DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center - Room 2275 Boston, Massachusetts 02203 CENTERS for MED/C4RF lB MEDN;4fD SFMCES Division of Medicaid and Children's Health O~erations / Boston Regional Ofice March 12,20 10 Michael P. Starkowski, Commissioner Department of Social Services 25 Sigourney Street Hartford, Connecticut 06 106 Dear Mr. Starkowski, We are pleased to enclose a copy of approved Connecticut State plan amendment (SPA) No. 09-01 5. This proposed plan submitted to my office on June 29,2009 transmitted an amendment to your Department's approved Title XIX State plan proposing to amend Title XIX of Connecticut's State Plan by using fj 1902 (r)(2) and 9 193 1 of the Social Security Act (the Act) to disregard, for certain mandatory and optional categorically needy and medically needy Medicaid eligibility groups, all wages paid by the U.S. Census Bureau related to temporary employment related to the decennial census activities. The approval for CT 09-0 15 is effective April 1,2009 as requested. Changes are reflected in the following sections of your approved State Plan; Supplement 8a to Attachment 2.6-A, page 8 Supplement 12 to Attachment 2.6A, pages 3-4 Deletes Supplement 12 to Attachment 2.6-A, addendum If you have any questions regarding this matter you may contact Don Novo of my staff. He can be reached at (61 7) 565-1 225 or by email at don.novo~,cms.hhs.~v . Sincerely, Richard R. McGreal Associate Regional Administrator cc: Marc Shok-Manager-Social Services Program Administration Steve Markowski-Social Services Program Analyst

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 CENTERS for MEDICARE& MEDC41D SERWCF5 Division of Medicaid and Children's Health Operations / Boston Regional Office December 30,2009 Michael P. Starkowski, Commissioner Department of Social Services 25 Sigourney Street Hartford, Connecticut 06 106-5033 Dear Mr. Starkowski: Enclosed is a copy of approved State plan amendment (SPA) No. 09-016. This SPA is effective April 1,2009, as requested. SPA 09-016, received on June 26,2009, transmitted an amendment to your approved Title XIX State plan to elect the option in $214 of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law No. 1 1 1-3. This option allows States to provide full Medicaid coverage to otherwise eligible alien children or pregnant women lawfully residing in the United States. You elected to cover pregnant women and children under age 2 1 Please contact Allen Bryan or Don Novo if you have any questions. They can be reached at (617) 565-1246 or (61 7) 565-1225, respectively. Sincerely, Richard R. McGreal Associate Regional Administrator Enclosure

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston. Massachusetts 02203 Division of Medicaid and Children's Health Operations / Boston Regional Office October 26,2009 Michael P. Starkowski, Commissioner Department of Social Services 25 Sigourney Street Hartford, Connecticut 06 106 Dear Mr. Starkowski, We are pleased to enclose a copy of approved Connecticut State Plan Amendment (SPA) No. 09-017. This proposed plan submitted to my office on September 28,2009, requests to amend your Department's approved Title XIX State plan as outlined in Section 5004 of the American Recovery and Reinvestment Act (ARRA). This approval allows your Department to extend Transitional Medical Assistance (TMA) coverage for individuals that received Section 193 1 eligibility for at least one of the previous six months from an initial period of six months to a full twelve month period of initial eligibility. The approval is effective July 1,2009 as requested. Attached are copies of the new and superseded State Plan pages to be incorporated within your approved State plan. Changes are reflected in the following sections of your approved State Plan: Supplement 12 to Attachment 2.6-A, Page(s)7 If you have questions regarding this matter please contact Don Novo of my staff. He can be reached at (61 7) 565-1225. Sincerely, Richard R. McGreal Associate Regional Administrator cc: Marc Shok, Manager-Assistance Programs Steve Markowski-Assistance Programs

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston. Massachusetts 02203 Division of Medicaid and Children's Health O~erations / Boston Regional Osee June 23,20 10 Michael P. Starkowski, Commissioner Department of Social Services 25 Sigourney Street Hartford, Connecticut 061 06 Dear Mr. Starkowski: We are pleased to enclose a copy of approved Connecticut State plan amendment (SPA) No. 09-025. This proposed plan submitted to my office on March 29,20 10 transmitted an amendment to your Department's approved Title XIX State plan proposing to amend Attachment 4.19-B of your State Plan to implement a more cost-effective fee for ceiling lifts in keeping with community pricing, without a negative impact on consumer access. This SPA has been approved effective January 1,20 10, as requested by the State. Changes are reflected in the following sections of your approved State Plan: Attachment 4.19-B, page 1 (a)(v) If you have any questions regarding this matter you may contact Julie McCarthy (6 1 7) 565- 1244 or by e-mail at Julie.McCarthv~;cms.hhs.~v. Sincerely, Richard R. McGreal Associate Regional Administrator cc: Mark Schaefer, Director, Medical Care Administration Patricia McCooey, Staff Attorney Dr. Robert Zavoski, Medical Director

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers t(>r Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 CA#S CENTERS for MEO/CARE & M£0fCAIO SERVICES Division of Medicaid and Children's Health Operations I Boston Regional Office Michael P. Starkowski, Commissioner Department of Social Services 25 Sigourney Street Hartford, Connecticut 06106 Dear Mr. Starkowski: December 8, 2010 We arc pleased to enclose a copy of approved Connecticut State Plan Amendment (SPA) No. 09-026, submitted to my office on March 31, 20 l 0. This SPA transmitted a proposed amendment to Connecticut's approved Title XIX State Plan Lo add authorization requirements to certain high- cost. high-utilization procedures. This SPA has been approved effective February 1, 2010 as requested by the State. Changes are reflected in the following sections of your approved State Plan: • Addendum pages 7, 8, 8a, 9, 9a to Attachment 3.1-A; and • Addendum pages 7, 8, 8a, 9, 9a to Attachment 3.1-8. If you have any questions regarding this matter you may contact Julie McCarthy (617) 565-1244 or by e-mail at Julie.McCarthy@cms.hhs.gov. Sincerely, Richard R. McGreal ~ Associate Regional Administrator cc: Mark Schacter, Director, Medical Care Administration Enclosure/s

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CaaS JFK Federal Building, Government Center CENTERS for MEDICARE & MEDICAID SERVICES

Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

June 16, 2011

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, Connecticut 06106

Dear Mr. Bremby:

We are pleased to enclose a copy of approved Connecticut State Plan Amendment (SPA) No. 11-004, submitted to my office on March 30, 2011. This SPA transmitted a proposed revision to Connecticut’s approved Title XIX State Plan in order to modify the physician’s fee schedule to reflect a proposed increase in the Medicaid fee for procedure code J7302 (Levonorgestrel- releasing intrauterine contraceptive system, 52mg). This SPA has been approved effective March 1, 2011, as requested by the State.

Changes are reflected in the following sections of your approved State Plan: e Attachment 4.19B, page !(a)i(E) » Attachment 4.19B, page I (a)iii e Attachment 4.19B, page 2(b)

If you have any questions regarding this matter you may contact Marie Montemagno at (617)

565-1227 or by e-mail at Marie. Montemagno@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

cc: Mark Schaefer, Director, Medical Care Administration

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO, 0938-0193 |. TRANSMITTAL NUMBER: 2. STATE: CT TRANSMITTAL AND NOTICE OF APPROVAL 1-004 OF STATE PLAN MATERIAL 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: HEALTH CARE FINANCING ADMINISTRATION SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CMS/CMSO 03-01-2011 N SERVICES.

5. TYPE OF STATE PLAN MATERIAL (Check One):

___ NEW STATE PLAN ___AMENDMENT TO BE CONSIDERED AS NEW PLAN 4 AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1905 (a)(5XA) of the Social Security Act a. FFY 2011- $468,000- cust 42 CFR 440.50 b.FFY 2012- $841,000 - cost

8 PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:| 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If applicable)

Attachment 4.19 B Page {{a)i(E) Attachment 4.19 B Page 1(a)i(E) Attachment 4.19 B Page I(a)iii Attachment 4.19 B page 1(a)iii Attachment 4.19 B Page 2(b) Altachment 4.19 B Page 2(b)

10 SUBJECT OF AMENDMENT: The Department of Social Services is proposing to revise its Medicaid State Pian effective March 1, 2011. The Department intends to modify Attachment 4.19-B of the Connecticut Medicaid Stat¢ Pian in order to amend its physician fee schedule. This amendment will reflect a proposed increase in the Medicaid fee for procedure code J7302 (Levonorgestrel-releasing intrauterine contraceptive system, 52mg). This amendment is expected to result in estimated federal costs of $468,000 in FFY 11 and $841,000 in FFY12.

te GOVERNOR'S REVIEW (Check One):

_X_ GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: __COMMENTS OF GOVERNOR'S OFFICE ENCLOSED “NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAI.

