1,875,757.63 Claims Processing $96,905.62 Outreach/marketing costs $11,271.85 Other $0.00 Total Administration Costs $2,479,201.94 10% Administrative Cap $2,690,540.20

Federal Share $17,351,141.45 State Share $9,342,922.32 Total Costs of Approved CHIP Plan $26,694,063.77 NOTE: Include the costs associated with the current SPA.

The Source of State Share Funds: 1The Managed Care payments reflect retro rate decreases back to July 1, 2010 for Aetna and CHN, as well as decreases back to July 1, 2011 for AmeriChoice. These retroactive adjustments were processed in the quarter ending December 31, 2011, offsetting the vast majority of capitation payments in that quarter. Medical benefits managed under fully

65 capitated risk arrangement terminated effective December 31, 2011.

2An Administrative Service Organization arrangement has been implemented on January 1, 2012. The ASO provides utilization management benefit information and intensive care management services within a centralized information system framework. CHIP eligibles will use the Connecticut Medical Assistance Program (CMAP) network, which is the Department’s existing fee-for-service network. Claims will be processed through the Department’s MMIS claims processing system. The ASO will be required to facilitate monitoring and expansion of the provider network in order to ensure access to necessary medical services.

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

66 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)

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.

In accordance with 42CFR Sections 457, 1120, 1130(a), 1130(c), 1140, 1150(a), 1160(a), 1170 and 1180, an applicant has the right to request an administrative review of eligibility and enrollment decisions described below. However, the State will not provide an opportunity for review of a matter if the sole basis for the decision is a provision in this plan or in federal or state law requiring automatic change in eligibility or enrollment that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances. The Department has a two level process to review appeals related to HUSKY B eligibility and enrollment. The Department’s agent (SPES) conducts the level one review and the Department’s Office of Legal Counsel, Regulations and Administrative Hearings conducts the level two review.

67 The State ensures that all enrollees and applicants receive timely written notice of any eligibility or enrollment decisions subject to review, as outlined below. All notices issued during the appeals process include the reasons for the determination, an explanation of applicable rights to review of that determination, the standard and expedited time frames (if any) for review, the manner in which a review can be requested, and the circumstances under which enrollment may continue pending review. Additionally, the State will ensure that applicants and enrollees have opportunities to represent themselves or have representatives of their choosing in the review process, to timely review their files and other applicable information relevant to the review of the decision, and to fully participate in the review process.

Eligibility

Eligibility decisions, which can be appealed, include denials, failure to make a timely determination of eligibility, discontinuances and income level assignment changes. When HUSKY B eligibility is denied, terminated, transferred to a higher premium level, or the State fails to make a timely determination of eligibility, a notice, described above, is sent to the applicant informing him of this decision. The notice also informs the applicant of his right to request an administrative review of this decision within ten business days from the date the notice was sent to the applicant. A supervisory level employee, who was not involved in the original decision, conducts the level one administrative review of the initial eligibility decision.

The SPES notifies the applicant in writing of its level one review decision not more than ten business days from receipt of a request for administrative level one review. Decisions related to expedited requests shall be made within five business days.

If the applicant is not satisfied with the SPES’s level one review decision, the applicant may request a level two administrative review within ten business days following the date on the notice of the level one decision. The level one decision notice contains information on how to request a second level review and information related to expedited review.

At the second level review, the DSS administrative reviewer, who was not involved in the prior decisions, evaluates all factors related to the SPES’s eligibility decision or failure to make a timely decision of eligibility. The level two review is a desk review unless the applicant requests a personal conference with the administrative reviewer as part of the review process. The personal conference may be conducted in person, by telephone or video conferencing.

The DSS administrative reviewer renders a decision in writing to the applicant not more than 45 calendar days following the date of receipt of the applicant’s written request for

68 the level two administrative review. Decisions related to expedited requests shall be made within 20 days.

The Commissioner may waive any of the time limits as provided for above as may become necessary.

To the extent that an applicant has coverage, coverage continues pending both levels of review and final decision from the level two appeal.

Enrollment

Enrollment decisions, which can be appealed, include any suspension or termination of enrollment, such as disenrollment due to non-payment of premiums and denial of good cause for early re-enrollment change.

When a HUSKY B client’s enrollment is suspended or terminated, a notice, described above, is sent to the client informing him of this decision. The denial notice also informs the client of his right to request an administrative review of the decision within ten business days from the date the denial notice was sent by the SPES.

An agent at the SPES, who was not involved in the original decision, conducts the initial level one administrative review and notifies the applicant in writing of its level one review decision not more than ten business days from receipt of a request for administrative level one review.

If the applicant is not satisfied with the level one review decision, the applicant may request a level two administrative review within ten business days following the date on the notice of the level one administrative decision.

The Department’s administrative reviewer, who was not involved in the previous decisions, shall evaluate all factors related to the agent’s enrollment decision and shall offer the applicant the opportunity to have a personal conference with the administrative reviewer as part of the review process. Such personal conference maybe conducted in person, by telephone or video conferencing.

Enrollment continues pending both levels of review and final decision from the level two appeal. Enrollment decisions are not subject to expedited appeals.