12, SIGNATUREAF STATE AGENCY OFFICIAL: 16. RETURN TO: 13. TYPEB’NAME: Rogercn om State of Connecticut Department of Social Services - 11" floor 14. TITLE: Commissioner 25 Sigoumey Street Hartford, CT 06106-5033 15. DATE SUBMITTED: Attention: Ginny Mahoney a March 30, 2011

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: March 30, 2011 18. DATE APPROVED: june 16, 2011

PLAN APPROVED - ONE COPY ATTACHED

19, EFFECTIVE DATE OF APPROVED MATERIAL. 20. SIA TBane ormanar arcicras. March 1, 2011 e — 21. TYPEDNAME: Richard R. McGreal 2 TILE: Associate Regional Aaministrarar——

Division of Medicaid & Children’s Health Operations

23, REMARKS:

FORM HCFA-179 (07-92)

Attachment 4.19B Page 1(a)i(E)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Connecticut

(5) Physician’s services - fixed fee schedule not to exceed the Medicare physician fee schedule. Fees may be deleted or added and priced in order to remain compliant with HIPAA or to correct pricing errors. The current fee schedule was set as of March 1, 2011 and is effective for services provided on or after that date. The fee schedule for physicians can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: wiww.ctdssmap.com. From this web page go to "Provider Services" then to "Fee Schedule Download." All governmental and private providers are reimbursed according to the same fee schedule.

° °

(6) Medical care or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. Fixed fee methodologies are summarized below. Fees may be deleted or added and priced in order to remain compliant with HIPAA or to correct pricing errors.

(a) Podiatrists - 90% of physician fees as noted in (5) above. The current fee schedule was set as of January 1, 2008 and is effective for services provided on or after that date. The fee schedule can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page go to "Provider Services" then to "Fee Schedule Download." All governmental and private providers are reimbursed according to the same fee schedule.

TN # 11-004 Approval Date [ ollie | I Effective Date 03-01-2011 Supersedes

TN # 10-018

Attachment 4.19B Page 1(a)iii

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Connecticut

TN # 11-004 Supersedes TN #.09-013

(ii)

(iii)

(iv)

Naturopaths — 90% of physician fees as noted in (5) above. The current fee schedule was set as of January 1, 2008 and is effective for services provided on or after that date. The fee schedule for naturopaths can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page go to "Provider Services" then to "Fee Schedule Download." All governmental and private providers are reimbursed according to the same fee schedule.

Nurse practitioners — 90% of physician fees as noted in (5) above. The current fee schedule was set as of March 1, 2011 and is effective for services provided on or after that date. The fee schedule for physicians can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page go to "Provider Services" then to "Fee Schedule Download." All governmental and private providers are reimbursed according to the same fee schedule.

Dental Hygienists - 90% of the department's fees for dentists. The fee schedule for dentists can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page go to "Provider Services" then to "Fee Schedule Download." The agency’s rates were set as of April 1, 2008 and are effective for services on or after that date. Rates are the same for private and governmental providers and are published at www.ctdssmap.com.

Approval Date _(» [Mol tt Effective Date 03-01-2011

Attachment 4.19B Page 2(b)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Connecticut

(17)

(18)

Nurse-mid wife services - are paid off of the physician fee schedule at 90% of physician fees. The agency’s physician fee schedule was set as of March 1. 2011 and is effective for services provided on or after that date, except that fees may be deleted or added and priced in order to remain compliant with HIPAA. The physician fee schedule can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page go to “Provider Services” then to “Fee Schedule Download”. All governmental and private providers are reimbursed according to the same fee schedule.

Hospice services — fees will equal Medicare fees for the same services in accordance with §1902(a)(13)(B) of the Social Security Act. The rate setting methodology is in compliance with State Medicaid Manual 4306. Total payments to a hospice are limited by the cap amount specified in 42CFR 418.309. Payment to the hospice for inpatient care is limited in accordance with 42CFR 418.302(f). For clients living in a nursing facility, the per diem nursing facility rate will equal 100% of the rate for that nursing home under the Medicaid program.

TN # 11-004 Approval Date bl Mle / 4 Effective Date 03-01-2011 Supersedes TN #.09-010

Table of Contents

State/Territory Name: CT

State Plan Amendment (SPA) #: 11-033

This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

Baltimore, MD 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES

(CENTER FOR MEDICAID & CHIP SERVICES

Financial Management Group APR 08 2085

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT.06106-5033

RE: Connecticut 11-033 Dear Mr. Bremby:

We have reviewed the proposed amendment to Attachments 4.19-A and 4.19-B, of your Medicaid State plan submitted under transmittal number (TN) 11-033. This amendment implements adjustments for Provider Preventable Conditions (PPCs), consistent with Section 2702 of the Affordable Care Act of 2010 (ACA) and the implementing final rule at 42 CFR 447 Subpart A, for attachments 4.19-A and 4.19-B.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), and 1903(a) of the Social Security Act and the implementing Federal regulations at 42 CFR 447. We are pleased to inform you that Medicaid State plan amendment 11-033 is approved effective March 1, 2012. We are enclosing the CMS- 179 and the amended plan pages.

If you have any questions, please call Novena James-Hailey at (617) 565-1291.

Sincerely,

Timothy Hill Director

ee

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEAL CARE FINANCING ADMINISTRATION

TRANSMITTAL AND NOTICE OF APPROVAL

FORM APPROVED OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2 STATE: CT 11-033

OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION

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

TO: REGIONAL ADMINISTRATOR - CMS/CSMO a dl aM ES

4. PROPOSED RFFECTIVE DATE 3/01/2012

3 TYPE OF STATE PILAN MATERIAL (Check One): _NEW STATE PLAN

___AMENDMENT TO BE CONSIDERED AS NEW PLAN

X AMENDMENT

COMPLETE BILOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate ‘transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: Section 2702 of the PPACA (Pub. L. No. 111-148 as amended by Pub. L. No. 111-152)

7. FEDERAL. BUDGET IMPACT:

FFY 2012 -$ b FFY 2013 -$ nie

8 PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT;

UNMK& gages Qeavd 27 4198 25 aua Blo

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If applicable)

New

SUBJRCT OF AMENDMENT: Under proposed State Plan Amendment No. 11-033. the Department will amend the state plan to prohibit payment to physicians, advanced practice registered nurses, clinics, and hospital outpatient departments for the following preventable procedures’conditions: wrong surgery or other invasive procedure on a patient; surgery or other invasive procedures on the wrong patient, and surgery or other invasive procedure performed on the wrong body part. The Department anticipates that this prohibition will take effect

on March !. 2012.

(1. GOVERNOR'S REVIEW (Check One):

_X _GOVERNOR’S OFFICE REPORTED NO COMMENT __COMMENTS OF GOVERNOR’S OFFICE ENCLOSED __NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER. AS SPECIFIED:

12 SIGNATURE OF STATE AGENCY OFFICIAL. 16. RETURN 10: Ts TYPENAME: Roderick L. Brembyf State of Connecticut Department of Social Services - 11" Noor 14. TITLE: Commissioner 25 Sigourney Street Hartford. CT 06106-5933 15 DATE SUBMITTED: Autention’ Ginny Muhoney September 30. 2011 FOR REGIONAL OFFICE USE ONLY 17, DATE RECEIVED: 18 DATE APPROVED: APR 08 2089

PLAN APPROVE!

— ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL:

-MAR 01 2012

20. SIGNs~ hens REGIONAL OFFICIAL:

21.

TYPED NAME: Amstiw LAN

22, TITLE?

/ FUG

~ Boxes Viel pen aud ink Changes per State Kg iwegt-

Attachment 4.19A Page 26

State: CONNECTICUT

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and

sections 1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider- preventable conditions.

Health Care-Acquired Conditions (HCACs)

The State identifies the following Health Care-Acquired Conditions for non-payment under Section 4.19 (A) of this State plan.

__X__ Hospital-Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non- payment under Section(s) 4.19(A).

X__ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

Additional Other Provider-Preventable Conditions identified below:

TIN #: 11-033 Approval Date: APR 08 2019 = Egvective Date 03/01/2012 Supersedes TN #: NEW

Attachment 4.19A Page 27

State: CONNECTICUT

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions

The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

In order to prevent payment to hospitals for the other provider preventable conditions, the Department requires hospitals to self report all of the following events: wrong surgical or other invasive procedure performed on a patient; surgical of other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

For hospital inpatient claims, the Department requires the use of diagnosis codes to identify those claims that fall into one of the three categories and the Department will deny any such claims.

Payment adjustment for hospital acquired conditions in a general acute care hospital subject to cost settlement is addressed on Attachment 4.19A, page 1(ii). All other hospitals are reimbursed under a per diem rate methodology and, to the extent that the cost of the hospital acquired condition can be isolated, payment for the cost of the hospital acquired condition will be denied.

Assurances

1. No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

2. Reductions in provider payment may be limited to the extent that the following apply: (i) The identified provider preventable conditions would otherwise result in an increase in payment; (ii) The State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

3. A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

TN #: 11-033 Approval Date:APR 08 2019 Effective Date 03/01/2012 Supersedes TN #: NEW

Attachment 4.19-B Page 25

State: CONNECTICUT

Citation

42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider- preventable conditions.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non- payment under Section(s) 4.19(B) .