12.2. Health Services Matters- Describe the review process for health services matters

that comply with 42 CFR 457.1120.

The State, pursuant to 42 CFR 457.1120(a)(1) has elected to comply with existing grievance and appeal requirements in effect for the HUSKY Health ASOs with which it

69 contracts. The same or more stringent requirements will be imposed on the ASOs for decisions related to denial of behavioral health services or dental health services. These existing requirements provide, in accordance with applicable State law, for internal reviews within the ASOs and external reviews. In addition, pursuant to the Department’s contract with the ASOs, the ASO’s internal appeals process for HUSKY B enrollees must allow for expedited review in certain circumstances described below.

In the State of Connecticut, ASOs must comply with various quality consumer protection requirements by State law.

The HUSKY Health medical ASO must clearly specify in its enrollee handbook/packet(s) the procedural steps and timeframes for each level of its internal appeals process and for filing an external appeal through the Department. The enrollee brochure that describes the appeals process and enrollee rights is provided to enrollees at the time of enrollment and will be included in the member handbook.

When a requested good or service is denied, the ASOs must provide a written denial notice to the enrollee, which includes the ASO’s denial decision as well as notice of the enrollee’s appeal rights. The notice must clearly state or explain what goods and/or services are being denied; the reasons for the denial; the contract section that supports the denial; the address and toll-free number of the ASO Member Services Department; the enrollee’s right to challenge the denial by filing an internal appeal with the ASO ; the procedure and timeframe for commencing each level of the ASO’s internal appeals process, including the address to which any written request for appeal may be mailed; the availability of expedited internal appeals; specifications and assistance as to the format in which the enrollee may request an internal appeal; that the enrollee will lose his or her right to challenge the denial with the ASO within 60 days from the date the ASO mailed the denial notice; that for each level of its appeals process, the ASO must issue a decision regarding an appeal no more than 30 days following the date that the ASO receives the request for review; that the ASO must be responsive to questions which the enrollee may have about the denial; that the enrollee may submit additional documentation or written material for the ASO’s consideration; and that the ASO’s review may be based solely on information available to the ASO and its providers, unless the member requests a meeting or the opportunity to submit additional information.

Internal appeal process

Enrollees must have the opportunity to request an internal appeal with the HUSKY Health ASO of a decision made by the HUSKY Health ASO regarding the denial of goods and services covered in the basic benefit package. The HUSKY Health ASO is required to have a timely and organized internal appeal process for receiving and acting upon these requests. This internal appeals process, may, at the HUSKY Health ASOs’ option, consist of more than one level of review. The internal appeals process shall be available

70 for resolution of disputes between the HUSKY Health ASO subcontractors and enrollees concerning the denial of a request for goods and services covered under the HUSKY B benefit package. The HUSKY Health ASO are responsible for ensuring compliance with the internal appeals process, whether the ASO or one of its subcontractors denies the goods or services.

The ASO must develop and make available to enrollees appropriate alternative language versions of internal appeal materials, including but not limited to, the standard information contained in denial notices. Such materials shall be made available in Spanish, English and any other language(s) if more than five percent of the HUSKY Health ASO’s enrollees in the State of Connecticut served by the HUSKY Health ASO speak the alternative language. The HUSKY Health ASO must submit such alternative language materials to the Department and the Department must approve any such materials in writing prior to use by the ASO.

The HUSKY Health ASO must develop written policies and procedures for each component of its internal appeals process, which must be approved by the Department in writing. The HUSKY Health ASO is required to maintain a record keeping system for each level of its appeal process, which shall include a copy of the enrollee’s request for review, the response, and the resolution, which the HUSKY Health ASO shall make available to the Department upon request.

An individual or individuals having final decision-making authority shall conduct the final level of the HUSKY Health ASOs’ reviews. One or more clinicians who were not involved in the denial determination must decide any appeal arising from an action based on a determination of medical necessity.

The HUSKY Health ASOs may decide an appeal on the basis of written documentation available to the HUSKY Health ASOs at the time of the request, unless the enrollee requests an opportunity to meet with the individual or individuals conducting the internal appeal on behalf of the HUSKY Health ASOs and/or requests the opportunity to submit additional written documentation or other written material. The HUSKY Health ASOs shall inform the enrollee that the HUSKY Health ASOs’ reviews may be based solely on information available to the HUSKY Health ASOs and their providers, unless the enrollee requests a meeting or the opportunity to submit additional information.

The HUSKY Health ASOs shall issue a written decision for each level of their internal appeals process. Each decision shall be sent to the member by certified mail. The HUSKY Health ASOs shall send a copy of each decision to the Department. The appeal decision shall be sent no later than 30 days from the date on which the HUSKY Health ASOs received the appeal.

71 If the HUSKY Health ASOs fail to issue a decision within 30 days, the Department will deem the decision to be a denial and the enrollee may file an external appeal with the Department of Social Services Medical, Behavioral Health or Dental Director.

A HUSKY Health ASO’s written decision must include the member’s name and address; the provider’s name and address; the ASO name and address; a complete statement of the ASO’s findings and conclusions, including the section number and text of any statute or regulation that supports the decision; a clear statement of the HUSKY Health ASO’s disposition of the appeal; a statement that the member has exhausted the HUSKY Health ASO’s internal appeal procedure concerning the denial at issue; and relevant information concerning the external appeals process available through the Department.