—X__ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

Additional Other Provider-Preventable Conditions identified below:

Assurances 1. No reduction in payment for a provider preventable condition will be imposed ona provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

2. Reductions in provider payment may be limited to the extent that the following apply: (i) The identified provider preventable conditions would otherwise result in an increase in payment; (ii) The State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

3. A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

TN #: 11-033 Approval Date:_APR 08 2019 Effective Date 03/01/2012 Supersedes

TN #: NEW

Attachment 4,19-B Page 26

State: CONNECTICUT

Payment Adjustment for Provider Preventable Conditions

In order to prevent payments for the other provider preventable conditions, the Department requires providers to self report all of the following events: wrong surgical or other invasive procedure performed on a patient; surgical of other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient. A claim submitted with any of the modifiers or diagnosis codes for any of those three events will be denied.

TN #: 11-033 Approval Date:_APR 08 2015 Effective Date 03/01/2012 Supersedes TN #: NEW

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT 12-003 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

JFK Federal Building. Government Center Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES Boston. Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

March 5, 2012

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

Dear Commissioner Bremby:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 12-003 with an effective date of January 1, 2012, as requested by your Agency.

This proposed SPA transmitted an amendment to Connecticut’s approved Title XIX State plan to increase the standards for the optional State supplementary payment program by an amount equal to the SSI cost of living increase proposed by the Social Security Administration.

We reviewed this SPA for compliance with §1902(a)(73) of the Social Security Act, as added by §5006(e) of the American Recovery and Reinvestment Act of 2009, Public Law 111-5. This SPA was also reviewed in conjunction with provisions of the Affordable Care Act, Public Law 111-148.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257.

Sincerely, Ss

Richard R. McGreal Associate Regional Administrator

Enclosure

ce: Claudette J. Beaulieu, Deputy Commissioner Mark Schaefer, Director, Medical Care Administration Marc Shok, Adult Services Program Manager Stephen Markoski, Public Assistance Consultant

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL

1. TRANSMITTAL NUMBER:

2. STATE: CT 12-003

OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION

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

TO: REGIONAL ADMINISTRATOR 4.

HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HLIMAN SERVICES

PROPOSED EFFECTIVE DATE 1-]-12

3. TYPE OF STATE PLAN MATERIAL (Check One):

NEW STATE PLAN

AMENDMENT TO BE CONSIDERED AS NEW PLAN

X AMENDMENT

COMPLETE BLOCKS 6 THRU J0 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: Section 1902 (a) (10) (A) (ii) (XI) of the Social Security Act

7, FEDERAL BUDGET IMPACT: a FFY 2012 $ 0 b. FFY 2013 $ 0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT;

Supplement 6 to Atlachment 2.6-A: Addendum pages 1-3 to Supplement 6 to Attachment 2.6-A

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If applicable)

Supplement 6 to Attachment 2.6-A: Addendum pages 1-3 10 Supplement 6 to Atachment 2.6-A

SUBJECT OF AMENDMENT: Standards for Optional State Suppiementary Payments

GOVERNOR'S REVIEW (Check One):

—___GOVERNOR’S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

X_OTHER. AS SPECIFIED:

Comments. if any. to follow.

12. SIGNATURE OF STATE AGENCY OFFICIAT-

lIrcv or Ulaucene J. Beaulieu

TITLE: Deputy Commissioner

15. DATE SUBMITTED: January 6, 2012

16. RETURN TO:

State of Connecticut Department of Social Services 25 Sigourney Street

Hartford, CT 06106-5033 Attention: Stephen Markoski

FOR REGIONAL OFFICE USE ONLY

17. DATERECEIVED: 1/6/12 18. DATE APPROVED: 3/5/12 : PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: ] /]/]2 20 SIGNATURE OF REGI 4 21. TYP! AME: Rj 22, E:Associate Regional Administrator, Division of Medicaid and EDN Richard R. McGreal Children's Health Operations, Boston Regional Office 23. REMARKS:

FORM HCFA-179 (07-92)

Supplement 6 to

Attachment 2.6- A State CT Standards for Optional State Supplementary Payments. i 2 3 4 5 Payment Category | Administered by Income Level Income Level Income Disregards Employed (Reasonable Gross Net Classification) Federal State person couple | person couple For Aged, Blind or X | 300% 2x300% | See Addendum to | Same disregards as SSI Disabled: ofFBR of FBR | Supplement 6, Additional disregards: Individual Coupte* Attachment 2.6-A | Earned Income Independent Blind $20.00 $105.00 Level 1 Disabled - $65.00 Level 2 Uneamed Income New Horizons (Aged, Blind, Disabled) Domiciliary Independent and New Horizons Not sharing $282.00 - Sharing with unrelated person $349.90 - Sharing with related person $282.00 $584.00 Domiciliary $189.70 $399.40 *If both members of the couple are eligible Note: Income-in-kind is counted in the gross income test, but disregarded (except when provided for the performance of services) in determining benefit amount. TN# __12-003 Approval Date _3-5-12. Effective Date__4-1-12___

Supersedes TN#___09-001_

Addendum Page 1 to

Supplement 6 to Attachment 2.6- A State CT Net Income Level Maximums Standards of Assistance Optional State Supplement Living Arrangement Individual Couple Independent Level 1 $564.10 N/A Level 2 $365.10 $730.20 New Horizons Unshared $1,792.00 NIA Shared with unrelated $1,724.10 : NIA person Shared with related $1,792.00 $3,886.00, one person eligible member $3,584.00, two eligible members Domiciliary $1,884.30 $3,978.30, one eligible member $3,768.60, two eligible members

For independent living arrangements, the standard of assistance includes a fixed amount for personal needs of $164.10 for a single person, $165.10 for a married person living with his or her spouse and an allowance for shelter. The shelter component of the standard is the actual cost, as paid, up to the specific maximums of $400.00 for Level 1 and $200.00 for Level 2.

For the New Horizons living arrangement, the standard of assistance includes a fixed amount for personal needs of $130.40, and an allowance for the charge to the individual for shelter set by the Department in accordance with State law. The maximum standards of assistance for the New Horizons living arrangement are $1,7920.00, for an individual living alone or with a related person, $1,724.10 for an individual fiving with an unrelated person, $3,886.00 for a coupte with one eligible member, and $3,584.00 for a couple with two eligible members.

TN No. 12-003 Approval Date 3-5-12 Effective Date 4-1-12 Supersedes TN No. 09-001

Addendum Page 2 to Supplement 6 to Attachment 2.6- A

State CT

For domiciliary living arrangements, the standard includes a fixed amount for personal needs of $28.90, and an allowance for the charge to the individual for room and board set by the Department in accordance with State law. The maximum standards of assistance for domiciliary living arrangements are $1,884.30 for an individual, $3,978.30 for a coupte with one eligible member, and $3,768.60 for a couple with two eligible members.

These limits are the maximum standards, except in unusual circumstances where certain special needs are included in the need standard. These special needs are generally authorized on a non-recurrent basis. The eligibility requirements and limitations of the special needs are set forth in detail in the Uniform Policy Manual, Chapter 4525.

The following special needs have fixed amounts:

Meals on Wheels $4.43 per diem (1) meal per day $8.09 per diem (2) meals per day

Purchase of Essential Clothing; As described in Chapter 4500,

Purchase, Repair or Replacement Appendix | of the Uniform Policy

of Essential Household Items Manual

Restaurant and Congregate Meals $36.20 per mo. per person residing in permanent housing in the community $7.80 per day per person residing in emergency housing

Security Deposit - Heating Service Amount charged to the person up to a

maximum of $200.00 for equipment only

Telephone Installation Standard residential line service connection charge; one-time product charge for telephone rental up to a maximum of $5.00; cost of labor up to a maximum of $23.00; cost of one telephone jack, up to a maximum of $4.00

Therapeutic Diet $36.20 per month per person TN No. 12-003 Approval Date 3-5-12 Effective Date __1-1-12_ Supersedes

TN No. 9-001

Addendum Page 3 to Supplement 6 to Attachment 2.6- A

State __¢cT

The following special needs are included in the assistance standard as needed for individuals whose gross income does not exceed the limit, up to the allowable maximum standards of assistance based on living arrangement. The maximum standards of assistance, including the special needs component are $1,792.00 for an individual living alone or with a related person, $1,724.10 for an individual living with an unrelated person, $3,886.00 for a couple with one eligible member, and $3,584.00 for a couple with two eligible members:

Emergency Housing As described in Chapter 4500, Index 4525.05 page 3 of the Uniform Policy Manual.

Moving Expenses As described in Chapter 4500, Index 4525.15 page 2 of the Uniform Policy Manual.

Refuse Collection Fee As described in Chapter 4500, Index 4525.30 of the Uniform Policy Manual.

Storage Charges As described in Chapter 4500, index 4525.50 of the Uniform Policy Manual.

TN No. 12-003 Approval Date 3-5-12 Effective Date 4-1-12

Supersedes

TN No. 09-001

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT 12-009 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203 * CENTERS FOR A R MID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

December 17. 2012

Roderick Bremby. Commissioner Department of Social Services

25 Sigourney Street

Hartford. Connecticut 06106

Dear Mr. Bremby:

We are pleased to enclose a copy of approved Connecticut State Plan Amendment (SPA) No. 12-009. submitted to my office on March 30. 2012. This SPA transmitted a proposed amendment to Connecticut's approved Title XIX State Plan Attachments 2.2A, 2.6A. 3.1A, and 4.19B in order to establish a Family Planning Services coverage group pursuant to Section 2303 of the Patient Protection and Affordable Care Act.. P.L. 111-148. This new eligibility group will provide coverage for family planning and family planning-related services to individuals of child-bearing age who are not otherwise eligible for Medicaid and whose income does not exceed 250% of the federal poverty level. The Department will offer presumptive eligibility for this coverage group.

This SPA has been approved effective March 1, 2012. as requested by the State.

Changes are reflected in the following sections of your approved State Plan:

© Attachment 2.2A,. page 9d

e Attachment 2.2A. page 9e

e Supplement 8a to Attachment 2.6A, page 10

e Attachment 3.1 A, page 2 Attachment 4.19B, page 19 Attachment 4.19B, pagel (aji(D)

If you have any questions regarding this matter you may contact Marie Montemagno (617) 565- 9157 or by e-mail at Marie. Montemagno

Sincerely, Richard R. MeGreal

Associate Regional Administrator

ce: Kate McEvoy. Associate Director of Medical Administration - Health Services and Supports

GEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS OF MEOICARE & MEDICAID SERVICES FORM APPROVES oe (OMB KO 0938019)

TRANSMITTAL AND NOTICE OF APPROVAL OF |" ANSMITIAL NUMBER jamie STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES |3 PROGRAM IDENTIFICATION: TITLE XIX GF THE SOCIAL” SECURITY ACT (MEDICAID)

"TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES

4. PROPOSED EFFECTIVE DATE

03/01/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES 2 5. TYPE OF PLAN MATERIAL (Check One) LJ NEW STATE PLAN L) AMENDMENT TO BE CONSIDERED AS NEW PLAN &] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL. BUDGET IMPACT 1802((a)(10)(A)(ii)(XX1); 1902(u); 1920C, and 1905(a)(4)(C) of a.FFY201200 __ $546,840. the Social Security Act b. FFY 2013 _ $1,800,000.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDLD PI AN SECTION OR Al TACHMENT (/f Applicable) Attachment 2.2-A page 9(d) (NEW) Attachment 3.1-A page 2 Attachment 3.1-A page 2 Attachment 4.19B page 1(a)(i)(D) Attachment 4.19B page 1(a)(i)(D) Supplement page Ba to Ne ment 2.6A, page 10 (NEW)

10, SUBJECT OF AMENDMENT

The Department of Social Services is proposing to modify Attachments 2.2-A, 3.1-A and 4.19-B of the Connecticut Medicaid State Plan in order to establish a Family Planning Services coverage group pursuant to Section 2303 of the Patient Protection and Affordable Care Act., P.L. 111-148. This new eligibility group will provide coverage for family planning and family planning-related services to individuals of child-bearing age who are not otherwise eligible for Medicaid and whose income does not exceed 250% of the federal poverty level. The Department will offer presumptive eligiblity for this coverage group.

11, GOVERNOR'S REVIEW (Check One)

f) GOVERNOR'S OFFICE REPORTED NO COMMENT (OTHER, AS SPECIFIED (0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

42. SIGNATURE) OF STATE AGENCY,DFFICIAL 16. RETURN TO

State of Connecticut —____¥ * seed Department of Social Services 13. TYPED NAME )

a { 4 25 Sigourney Street Roderick L. Bremby __ free 4 Hartford, CT 06106-5033

44. TITLE ; Attention: Ginny Mahoney _Commissioner

“75. DATE SUBMITTED March 30, 2044 2012

_, _ FOR REGIONAL OFFICE USE ONLY __ “17. DATE RECEIVED | 18. DATE APPROVED {

March 30, 2012

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OB-REGIONAL OFFICIAL March 1, 2012 _ . = _ a

“24. TYPED NAME 22. TITLE Richard R, MeGreak Associate Regional Administrator “State approved pen and ink change to box 8 and 15 Div of Medicaid and Children’s Health Operations~— = ~*~

FORMS CMS-179 (07/92) Instructions of Back

American LegalNet, inc. were. USCourtForms.com

ATTACHMENT 2.2-A Page 9d

State: Connecticut

Citation

Groups Covered

B.

(1902(a)(10)(A)(ii(XX1) 1902(ii)

1920C

TN No.12-009_

Supersedes TN No.: NEW

Optional Groups Other Than the Medically Needy (cont'd)

EX] Individuals who are nor pregnant and whose income does not exceed the State established income standard of 250% of the Federal Poverty Level. This amount does not exceed the highest income limit for pregnant women in this State Plan. which is 250% of the Federal Poverty Level.

The State applies the income disregard listed on supplement 8A to Attachment 2.6-A.

Note: Services are limited to family planning services and family

. - cnt . planning-related services as described in section 4.c(ii) of Attachment 3.1-A.

Presumptive Eligibility for Family Planning:

The State provides a period of presumptive eligibility for family planning services to individuals determined by a qualified entity. based on preliminary information from the individual. described in the group the State has elected to make eligible under the above option. The period of presumptive cligibility ends on the earlier of the date a formal determination of Medicaid eligibility is made under 1902(a)(10)(A)Gii)(XX1). or. when no application has been filed. the last day of the month following the month during which the qualified entity determines the individual presumptively eligible.

Approval Date_ 1 >4 1a [1 Effective Date: March 1. 2012

ATTACHMENT 2.2-A Page 9¢

State: Connecticut

Citation Groups Covered

In addition to family planning services, the State covers family planning-related services to such individuals during the period of presumptive eligibility.

TN No.12-009 Approval Date \2)12) Vr Effective Date: March 1. 2012

Supersedes TN No.: NEW

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Citation

ATTACHMENT 3.1-A Page 2

State/Territory: Connecticut

AMOUNT. DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE

dia.

4.b

AND SERIVCES PROVIDED TO THE CATEGORICALLY NEEDY

Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.

Provided: X_ No limitations With limitations*

Early and period screening, diagnosis and treatment services for individuals under 21 years of age, and treatment of conditions found.*

1905(a)(4)(C) 4e.(i) Family planning services and supplies for individuals of child-bearing age and for

Individuals cligible pursuant to Att. 2.2-A, B, if this eligibility option is elected by the State.

Provided: X__ No limitations With limitations*

de.(ii) Family-planning related services provided under the above State Eligibility Option.

5.a Physicians’ services whether furnished in the office, the patient’s home, a hospital, a nursing facility or elsewhere. Provided: No limitations X_ With limitations*

3.b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act). Provided: No limitations X__ With limitations*

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law.

a. _ Podiatrists services. Provided: No limitations X__ With limitations* TN No.: 12-009 Approval Date_ 12/I2]ID— Ettective Date 3/01/2012

Supersedes TN No. 93-13

ATTACHMENT 4.19-B Page 19

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE/TERRITORY: CONNECTICUT

Methods and Standards lor Establishing Rates -Other types of Care

23. Pediatric and family nurse practitioners

Rates for cach procedure shall be set at 90% of the department's fees for physician procedure codes. The department's fees were set as of July 1. 2008 and are effective for services provided on or afier that date. Rates are published on the department's website at Connecticut Medical Assistance manual located at hutp:/Avww.ctdssmap.com.

TN No. 12-009 Approval Date b>] t 21> Effective Date 03/01/2012 Supersedes TN No. 08-002

Attachment 4.19B Page 1(a)i(D)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: CONNECTICUT

1. Cost Settlement Cost reports will be reconciled and settlements will occur within 24 months of the reporting period contained in the annual SBCH cost report. Connecticut will not madily the CMS-approved scope of casts. time study methodology or the annual cost report methodology without CMS approval. If it has been determined that an overpayment has been made. the Department of Social Services will return the federal share of the overpayment. If the actual. certified Medicaid allowable costs of a School Based Child Health Service Provider exceed the interim Medicaid rates. the Department of Social Services will submit claims to CMS for the underpayment. Cost settlement will occur within the timelines set forth in 42 CFR 433 Subpart F.

Audit

All supporting accounting and school records. statistical data and all other records related to the provision of School Based Child Health services paid for by the Department shall be subject to audit. If an audit discloses discrepancies in the accuracy and/or allowances of actual direct or indirect costs or statistical data as submitted for each fiscal year by the Local Educational Agency. the Department's payment rate for the said period shall be subject to adjustment.