The Department shall have a process through which a health care provider may grieve a decision on behalf of a member. The Department shall provide information on the availability of this process to the providers in the CMAP network.

Expedited internal appeal process

Pursuant to the Department’s contract with its medical, behavioral health, and dental ASOs, each ASO’s internal appeals process for HUSKY B enrollees must allow for expedited review. If an enrollee requests an expedited review, the HUSKY Health ASOs must determine within one business day of receipt of the request, whether to expedite the review or whether to perform the review according to the standard timeframes.

External appeal process

The HUSKY Health ASOs must include the following information concerning the Department’s external appeal process in the enrollee’s member handbook: that if the member has exhausted the HUSKY Health ASO’s internal appeals process and has received a final written decision from the ASO upholding the HUSKY Health ASO’s original denial of the good or service, the member may file an external appeal with the Department’s Medical, Behavioral Health, or Dental Clinical Directors, within 30 days of receiving the final written appeal decision; that the enrollee will be asked to submit certain information in support of the appeal request, including a release of medical records; that the enrollee will be notified within five business days of the Department’s Medical, Behavioral Health, or Dental Clinical Director’s receipt of the request whether the appeal has been accepted or denied for full review; and that the HUSKY Health ASO shall be bound by the Department’s Medical, Behavioral Health, or Dental Clinical Director’s external appeal decision.

HUSKY Plus Physical appeals process

72

The HUSKY Plus Physical program has its own separate appeals process that addresses issues specific to the services covered by HUSKY Plus Physical. The HUSKY Plus Physical appeals process has three levels. The first level is an informal appeal that is addressed by the participating HUSKY Plus Physical Center. If the enrollee wishes to pursue the matter further, a written request is submitted to the HUSKY Plus Physical Appeals Subcommittee. The subcommittee in HUSKY Plus Physical consists of impartial representatives from the Department of Social Services, the Department of Public Health, and the contracting Title V center. The appeals subcommittee hears appeals for both HUSKY Plus Physical and Title V. If the enrollee is still dissatisfied, the appeal subcommittee’s decision may be further appealed through the Commissioner of the Department. A detailed description of this appeals process is included in Appendix 3.1.

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.

73

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)

74

CMS Regional Offices CMS Regional Offices States Associate Regional Administrator Regional Office Address

75 Region 1- Boston Connecticut Massachuset ts Maine New Hampshire Rhode Island Vermont Richard R. McGreal richard.mcgreal@cms.hhs.gov John F. Kennedy Federal Bldg. Room 2275 Boston, MA 02203-0003 Region 2- New York New York Virgin Islands New Jersey Puerto Rico Michael Melendez michael.melendez@cms.hhs.gov 26 Federal Plaza Room 3811 New York, NY 10278-0063

Region 3- Philadelphia Delaware District of Columbia Maryland Pennsylvania Virginia West Virginia Ted Gallagher ted.gallagher@cms.hhs.gov The Public Ledger Building 150 South Independence Mall West Suite 216 Philadelphia, PA 19106

Region 4- Atlanta Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee Jackie Glaze jackie.glaze@cms.hhs.gov

Atlanta Federal Center 4th Floor 61 Forsyth Street, S.W. Suite 4T20 Atlanta, GA 30303-8909 Region 5- Chicago Illinois Indiana Michigan Minnesota Ohio Wisconsin Verlon Johnson verlon.johnson@cms.hhs.gov 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 Region 6- Dallas Arkansas Louisiana New Mexico Oklahoma Texas Bill Brooks bill.brooks@cms.hhs.gov 1301 Young Street, 8th Floor Dallas, TX 75202 Region 7- Kansas City Iowa Kansas Missouri Nebraska

James G. Scott james.scott1@cms.hhs.gov Richard Bulling Federal Bldg. 601 East 12 Street, Room 235 Kansas City, MO 64106-2808 Region 8- Denver Colorado Montana North Dakota South Dakota Utah Wyoming Richard Allen richard.allen@cms.hhs.gov Federal Office Building, Room 522 1961 Stout Street Denver, CO 80294-3538 Region 9- San Francisco

Arizona California Hawaii Nevada American Samoa Guam Northern Mariana Islands Gloria Nagle gloria.nagle@cms.hhs.gov 90 Seventh Street Suite 5-300 San Francisco Federal Building San Francisco, CA 94103 Region 10- Seattle

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

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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.

77 21. Care coordination services. 22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. 23. Hospice care. 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

78 income level' means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under title XIX (including under a waiver authorized by the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical assistance under Section 1902(l)(2) for the age of such child. 5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‘targeted low- income pregnant woman’ means an individual—‘‘(A) during pregnancy and through the end of the month in which the 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.