Bo

(c) Family Planning services, drugs. supplies and devices when such services are under the supervision of a physician: outpatient hospital services. same as item (2): Federally Qualified Health Centers, same as item (2)(c): laboratory services. same as item (3): physician services. same as item (5): clinics, same as item (9): drug and supplies. same as item (12): nurse midwifes, same as item (17) and pediatric or family nurse practitioners. same as (23).

TN # 12-009 Approval Date |2{l2-||>- Effective Date 3-1-2012 Supersedes TN # 10-018

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT 12-010 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

wer sy

oo _. “a> “ CENTERS FOR MEDICARE & MEDICAID

Boston, Massachusetts 02203 :

ICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

January 2, 2013

Roderick Bremby. Commissioner Department of Social Services

25 Sigourney Street

Hartford, Connecticut 06106

Dear Mr. Bremby:

We are pleased to enclose a copy of approved Connecticut State Plan Amendment (SPA)

No. 12-010. submitted to my office on March 30, 2012. This SPA transmitted a proposed amendment to Connecticut's approved Tithe XIX State Plan Attachments 3.1A, 3.1B and 4.19B in order to revise the rcimoursement methodology for other practitioner services.

The Department proposed to revise the fee schedule for optometrists. chiropractors. psychologists. naturopaths, and Heensed behavioral health practitioners. These fees are based upon the physician fee schedule which will be recalculated based on reimbursement for the fee- for-service population and reimbursement for the population formerly covered under 1915(b) managed care waiver that terminated on December 31, 2011. Occupational therapist will be reimbursed according to the fee schedule for physical therapists. which will be amended to include two occupational therapy codes. In addition, DSS will add coverage of independent occupational therapisis for ind/viauals under 21 vears of age.

This SPA has been approved effective January |. 2012. as requested by the State.

Changes are reflecied in the foilowing sections of your approved State Plan: e@ Addendum page 4d to Atuicament 3.1A

achment 3.1A

nent 3.1B

e Addendum page 4d(i) te Attachment 3.1B

e Addendum page %b to Attachment 3.1A

e Addendum page 95(i) to Attachment 3.1

@ Addendum page Yt tachment 3.1B

@ Addendum page 9b) to Attachment 3.1B

e Attachment 4.19B page 1:

© Attachment 4.192 5

® Attachment 4.19P x: {

e Attachment 4./9B vage Hey

® Addenduin page 4dq) to 4

e Addendum page 4d to Atiach

Page 2 — Roderick L. Bremby, Commissioner

If you have any questions regarding this matter you may contact Marie Montemagno (617) 565- 9157 or by e-mail at Marie. Montemagno(@cms.hss.gov

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosures

cc: Kate McEvoy, Associate Director of Medical Administration - Health Services and Supports

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HPAL TH CARE FINANCING ADMINISTRATION OMB NO, 0938-0193 . 1. TRANSMITTAL NUMBER: as 2. STATE: CT TRANSMITTAL AND NOTICE OF APPROVAL 12-010 OF STATE PLAN MATERIAL 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: HEALTH CARE FINANCING ADMINISTRATION SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE: CENTERS FOR MEDICARE AND MEDICAID SERVICES 01-01-2012

DEPARTMENT OF HEALTH AND LIUMAN SERVICES 5. TYPE OF STATE PLAN MATERIAL (Check One):

___ NEW STATE PLAN ___AMENDMENT TO BE CONSIDERED AS NEW PLAN _X__ AMENDMENT

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

6. FEDERAL. STATUTE/REGULATION CITATION: 7, FEDERAL BUDGET IMPACT: Section 1905(a)(6) of the Sacial Security Act and a. FFY 2012 $ 6.2 million (costs) 42 CFR 440.60 b.FFY 2013 $ 9.3 million (costs)

8 PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:) 9. PAGE NUMBER OF THE SUPERSEDED PI.AN SECTION OR ATTACHMENT (If applicable)

Addendum Page 9b to Attachment 3.1-A and 3.1-B Addendum Page 9b to Attachment 3.1-A and 3.1-B Attachment 4.19B Page |(a)ii through }(a)iv Attachment 4.19B Page 1(a)ii through I(a)iv Attachment 4.19B Page le Attachment 4.19B Page Ie

SUBJECT OF AMENDMENT: The Department intends to modify Attachments 3.1A, 3.1B and 4.19-B of the Connecticut Medicaid State Plan in order to revise the reimbursement methodology for order to revise the reimbursement methodology for other practitioner services. In particular the Department will revise the fee schedule for optometrists, chiropractors, psychologists, naturopaths, and licensed behavioral health practitioners. These fees are based upon the physician fee schedule which will be recalculated based on reimbursement for the fee-for-service population and reimbursement for the population formerly covered under the 1915(b) managed care waiver that (enninates on December 31. 2011. Occupational therapists will be reimbursed according to the fee schedule for physical therapists, which will be amended to include two occupational therapy specific codes. In addition, DSS will add coverage of independent occupational therapists for individuals under 21 years of age. These change are expected to result in estimated federal costs of $6.2 million in FFY 12 and $9.3 million in FFY 13.

It. GOVERNOR'S REVIEW (Check One):

__GOVERNOR’S OFFICE REPORTED NO COMMENT _X_OTHER. AS SPECIFIED: __COMMENTS OF GOVERNOR'S OFFICE ENCLOSED “NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Commeats, if any, to follow.

2. SIGNATURE 16. RETURN TO:

OF STATE AGENCY OFBIC!

TYPED NAME: Roderick L. Bremby State of Connecticut

Department of Social Services - 11" floor

14. TITLE: Commissioner 25 Sigourney Street Hartford, CT 06106-5033 15. DATE SUBMITTED: Attention: Ginny Mahoney March 30, 2012

FOR REGIONAL OFFICE USE ONLY

17, DATERECEIVED: March 30, 2012 1g, DATEAPPROVED: ~ December 21, 2012

PLAN APPROVED - ONE COPY ATTACHED

GIONAL OFFIC

19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGN. January 1, 2012

1. TYPED NAME: Richard R. McGreal 22. TITLE: Associate Regional Administrator ’ Division of Medicaid and Children's Health Oper _

23. REMARKS:

FORM HCFA-179 (07-92)

’

Addendum Page 9b To Attachment 3.1-A State: CONNECTICUT

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY GROUP(S): ALL

11. Independent Therapies.

a. Physical Therapy

Physical therapists must meet the requirements of 42 CFR 440.110 and be licensed by the Connecticut Department of Public Health (DPH) after: (a) graduating from a school of physical therapy approved by the Connecticut Board of Examiners for Physical Therapists with the consent of DPH and passing the physical therapist examination administered by DPH or (b) without taking the DPH examination, if the individual is already licensed in another state or territory, any province of Canada, or any other country, if DPH finds those requirements equivalent or higher than Connecticut’s standards.

The Department will pay enrolled physical therapists only for services provided to individuals under twenty-one (21) years of age.

Services must meet the requirements of 42 CFR 440.110 and are limited to a physical therapist's scope of practice and services set forth in Sections 17b-262-630 through 640 of the Regulations of Connecticut State Agencies and the applicable published fee schedule.

b. Occupational Therapy

TN # 12-010 Supersedes TN # 09-013

i.

iii.

Occupational therapists must meet the requirements of 42 CFR 440.110 and be licensed by the Connecticut Department of Public Health (DPH): (a) after (i) attaining a bachelor’s degree and graduating from an educational program accredited by the American Occupational Therapy Association or education deemed equivalent by DPH, (ii) completing at least twenty-four weeks of supervised field work experience, and (iii) passing an exam prescribed by DPH or (b) without meeting the above requirements, if the individual is already licensed or certified as an occupational therapist in another state or other jurisdiction whose requirements for practice are substantially similar to Connecticut’s standards.

The Department will pay enrolled occupational therapists only for services provided to individuals under twenty-one (21) years of age.

Services must meet the requirements of 42 CFR 440.110 and are limited to an occupational therapist’s scope of practice and services set forth in

Approval Date Ja f2ip(>— Effective Date: 01-01-12

Addendum Page 9b(i) To Attachment 3.1-A

State: CONNECTICUT

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED CATEGORICALLY NEEDY GROUP(S): ALL

Section 17b-262-630 through 640 of the Regulations of Connecticut State Agencies and the applicable fee schedule.

TN # 12-010 Approval Date lo. \>1 | \>- Effective Date: 01-01-12 Supersedes

TN # 09-013

Addendum Page 9b To Attachment 3.1-B State: CONNECTICUT

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY GROUP(S): ALL

11. Independent Therapies.

a. Physical Therapy

Physical therapists must meet the requirements of 42 CFR 440.110 and be licensed by the Connecticut Department of Public Health (DPH) after: (a) graduating from a school of physical therapy approved by the Connecticut Board of Examiners for Physical Therapists with the consent of DPH and passing the physical therapist examination administered by DPH or (b) without taking the DPH examination, if the individual is already licensed in another state or territory, any province of Canada, or any other country, if DPH finds those requirements equivalent or higher than Connecticut’s standards.