_ CT-17-0010-CHIP APPENDIX 1.4 MAGI TEMPLATES CT 14-0001- MAGI Eligibility and Methods — CS7, CS10 (with attachments) and CS15 CT 14-0003 ; Establish 2101(f) group — CS 14

CT 14-0004 - General Eligibility/Eligibility Processing ~.CS24

CT 14-0005 - Non Financial Eligibility -CS17, CS18, CS19, CS20, CS21 and CS28

Revised 11/17/2017

CHIP Eligibility

Arran ALDI ICTY

OMB Control Number: 0938-1148

_ Expiration date: 10/31/2014 Separate Child. Health Insurance Program ; ae cs 5

Eligibility - Targeted Low-Income Children

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

Cl 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.

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

No

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)

+ lo 19 196 318 xX

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.

Special Program for Children with Disabilities Does the state have a special program for children with disabilities? _ Is the program available to all eligible targeted low-income children?

Program Description

Describe disability criteria used.

The clinical eligibility standard for the HUSKY Plus Physical (HPP) program is based on diagnostic and/or acuity criteria

Page | of 2

CHIP Eligibility

and shall be the same as those for the Title V program currently operating in the state.

Describe program, including additional benefits offered.

All children determined eligible for HPP will receive care coordination, advocacy, family support and case management services as well as comprehensive multidisciplinary evaluation once a year and up to three follow-up visits per year with members of the multidisciplinary group as needed. In addition, the range of services will include the following to the extent that they are not covered under the HUSKY, Part B benefit package and when such services have been otherwise exhausted under the HUSKY B basic benefit package, including but not limited to, 1) over the counter medications, if medically necessary and related to the condition that qualifies the child for the program; 2) A home health aide provided by a licensed home health agency to assist the family to provide personal care to the child up to ten hours per week; 3) medical or surgical supplies, if medically necessary and related to the condition that qualifies the child for the program;4) long term rehabilitation or long term physical therapy; 5) durable medical equipment, exclusive of the basic HUSKY B Plan, including, but not limited to, items that assist in the activities of daily living; 6) orthotics and prosthetics; 7) hearing

aids; 8) nutritional counseling; and 9) limited non-emergency medical transportation. Certain services are subject to limitations.

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.20130917

Page 2 of 2

CMs. CHIP Eligibility

State Name:|Connecticut | OMB Control Number: 0938-1148 Transmittal Number: CT - 14-0001 Expiration date: 10/31/2014 Separate Child Health Insurance Program soe csi0 Eligibility - Children Who Have Access to Public Employee Coverage

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

im 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.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 21 10(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 21 10(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 C. 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:

[M] 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.

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.

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.

Page | of 2

Plan: Anthem Blue Cross State Preferred

Total Family Employee State Total Family Employee Year Monthly Monthly Family Monthly Annual Annual Family Premium Premium Expenditure Premium Premium 1997 $650.81 $151.71 $499.10 $7,809.72 $1,820.52 1998 $650.81 $151.71 $499.10 $7,809.72 $1,820.52 1999 $920.24 $212.26 $707.98 $11,042.88 $2,547.12 2000 $920.24 $212.26 $707.98 $11,042.88 $2,547.12 2001 $1,057.35 $243.82 $813.53 $12,688.20 $2,925.84 2002 $1,210.65 $279.18 $931.47 $14,527.80 $3,350.16 2003 $1,387.77 $320.02 $1,067.75 $16,653.24 $3,840.24 2004 $1,490.96 $371.09 $1,119.87 $17,891.52 $4,453.08 2005 $1,534.57 $353.87 $1,180.70 $18,414.84 $4,246.44 2006 $1,684.23 $388.38 $1,295.85 $20,210.76 $4,660.56 2007 $1,789.53 $412.67 $1,376.86 $21,474.36 $4,952.04 2008 $1,916.41 $441.92 $1,474.49 $22,996.92 $5,303.04 2009 $2,090.21 $511.17 $1,579.04 $25,082.52 $6,134.04 2010 $2,334.69 $571.07 $1,763.62 $28,016.28 $6,852.84 2011 $2,413.72 $590.40 $1,823.32 $28,964.64 $7,084.80 2012 $2,413.72 $590.40 $1,823.32 $28,964.64 $7,084.80 2013 $2,630.96 $619.51 $2,011.45 $31,571.52 $7,434.12

2014 = $2,912.00 $651.09 $2,260.91 $34,944.00 $7,813.08

1997 Annual CPl-Medical Inflation State Expenditue Increased by CPI

State Annual Expenditure

$5,989.20 - - $5,989.20

$5,989.20 3.2% $191.65 $6,180.85

$8,495.76 3.5% $216.33 $6,397.18

$8,495.76 4.1% $262.28 $6,659.47

$9,762.36 4.6% $306.34 $6,965.80 $11,177.64 4.7% $327.39 $7,293.20 $12,813.00 4.0% $291.73 $7,584.93 $13,438.44 4.4% $333.74 $7,918.66 $14,168.40 4.2% $332.58 $8,251.25 $15,550.20 4.0% $330.05 $8,581.30 $16,522.32 4.4% $377.58 $8,958.87 $17,693.88 3.7% $331.48 $9,290.35 $18,948.48 3.2% $297.29 $9,587.64 $21,163.44 3.4% $325.98 $9,913.62 $21,879.84 3.0% $297.41 $10,211.03 $21,879.84 3.7% $377.81 $10,588.84 $24,137.40 2.5% $264.72 $10,853.56

$27,130.92 $0.00 $10,853.56

Plan: Anthem Blue Cross Out of Area

Year

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Total Family Monthly Premium

$650.81

$650.81

$897.67

$897.67 $1,031.43 $1,180.98 $1,353.75 $1,376.94 $1,415.28 $1,553.36 $1,651.48 $1,836.38 $2,001.57 $2,233.90 $2,309.61 $2,309.61 $2,517.48 $2,807.86

Employee Monthly Family Premium

$93.12

$93.12

$97.24

$97.24 $111.71 $127.90 $146.61 $170.01 $176.07 $193.27 $205.80 $203.88 $240.11 $277.19 $287.03 $287.03 $301.18 $316.52

State Monthly Expenditure

$557.69

$557.69

$800.43

$800.43

$919.72 $1,053.08 $1,207.14 $1,206.93 $1,239.21 $1,360.09 $1,445.68 $1,632.50 $1,761.46 $1,956.71 $2,022.58 $2,022.58 $2,216.30 $2,491.34

Total Family,

Annual Premium

$7,809.72

$7,809.72 $10,772.04 $10,772.04 $12,377.16 $14,171.76 $16,245.00 $16,523.28 $16,983.36 $18,640.32 $19,817.76 $22,036.56 $24,018.84

$26,806.80:

$27,715.32 $27,715.32 $30,209.76 $33,694.32

Employee Annual Family Premium

. $1,117.44 $1,117.44 $1,166.88 $1,166.88 $1,340.52 $1,534.80 $1,759.32 §2,040.12 $2,112.84 $2,319.24 $2,469.60 §2,446.56 $2,881.32 $3,326.28 $3,444.36 $3,444.36 $3,614.16 $3,798.24

Plan: Anthem Blue Cross Out of Area

Total Family Employee State Total Family Employee Year Monthly Monthly Family Monthly Annual Annual Family Premium Premium Expenditure Premium Premium 1997 $650.81 $93.12 $557.69 $7,809.72 $1,117.44 1998 $650.81 $93.12 $557.69 $7,809.72 $1,117.44 1999 $897.67 $97.24 $800.43 $10,772.04 $1,166.88 2000 $897.67 $97.24 $800.43 $10,772.04 $1,166.88 2001 $1,031.43 $111.71 ' $919.72 $12,377.16 $1,340.52 2002 $1,180.98 $127.90 $1,053.08 $14,171.76 $1,534.80 2003 $1,353.75 . $146.61 $1,207.14 $16,245.00 $1,759.32 2004 $1,376.94 $170.01 $1,206.93 $16,523.28 $2,040.12 2005 = $1,415.28 $176.07 $1,239.21 $16,983.36 $2,112.84 2006 = $1,553.36 $193.27 $1,360.09 $18,640.32 $2,319.24 2007. = $1,651.48 $205.80 $1,445.68 $19,817.76 $2,469.60 2008 $1,836.38 $203.88 $1,632.50 $22,036.56 $2,446.56 2009 $2,001.57 $240.11 $1,761.46 $24,018.84 $2,881.32 2010 $2,233.90 $277.19 $1,956.71 $26,806.80 $3,326.28 2011 $2,309.61 $287.03 $2,022.58 $27,715.32 $3,444.36 2012 $2,309.61 $287.03 $2,022.58 $27,715.32 $3,444.36 2013 = $2,517.48 $301.18 $2,216.30 $30,209.76 $3,614.16

2014 $2,807.86 $316.52 $2,491.34 $33,694.32 $3,798.24

Plan: Anthem Blue Cross POS

Total Family Employee State Total Family Employee Year Monthly = “Monthly Family Monthly Annual Annual Family Premium Premium Expenditure Premium Premium 1997 $592.22 $93.12 $499.10 $7,106.64 $1,117.44 1998 $592.22 $93.12 $499.10 $7,106.64 $1,117.44 1999 $646.84 $97.24 ' $549.60 $7,762.08 $1,166.88 2000 $646.84 $97.24 $549.60 $7,762.08 $1,166.88 2001 $743.23 $111.71 $631.52 $8,918.76 $1,340.52 2002 $850.99 ° $127.90 $723.09 $10,211.88 $1,534.80 2003 $975.48 $146.61 $828.87 $11,705.76 $1,759.32. 2004 = $1,132.16 $170.01 $962.15 $13,585.92 $2,040.12 2005 = $1,171.45 $176.07 $995.38 $14,057.40 $2,112.84 2006 $1,285.87 $193.27 $1,092.60 $15,430.44 $2,319.24 2007 $1,369.28 $205.80 $1,163.48 $16,431.36 $2,469.60 2008 ~° $1,356.48 $203.88 $1,152.60 $16,277.76 $2,446.56 2009 $1,470.05 $250.11 $1,219.94 $17,640.60 $3,001.32 2010 $1,629.56 $277.19 $1,352.37 $19,554.72 $3,326.28 2011 $1,685.45 $287.03 $1,398.42 $20,225.40 $3,444.36 2012 $1,685.45 $287.03 $1,398.42 $20,225.40 $3,444.36 2013 = $1,837.14 $301.18 $1,535.96 $22,045.68 $3,614.16