The Department will pay enrolled physical therapists only for services provided to individuals under twenty-one (21) years of age.

Services must meet the requirements of 42 CFR 440.110 and are limited to a physical therapist's scope of practice and services set forth in Sections 17b-262-630 through 640 of the Regulations of Connecticut State Agencies and the applicable published fee schedule.

b. Occupational Therapy

TN # 12-010 Supersedes TN # 09-013

ii.

Occupational therapists must meet the requirements of 42 CFR 440.110 and be licensed by the Connecticut Department of Public Health (DPH): (a) after (i) attaining a bachelor’s degree and graduating from an educational program accredited by the American Occupational Therapy Association or education deemed equivalent by DPH, (ii) completing at least twenty-four weeks of supervised field work experience, and (iii) passing an exam prescribed by DPH or (b) without meeting the above requirements, if the individual is already licensed or certified as an occupational therapist in another state or other jurisdiction whose requirements for practice are substantially similar to Connecticut’s standards.

The Department will pay enrolled occupational therapists only for services provided to individuals under twenty-one (21) years of age.

Services must meet the requirements of 42 CFR 440.110 and are limited to an occupational therapist's scope of practice and services set forth in

Approval Date \2-J.21] la Effective Date: 01-01-12

Addendum Page 9b(i) To Attachment 3.1-B

State: CONNECTICUT

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED CATEGORICALLY NEEDY GROUP(S): ALL

Section 17b-262-630 through 640 of the Regulations of Connecticut State Agencies and the applicable fee schedule.

‘TN # 12-010 Approval Date \2\2\\\>~- Effective Date: 01-01-12 Supersedes TN # 09-013

Addendum Page 4d To Attachment 3.1-A State: CONNECTICUT

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED CATEGORICALLY NEEDY GROUP(S): ALL

h. Licensed Clinical Social Worker Services

i Clinical social workers must be licensed by the Connecticut Department of Public Health (DPH) (a) after (i) completing a doctorate or master’s degree in a social work program accredited by the Council on Social Work Education or a program outside the United States deemed equivalent by the Council on Social Work Education, (ii) complete 3,000 hours of post-master’s social work experience, including at least 100 hours under supervision by a licensed clinical or certified independent social worker, with such hours completed in Connecticut as a licensed master social worker, (iii) pass the clinical level examination of the Association of Social Work Boards or any other examination prescribed by DPH or (b) without meeting the — above requirements if the individual is licensed or certified as a clinical social worker in another jurisdiction whose requirements are substantially similar or higher than Connecticut’s requirements and who has also passed the clinical level examination of the Association of Social Work Boards or any examination prescribed by DPH.

ii The Department will pay enrolled licensed clinical social workers only for services provided to individuals under twenty-one (21) years of

age.

iii Services are provided under the benefit category of 42 C.F.R. § 440.60, other practitioners, and include routine diagnostic, assessment, treatment, rehabilitation or palliative services provided to individuals with a behavioral health disorder, within a licensed clinical social worker’s scope of practice and as set forth on the applicable published fee schedule.

i. Licensed Marital and Family Therapists Services

i Marital and family therapists must be licensed by the Connecticut Department of Public Health (DPH) (a) after (i) completing a graduate degree program in marital and family therapy from a regionally accredited college or university or an accredited postgraduate clinical training program approved by the Commission on Accreditation for Marriage and Family Therapy Education and recognized by the U.S.

TN# 12-010 Approval Date ala Effective Date: 01-01-12 Supersedes TN# 07-013

Addendum Page 4d(i) To Attachment 3.1-A State: CONNECTICUT

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY GROUP(S): ALL

TN# 12-010 Supersedes TN# 07-013

iii

Department of Education, (ii) completing a supervised practicum or internship with emphasis on marital and family therapy supervised by the program granting the degree or by an accredited postgraduate clinical training program approved by the Commission on Accreditation for Marriage and Family Therapy Education and recognized by the U.S. Department of Education with at least 500 clinical hours, including 100 hours of clinical supervision, (iii) complete at least twelve months of relevant postgraduate experience after being awarded a master’s or doctorate or the training specified in (ii) and including at least 1,000 hours of direct client contact offering marital and family therapy and 100 hours of postgraduate clinical supervision by a licensed marital and family therapy, and (iv) passed an examination prescribed by DPH or (b) without taking the examination if the individual is currently licensed or certified as a marital or marriage and family therapist in another jurisdiction whose standards, in DPH’s opinion, are equivalent to or higher than Connecticut's standards. However, an individual licensed or certified as a marital or marriage and family therapist in another jurisdiction whose standards are not equivalent to or higher than Connecticut's standards may substitute five years of licensed or certified work experience in the practice of marital and family therapy in lieu of the requirements of (a)(ii) and (iii) above.

The Department will pay enrolled licensed marital and family therapists only for services provided to individuals under twenty-one (21) years of age.

Services are provided under the benefit category of 42 C.F.R. § 440.60, other practitioners, and include routine diagnostic, assessment, treatment, rehabilitation or palliative services provided to individuals with a behavioral health disorder, within a licensed marital and family therapist’s scope of practice and as set forth on the applicable published fee schedule.

Approval Date __ |} \21 {a Effective Date: 01-01-12

Addendum Page 4d To Attachment 3.1-B State: CONNECTICUT

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED CATEGORICALLY NEEDY GROUP(S): ALL

h. Licensed Clinical Social Worker Services

i Clinical social workers must be licensed by the Connecticut Department of Public Health (DPH) (a) after (i) completing a doctorate or master’s degree in a social work program accredited by the Council on Social Work Education or a program outside the United States deemed equivalent by the Council on Social Work Education, (ii) complete 3,000 hours of post-master’s social work experience, including at least 100 hours under supervision by a licensed clinical or certified independent social worker, with such hours completed in Connecticut as a licensed master social worker, (iii) pass the clinical level examination of the Association of Social Work Boards or any other examination prescribed by DPH or (b) without meeting the above requirements if the individual is licensed or certified as a clinical social worker in another jurisdiction whose requirements are substantially similar or higher than Connecticut’s requirements and who has also passed the clinical level examination of the Association of Social Work Boards or any examination prescribed by DPH.

ii The Department will pay enrolled licensed clinical social workers only for services provided to individuals under twenty-one (21) years of age.

iii Services are provided under the benefit category of 42 C.F.R. § 440.60, other practitioners, and include routine diagnostic, assessment, treatment, rehabilitation or palliative services provided to individuals with a behavioral health disorder, within a licensed clinical social worker’s scope of practice and as set forth on the applicable published fee schedule.

i. Licensed Marital and Family Therapists Services

i Marital and family therapists must be licensed by the Connecticut Department of Public Health (DPH) (a) after (i) completing a graduate degree program in marital and family therapy from a regionally accredited college or university or an accredited postgraduate clinical training program approved by the Commission on Accreditation for Marriage and Family Therapy Education and recognized by the U.S.

TN# 12-010 Approval Date _ 12 Pal \\>- Effective Date: 01-01-12 Supersedes

TN# 07-013

Addendum Page 4d(i) To Attachment 3.1-B State: CONNECTICUT

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY GROUP(S): ALL

TN# 12-010

Supersedes TN# 07-013

Department of Education, (ii) completing a supervised practicum or internship with emphasis on marital and family therapy supervised by the program granting the degree or by an accredited postgraduate clinical training program approved by the Commission on Accreditation for Marriage and Family Therapy Education and recognized by the U.S. Department of Education with at least 500 clinical hours, including 100 hours of clinical supervision, (iii) complete at least twelve months of relevant postgraduate experience after being awarded a master’s or doctorate or the training specified in (ii) and including at least 1,000 hours of direct client contact offering marital and family therapy and 100 hours of postgraduate clinical supervision by a licensed marital and family therapy, and (iv) passed an examination prescribed by DPH or (b) without taking the examination if the individual is currently licensed or certified as a marital or marriage and family therapist in another jurisdiction whose standards, in DPH’s opinion, are equivalent to or higher than Connecticut's standards. However, an individual licensed or certified as a marital or marriage and family therapist in another jurisdiction whose standards are not equivalent to or higher than Connecticut’s standards may substitute five years of licensed or certified work experience in the practice of marital and family therapy in lieu of the requirements of (a)(ii) and (iii) above.

The Department will pay enrolled licensed marital and family therapists only for services provided to individuals under twenty-one (21) years of age.

Services are provided under the benefit category of 42 C.F.R. § 440.60, other practitioners, and include routine diagnostic, assessment, treatment, rehabilitation or palliative services provided to individuals with a behavioral health disorder, within a licensed marital and family therapist’s scope of practice and as set forth on the applicable published fee schedule.