2014 $2,032.26 $316.52 $1,715.74 $24,387.12 $3,798.24

State Annual Expenditure

$5,989.20 $5,989.20 $6,595.20 $6,595.20 $7,578.24 $8,677.08 $9,946.44 $11,545.80 $11,944.56 $13,111.20 $13,961.76 $13,831.20 $14,639.28 $16,228.44 $16,781.04 $16,781.04 $18,431.52 $20,588.88

CPI-Medical

3.2% 3.5% 4.1% 4.6% 4.7% 4.0% 4.4% 4.2% 4.0% 4.4% 3.7% 3.2% 3.4% 3.0% 3.7% 2.5%

Inflation

$191.65 $216.33 $262.28 $306.34 $327.39 $291.73 $333.74 $332.58 $330.05 $377.58 $331.48 $297.29 $325.98 $297.41 $377.81 $264.72

$0.00

1997 Annual State Expenditue Increased by CP

$5,989.20 $6,180.85 $6,397.18 $6,659.47 $6,965.80 $7,293.20 $7,584.93 $7,918.66 $8,251.25 $8,581.30 $8,958.87 $9,290.35: $9,587.64 $9,913.62 $10,211.03 $10,588.84 $10,853.56 $10,853.56

Plan: Anthem Blue Cross POE

Year

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Total Family Monthly Premium

$533.01 $533.01 $613.80 $613.80 $705.27 $807.54 $925.70 $1,088.83 $1,125.49 $1,235.46 $1,316.09 $1,314.82 $1,423.90 $1,577.10 $1,631.29 $1,631.29 $1,778.11 $1,969.05

Employee Monthly Family Premium

$67.12 $67.12 $71.20 $71.20 $81.81 $93.67 $107.38 $124.52 $130.56 $143.32 $152.67 $152.52 $194.34 $215.27 $223.65 $223.65 $234.67 $246.62

State Monthly Expenditure

$465.89 $465.89 $542.60 $542.60 $623.46 $713.87 $818.32 $964.31 $994.93 $1,092.14 $1,163.42 $1,162.30 $1,229.56 $1,361.83 $1,407.64 $1,407.64 $1,543.44 $1,722.43

Total Family Annual Premium

$6,396.12 $6,396.12 $7,365.60 $7,365.60 $8,463.24 $9,690.48 $11,108.40 $13,065.96 $13,505.88 $14,825.52 $15,793.08 $15,777.84 $17,086.80 $18,925.20 $19,575.48 $19,575.48 $21,337.32 $23,628.60

Employee Annual Family Premium

$805.44

$805.44

$854.40

$854.40

$981.72 $1,124.04 $1,288.56 $1,494.24 $1,566.72 $1,719.84 $1,832.04 $1,830.24 $2,332.08 $2,583.24 $2,683.80 $2,683.80 $2,816.04 $2,959.44

1997 Annual

State Annual 3 CPl-Medical Inflation State Expenditue

Expenditure

Increased by CPI $5,590.68 - - $5,590.68 $5,590.68 3.2% $178.90 $5,769.58 $6,511.20 3.5% $201.94 $5,971.52 $6,511.20 4.1% $244.83 $6,216.35 $7,481.52 4.6% $285.95 $6,502.30 $8,566.44 4.7% $305.61 $6,807.91 $9,819.84 4.0% $272.32 $7,080.23

$11,571.72 4.4% $311.53 $7,391.76 $11,939.16 4.2% $310.45 $7,702.21 $13,105.68 4.0% $308.09 $8,010.30 $13,961.04 4.4% $352.45 $8,362.75 $13,947.60 3.7% $309.42 $8,672.17 ; $14,754.72 3.2% $277.51 $8,949.68 $16,341.96 3.4% $304.29 $9,253.97 $16,891.68 3.0% $277.62 $9,531.59 $16,891.68 3.7% $352.67 $9,884.26 $18,521.28 2.5% $247.11 $10,131.37

$20,669.16 $0.00 $10,131.37

Plan: Anthem Blue Cross State Preferred

Year

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Total Family Employee State Monthly Monthly Family Monthly Premium “Premium Expenditure

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Total Family Annual Premium

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Employee Annual Family Premium

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

State Annual Expenditure

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 .$0.00 $0.00 $0.00 $0.00

CPl-Medical

3.2% 3.5% 4.1% 4.6% 4.7% 4.0% 4.4% - 4.2% 4.0% 4.4% 3.7% 3.2% 3.4% 3.0% 3.7% 2.5%

Inflation

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

1997 Annual State Expenditue Increased by CPI

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

cems CHIP Eligibility

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

Separate Child Health Insurance Program : CS15 MAGI-Based Income Methodologies... SASS : Pe

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

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. C 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: LJ Include a prorated portion of the reasonably predictable increase in future income and/or family size. (J Account for a reasonably predictable decrease in future income and/or family size.

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

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

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

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

_An attachment is submitted.

PRA Disclosure Statement

Page 1 of 2

Ceeeeeeeeeeeeeeeeee as cCcmMs. CHIP Eligibility

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

V.20130917

Page 2 of 2

ccmMs CHIP Eligibility

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

esis

Child: Health Insurance Program: ~ as : oo : Eligibility - ‘Children Ineligible for Medicaid‘as a Result of the: Elimination. of Thiceme ‘buieeanis:

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

[mi] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards

The CHIP agency provides coverage for this group of children as follows:

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of > income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected ** from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ). Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

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

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

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

Cc

(%o FPL

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

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

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cms. CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

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

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CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014 Separate Child Health’ Insurance Program cee

General Eligibility - Eligibility Processing © ree : cles ee ced

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.

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

‘An attachment is submitted.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the [J agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

. An attachment is submitted:

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 CFR 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. [] 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-

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:

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

im 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

Page | of 2

im] 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:

[M] Once every 12 months.

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

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

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 oO insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements 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. :

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

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.20130917

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cms. CHIP Eligibility

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

Separate Child Health Insurance Program : ° “0817 Non-Financial Eligibility -- Residency. ; : : : F

42 CFR 457.320

Residency

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

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

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

1, Intends to reside in the state, including without a fixed address, or 2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [mj A non-institutionalized child not described above and a child who is not a ward of the state:

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

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

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

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

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

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

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

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

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

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

Page | of 2

cemMs. CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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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cmMs. CHIP Eligibility

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

Separate Child Health Insurance Program 3 : : : ; Csis Non-Financial Eligibility - Citizenship ; ; : : : ;

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[m] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the [Yes verification process.

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

The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

@: Other date, as described:

The date on which CHIP benefits would have otherwise been furnished had the inconsistency not arisen.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status. ,

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

Page | of 3

a CHIP Eligibility

STEER TOM EACANY A MEDICAID EEIMICTY

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

No

ci An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

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

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

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

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

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

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

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

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

(i) Has been granted employment authorization; or (ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); , 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

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

Page 2 of 3

cms. CHIP Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not

be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

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.20130917

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cms CHIP Eligibility

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

Separate Child Health Insurance Program : : - “E819 (Non-Financial Eligibility - Social Security Number : ; ; .

42 CFR 457.340(b)

Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions: ;

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

im The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[m] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their Ves SSN. .

Whien requesting an SSN for non-applicant household members, the state assures that:

im At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

im The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

Page | of 2

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. If you have comments concerning the accuracy of

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

V.20130917

Page 2 of 2

Cems. CHIP Eligibility

State Name: [Connecticut OMB Control Number: 0938-1148 Transmittal Number:. CT - 14 - 0005 Expiration date: 10/31/2014

Separate Child Health Insurance Program Non-Financial Eligibility - Substitution of Coverage

“S20

Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3), 457.350(i), and 457.805

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[M] Substitution of coverage prevention strategy:

Name of policy Description

Substitution Monitoring Applicants may not be covered by other comprehensive health insurance. The application used by the CHIP agency and the state-based marketplace asks applicants to report other health insurance coverage. If a household reports creditable coverage, any child in the household will be found ineligible for CHIP. To determine the percent of enrollees who dropped group health + insurance without good cause in order to gain eligibility for HUSKY, xX the Department will generate quarterly reports to compare the number of individuals under age 19 that were denied due to other insurance and then reapplied within a six (6) month time frame. The report will monitor the percentage of such applicants who are subsequently approved for HUSKY, but no longer report other insurance. If substitution exceeds ten (10) percent, the Department will collaborate with CMS to identify an alternative strategy to reduce substitution.

A waiting period during which an individual is ineligible due to having dropped group health coverage. No

If the state elects to offer dental only supplemental coverage, the following assurances apply:

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

(F The waiting period does not apply to children eligible for dental only supplemental coverage.

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 contro! 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.20140415

Page | of 1

CccCmMs. CHIP Eligibility

State Name: [Connecticut | OMB Control Number: 0938-1148 Transmittal Number: CT - ‘14- 0005 Expiration date: 10/31/2014

Separate Child Health Insurance Program : cs21

Non-Financial Eligibility - ‘Non-Payment of Premiums.

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? INo

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.20140415

Page 1 of 1

CCoMS. CHIP Eligibility

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

cs28

Separate Child Health Insurance Program: ». es General Eligibility = Presumptive Eligibility for Children:

42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. |Yes

[| Describe the population of children to whom presumptive eligibility applies:

All children, from birth to the age of nineteen, with incomes above 196% of the FPL and up to and including 318% of the FPL.

[m] Describe the duration of the presumptive eligibility period and any limitations:

The date the eligibility determination for CHIP is made, if an application for CHIP is filed by the last day of

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

The last day of the month following the month in which the determination of presumptive eligibility is made, ifno application for CHIP is filed by that date.

‘No more than two periods within a calendar year.

[| Describe the application process and eligibility determination factors used:

Qualified entities may use either an online portal for presumptive eligibility applications or a simplified, one page presumptive eligibility paper application.

[m] The CHIP Agency uses qualified entities, as defined in section 1920A, to determine sligibility presumptively for children.