Approval Date ijav\o- Effective Date: 01-01-12

Attachment 4.19B Page 1(a)ii

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Connecticut

(b) Optometrists — 90% of physician fees as referenced in (5) above. The fee schedule can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page go to “Provider,” then to “Provider Fee Schedule Download.” Rates are the same for private and governmental providers and are published at www.ctdssmap.com.

(c) Chiropractors — 100% of physician fees as referenced in (5) above. The current fee schedule was set as of January 1, 2012 and is effective for services provided on or after that date. The fee schedule for chiropractors can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: _www.ctdssmap.com. From this web page go to “Provider,” then to “Provider Fee Schedule Download.” Rates are the same for private and governmental providers and are

published at www.ctdssmap.com. (d) Other practitioners —

(i) Psychologists — The current fee schedule was set as of January 1, 2012 and is effective for services provided on or after that date. The fee schedule for psychologists can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: _www.ctdssmap.com. From this web page go to “Provider,” then to “Provider Fee Schedule Download.” Rates are the same for private and governmental providers and are published at www.ctdssmap.com.

TN # 12-010 Approval Date (>| 2.) ies Effective Date 01-01-2012 Supersedes TN # 10-020

Attachment 4.19B

Page I(a)iv

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Connecticut

(v)

(vi)

TN # 12-010 Supersedes TN # 09-013

Licensed behavioral health practitioners to include licensed clinical social workers, licensed marital and family therapists, licensed professional counselors, and licensed alcohol and drug counselors — not to exceed 75% of the Medicare physician fee schedule. The fee schedule for licensed behavioral health practitioners can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page go to “Provider,” then to “Provider Fee Schedule Download.” The agency’s rates were set as of January 1, 2012 and are effective for services on or after that date. Rates are the same for private and governmental providers and are published on the agency’s website.

Physician assistants — 100% of the department's fees for physicians. The fee schedule for physicians can be accessed and downloaded by going to the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page go to “Provider,” then to “Provider Fee Schedule Download.” The agency's rates were set as of January 1, 2012 and are effective for services on or after that date. Rates are the same for private and governmental providers and are published at www.ctdssmap.com.

Approval Date |2\2\ | 2 Effective Date 01-01-2012

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov Sample Template is below this line. Do not print the wording above this line. Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT 12-013 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

I I I DEPi\R I~ IE:\ I" OF HEt\LI I I & H U~ l 1\ :\ SEI\\"ICES Cenl~rs for i\ ledilMe & 1-.led ic,tid :X•JYin·s jr-K h~ dl' ral llu ild in ~, Govl·rnnwnl Ct•nt(•r f{oom 2275 Uoslon, t\ lass.Jchu!>Clls 02203 Division of Medicaid and Children's Health Operations/ Boston Hcgional Office Roderick Brcmhy. Commissioner Department or Social Services 25 Sigounu;y Street llartl"ord. Con n~cticut 06106 Dear i'vlr. Brcmby: Scpt~.:mber 21. 20 12 We are pleased to enclose a copy ul' appn1\'~d Co nn~c ti cut S tat~ Plan Amendment (SP /\)No. 12-013. submitlcd to my of'licc on.lunc 29.20 12. This SPA tran:mittcd a proposed amendment to Cunnccticut"s appro,·ed Titk XIX State Plan Allachmcnts 1.1 A. 3. 1 Band 4.1913 to establish methods and standards ror setting payment rates f(Jr birth ccn1cr services and other ambulmory services ofl'cred by a birth center and othen,·ise included in the f\ ledicaid State Plan. These changt:s are nceckd to comply with Section 2301 of' the Pati~nt Protection and AJ'I'ordablc Care Act. codilied at 42 U.S.C *~ 1390d(n)(2X) and 1396d(l)(3 ). \\hicll requi res states w provide ivleclicaid co,·cragc lor birth center scn·iccs and other nmbulatllr) sc rvic~s ol'fcrcd by a birth ccmer and otllcn\'isc incluck d in tiH.: Medicaid S t at~ Plan. This SP.t\ has been ~1ppro' eel c!Tcdivc April I. 2012. as rcqueslcd by tile Stall.:. Changes arc rclkctcd in the ft1llm' ing sections ol' your appru , ·~d State Plan: • Attachmcnt 3.1 A page 12 • /\ttachmcnt 3. 113. page I I • /\ ttachm~nt 4.1913. page 21 If you have any questions regarding Lhis matt~r you may contact i\tlaric Montcmagno (617) 5(>5- 91 57 or by c-t.nail at Maric.\·l(lntcnw!!nn·(, c1n ~. llss. !.!tn. Sincerely. /s/ Richard It 1 lcGrenl Asso ciat~ Regional .'\dministrator cc: Kate McLvoy. Associate Director or 1\•kJical J\dministration - llc<llth Services and Supports

lENT OF HEALTH AND HUMAN SERVICES OF MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITIAL NUMBER 12-013 2.STATE CT FORM APPRO\'fO OMS NO. 0938-<1193 FOR: CENTERS FOR MEDICA~ & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (CheCk One} 4. PROPOSED EFFECTIVE DATE 04/01/2012 ('8) NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 0AMENOMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION ,7. FEDERAL BUDGET IMPACT Section 2301 of the Patient Protection and Affordable Care Act a. FFY:::20::..:1:.::2'------ codified at 42 U.S.C. §§ 1396d(a)(28) and 1396d(l)(3) b. FFY2013 $20,000 (cost) $40.000 (cost) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 3.1 A page 12 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Appllcebfe) Attachment 3.1 B page 11 Attachment 3.1A page 12 Attachment 4.198 page 21 (New) Attachment 3. 1 B page 11 (New) 10. SUBJECT OF AMENDMENT The Department of Social Services will amend its Medicaid State Plan effective April1, 2012. Attachments 3.1-A, 3.1-8 and 4.19-8 \Viii be amended to establish methods and standards for setting payment rates for birth center services and other ambulatory services offered by a birth center and otherwise included in .the Medicaid State Plan. These changes are needed to comply with Section 2301 of the Patient Protection and Affordable Care Act, codified at 42 U.S.C. §§ 1396d(a)(28) and 1396d(J)(3), which requires states to provide Medicaid coverage for birth center services and other ambulatory services offered by a birth center and otherwise Included in the Medicaid State Plan. These statutory provisions require payments to licensed clinicians who perform services at a birth center to be excluded from the payments to the birth center. The Department's estimated federal fiscal impact for FFY 2012 and FFY 2013 has not yet been determined. 11. GOVERNOR'S REVIEW (Check On~) ~ GOVERNOR'S OFFICE REPORTED NO COMMENT 0 OTHER, AS SPECIFIED 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL OFFICIAL 14. TITLE Commissione.~ ----------------1 15. DATE SUBMITTED June 29. 2012 16. RETURN TO State of Connecticut Department of Social Services 25 Sigourney Street Hartford, CT 06106-5033 Attention: Ginny Mahoney FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 6/29112 21. TYPED NAME Richard R MCGreal 18. DATE APPROVED 9/21/12 22. TITLE Associate Regional Administrator Div. of Medicaid & Children's Health Operations FORMS CMS-179 (07192} Instructions of Back Amc rl~ L~Kcl,lnt. www.USCour1Fonnt.com

A TI ACHMENT 3.1 -A Page 12 State: CONNECTICUT AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED CATEGORICALLY NEEDY GROUP(S): ..ALb Freestanding Birth Center Services 28. (i) Licensed or Otherwise State-Approved Freestanding Birth Centers Provided: ~ No limitations L With limitations 0 None licensed or approved Please describe any limitations: 28. (ii) Licensed or Otherwise State-Recognized covered professionals providing services in the Freestanding Birth Center Provided: ~ No limitations 0 With limitations (please describe belo\v) 0 Not Applicable (there are no licensed or State approved Freestanding Birth Centers) Please describe any limitations: Please check all that apply: I2Q (a) Practitioners furnishing mandatory services described in another benefit category and otherwise covered under the State plan (i.e., physicians and certified nurse midwives). 0 (b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth center within the scope of practice under State law whose services are otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professional midwives (CPMs), and any other type of licensed midwife).* 0 (c) Other health care professionals licensed or othetwise recognized by the State to provide these birth attendant services (e.g., doulas, lactation consultant, etc.).* *For (b) and (c) above, please list and identify below each type of professional who will be providing birth center services: TN# 12-013 Supersedes TN#New Approval Date ql3\\~ Effective Date: 4/1/2012

ATTACHMENT3.1-B Page It State: CONNECTICUT AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): ALL Freestanding Birth Center Services 28. (i) Licensed or Otherwise State-Approved Freestanding Birth Centers Provided: ~ No limitations Q With limitations 0 None licensed or approved Please describe any limitations: 28. (ii) Licensed or Otherwise State-Recognized covered professionals providing services in the Freestanding Birth Center Provided: ~ No limitations 0 With limitations (please describe below) 0 Not Applicable (there are no licensed or State approved Freestanding Birth Centers) Please describe any limitations: Please check all that apply: ~ (a) Practitioners furnishing mandatory services described in another benefit category and otherwise covered under the State plan (i.e., physicians and certified nurse midwives) .. 0 (b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth center within the scope of practice under State law whose services are otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professional midwives (CPMs), and any other type of licensed midwife). • 0 (c) Other health care professionals licensed or otherwise recognized by the State to provide the~ birth attendant services (e.g., doulas, lactation consultant, etc.).* *For (b) and (c) above, please list and identify below each type of professional who will be providing birth center services: TN# 12-013 Supersedes TN#New Approval Date q,\~\(\~ Effective Date: 41112012