Separate Child:Health Insurance Program

General Eligibility - List of Qualified Entities ESO

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

X Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan

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

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

x

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

Page 1 of 2

i j i j { i i | | | |

CMs CHIP Eligibility

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

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

[X] Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs [J Isa state or Tribal child support enforcement agency under title IV-D of the Act

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

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

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

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

(7) Any other entity the state so deems, as approved by the Secretary The CHIP Agency assures that it has communicated the requirements for qualified entities, at 1920A(b)(3)

of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

An attachment is submitted.

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

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop ‘C4-26-05, Baltimore, Maryland 21244-1850.

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Page 2 of 2

APPENDIX 6.1.4:

HUSKY B BENEFIT COVERAGE 9/25/17

Benefit Features

HUSKY B Coverage

State pays

Member pays

Outpatient Physician Visits*

Allowed fee less $10

$10 copay (unless preventive)

Preventive Care * Allergy Injections *

Periodicity schedule *

100% 100%

100%: newborn exam in the hospital, regular newborn screening exam (in hospital or office), periodic and well child visits, immunizations, WIC evaluations as applicable, and prenatal care for women under age 19.

Periodicity schedule and reporting based on the American Academy of Pediatrics (AAP) as amended from time to time:

Immunization schedule according to Department of Health and Human Services Centers for Disease Control and Prevention recommendations and guidelines.

No copay No copay

No copay

No copay

No copay

Family Planning

100%

Family Planning Services include: Reproductive health exams; Patient Counseling;

Patient Education;

Lab tests to detect the presence of conditions affecting reproductive health;

Screening, testing and treatment;

Pre and post-test counseling for sexually transmitted diseases and HIV;

Abortions that are necessary to save the life of the mother or if the pregnancy resulted from rape or incest or if pregnancy resulted from rape or incest.

No copay

Preventive Family Planning Services*

100%

No copay

Pre-Admission Testing/ Continued Stay

100% Arranged through provider.

No copay

Inpatient Physician

100%

No copay

Note: Prior authorization may be required by the MCO unless otherwise noted by an asterisk (*).

HUSKY B

Appendix B — Covered Benefits

Provided to members who are diagnosed as having a terminal illness with a life expectancy of six months or less. Covered care includes

Nursing care;

Physical therapy, Speech therapy, and Occupational therapy;

Medical social services;

Home health aides and homemakers; Medical supplies;

Drugs;

Appliances;

Inpatient Hospital 100% No copay Outpatient Surgical 100% No copay Facility Short Term 100% No copay Rehabilitation, For conditions where significant improvement is including: expected within 60 days: Physical Therapy; Speech Therapy; Occupational Therapy; and Skilled Nursing Care (excludes private duty nursing), Behavioral health home-based and “emergency mobile rehab. Home Health Care 100% No copay Includes disposable medical supplies for homebound members Excludes: Custodial care, homemaker care or care that may be provided in a medical office, hospital or skilled nursing facility and offered to the member is such setting. Note: Supplemental coverage available No copay under HUSKY Plus Physical for medically eligible children. Hospice 100% No copay

Note: Prior authorization may be required by the MCO unless otherwise noted by an asterisk (*).

2

HUSKY B

Appendix B — Covered Benefits

DME; . Physician services;

Short-term inpatient care, including respite care and care for pain control and acute and chronic symptom management; services of volunteers and other benefits when ordered by a physician.

Limitations on short-term therapies do not apply.

Long Term Not covered under HUSKY B. N/A Rehabilitation, including: Note: Supplemental coverage available Physical Therapy; under HUSKY Plus Physical for medically Husky Plus No Speech Therapy; eligible children. copay, Occupational Therapy. Long Term Skilled Not covered under HUSKY B. N/A Nursing Care Note: Supplemental coverage available HUSKY Plus No under HUSKY Plus Physical for medically copay eligible children. . Ambulance* 100% No copay if determined to be an emergency Emergency Care* 100% No copay If determined to be an emergency in accordance with state law. Urgent Care Allowed fee less $10. $10 copay Lab and X-Ray 100% No copay Radiation Therapy 100% No copay Chemotherapy | 400% No copay Heimodialysis 100% No copay Durable Medical 100% No copay

Equipment (DME)

DME means equipment that is furnished by a supplier or home health agency that:

1. can withstand repeated use; 2. is primarily and customarily used to

Note: Prior authorization may be required by the MCO unless otherwise noted by an asterisk (*).

3

HUSKY B

Appendix B — Covered Benefits

serve a medical purpose;

3. is generally not useful to an individual in the absence of an illness or injury; and

4. is appropriate for use in the home

Excludes:

e Power wheelchairs for members who are eligible for HUSKY Plus Physical;

e Devices not medical in natures such as: e whirlpools,

e saunas,

e elevators,

e vans,

e van lifts,

e home convenience items (e.g., air cleaners, filtration units and related apparatus, exercise bicycles and other types of exercise equipment),

e insulin injectors,

e non-rigid appliances and supplies, such as, sheets, self-help devices, experimental or investigational research equipment,-and

e items for personal comfort and or usefulness to the member's household.

Note: Supplemental coverage available under HUSKY Plus Physical for medically eligible children.