ATTACHMENT 4.1- B Page 21 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: CONNECTICUT METHODS AND STANDARDS FOR ESTABLISHING RATES 28. Freestanding Birth Center Senices Fixed fee schedule. The agency's rates were set as of April I, 2012 and are effective for services on or after that date. Rates are the same for private and governmental providers and are published at www.ctdssmap.com. Payment to the freestanding birth center excludes all services provided by licensed practitioners. The Department will reimburse licensed practitioners for services in accordance with the reimbursement methodology applicable to the licensed practitioner's provider type. TN# 12-013 Supersedes TN#New Approval Date Cl\ ~\ \ l Ql, Effective Date: 4/1/2012

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT 12-014 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CLAS JFK Federal Building, Government Center CENTERS for MEDICARE & MEDICAID SERVICES

Room 2275 Boston, Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

June 28, 2012

Roderick Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, Connecticut 06106

Dear Mr. Bremby:

We are pleased to enclose a copy of approved Connecticut State Plan Amendment (SPA) No. 12-014, submitted to my office on March 30, 2012. This SPA proposes to modify the Connecticut State Plan in order to comply with the Patient Protection and Affordable Care Act (Pub. L. 111-148. enacted on March 23, 2010). This section makes assurances regarding provider screening and enrollment in accordance with the CMS preprinted template. This SPA has been approved effective April Ist, 2012, as requested by the State.

Changes are reflected in the following sections of your approved State Plan: © Section 4.46, page 80 e Section 4.46. page 81 © Section 4.46, page 82

If you have any questions regarding this matter you may contact Marie Montemagno (617) 565- 9157 or by e-mail at Marie. Montemayno‘@cms.hss.gov

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

cc: Mark Schaefer, Director, Medical Care Administration

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS OF MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

1. TRANSMITTAL NUMBER 12-014

2. STATE CT

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

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE 04/01/2012

5. TYPE OF PLAN MATERIAL (Check One)

XJ NEW STATE PLAN (1 AMENDMENT TO BE CONSI

OERED AS NEW PLAN ( AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION Sections 1902(a)(77), 1902(a)(39) and 1902(kk) of the Social Security Act; P.L. 111-148 and P.L. 111-152

7. FEDERAL BUDGET IMPACT

a. FFY_2012 $46,000.00 costs

b. FFY_2013 $69,000.00 costs

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Section 4.46 (NEW)

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

10. SUBJECT OF AMENDMENT

The Department of Social Services is proposing to amend its Medicaid State Plan effective April 1, 2012 in order to comply

with the Patient Protection and Affordable Care Act (Pub. L. 1

11-148, enacted on March 23, 2010), This section makes

assurances regarding provider screening and enrollment in accordance with the CMS preprinted template.

11. GOVERNOR'S REVIEW (Check One) GOVERNOR'S OFFICE REPORTED NO COMMENT (1 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (J NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

(J OTHER, AS SPECIFIED

12, SIGNATURE OF STATE AGENCY OFFICIAL

13. FYPED NAME

___ Roderick L. Bre 14. TITLE

___ Commissioner 15. DATE SUBMITTED

16. RETURN TO State of Connecticut Department of Social Services 25 Sigourney Street Hartford, CT 06106-5033 Attention: Ginny Mahoney

March 30, 2012 Z FOR REGIONAL: OF;

FICE USE ONLY

17; DATE RECEIVED March 30; Cask 2

a5 AB. DATE APPROVED ~~

. June. 285 2012":

PLAN APPROVED - ON

E COPY ATTACHED

19. EFFECTIVE DATE OF F APPROVED MATERIAL April 14,2012

21, TYPED NAME ae Richard R..McGreal

“Associate Regiohal Administrator’

FORMS CMS-179 (07/92)

Division of Medicaid & Children's Health Operations

instructions of Back

American LogaiNot, lac, werw.USCourtForms.com

Page 80

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

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

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

42 CFR 455 Subpart E

42 CFR 455.410

42 CFR 455.412

42 CFR 455.414

42 CFR 455.416

42 CFR 455.420

State: CONNECTICUT

4.46 Provider Screening and Enrollment

The State Medicaid agency gives the following assurances:

PROVIDER SCREENING

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

ENROLLMENT AND SCREENING OF PROVIDERS X*_ Assures enrolled providers will be screened in accordance with 42 CFR 455.400 et seq.

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

VERIFICATION OF PROVIDER LICENSES

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

REVALIDATION OF ENROLLMENT X*_ Assures that providers will be revalidated regardless of provider type at least every 5 years.

TERMINATION OR DENIAL OF ENROLLMENT

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

REACTIVATION OF PROVIDER ENROLLMENT X_ Assures that any reactivation of a provider will include re-screening and payment of application fees as required by 42 CFR 455.460.

* Sce Implementation Plan attached to transmittal letter for implementation process on starred items.

YN#: 12-014 Supercedes TN#: NEW

Approval Date: 6/28/2012

Effective Date: 4/01/2012

Page 81

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

42 CFR 455.422

42 CFR 455.432

42 CFR 455.434

42 CFR 455.436

42 CFR 455.440

42 CFR 455.450

42 CFR 455.460

State: CONNECTICUT

APPFAL RIGHTS

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

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

CRIMINAL BACKGROUND CHECKS

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

FEDERAL DATABASE CHECKS

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

NATIONAL PROVIDER IDENTIFIER

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

SCREENING LEVELS FOR MEDICAID PROVIDERS

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

APPLICATION FEE

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

* See Implementation Plan attached to transmittal letter for implementation process on starred items.

TN#: 12-014 Supercedes TN#: NEW

Approval Date: 6/28/2012 Effective Date: 4/01/2012

Page 82 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: CONNECTICUT

42 CFR 455.470 TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PROVIDERS OR SUPPLIERS _X_ Assures that the State Medicaid agency complies with any temporary moratorium on the enrollment of new providers or provider types imposed by the Secretary under section 1866(j)(7) and 1902(kk)(4) of the Act, subject to any determination by the State and written notice to the Secretary that such a temporary moratorium would not adversely impact beneficiaries’ access to medical assistance.

TN#: 12-014 Approval Date: 6/28/2012 3 i : Superenies Effective Date: 4/01/2012

TN#: NEW

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT 12-015 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

November 21, 2012 Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street Hartford, CT 06106-5033

Dear Commissioner Bremby:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 12-015 with an effective date of January 1, 2012, as requested by your Agency.

This proposed SPA transmitted an amendment to Connecticut’s approved Title XIX State plan to

exclude the amount of the Connecticut Earned Income Tax Credit in determining Medicaid

eligibility for the eligibility groups specified in this SPA.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257. Sincerely,

/s/

Richard R. McGreal Associate Regional Administrator

Enclosure

ce: Claudette J. Beaulieu, Deputy Commissioner Marc Shok, Adult Services Program Manager Noeline Kay Randall, Public Assistance Consultant

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

TRANSMITTAL AND NOTICE OF APPROVAL

OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2, STATE: CT 12-015

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

TO: REGIONAL ADMINISTRATOR

HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HIIMAN SERVICES

4, PROPOSED EFFECTIVE DATE 1-1-12

5.

TYPE OF STATE PLAN MATERIAL (Check One):

___X___ NEW STATE PLAN

___AMENDMENT TO BE CONSIDERED AS NEW PLAN

__ AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1902(r )( 2) of the Social Security Act a. FFY 2013 $ None-see attached b FFY 2014 $ None-see attached

8.

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Supplement 8A to attachment 2.6A page 11 Supplement 12 to Attachment 2.6-A, page 3

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If applicable)

Supplement 12 to Attachment 2.6-A, page 3

10. SUBJECT OF AMENDMENT: Connecticut State Earned Income Tax Credit Exclusion

GOVERNOR’S REV1EW (Check One):

_x__GOVERNOR’S OFFICE REPORTED NO COMMENT

COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

~_NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL ,

__OTHER, AS SPECIFIED:

Comments, if any, to follow.

12.

SIGAJATURE OF STATE AGENCY OFFICIAL: /s/

16. RETURN TO:

13 TYPED Neer erate J. Beaulieu

State of Connecticut Department of Social Services

14. TITLE-Deputy Commissioner 25 Sigourney Street Hartford, CT 06106-5033 15. DATE SUBMITTED: Attention: Noeline Kay Randall 3/30/12

_ FOR REGIONAL OFFICE USE ONLY

17.

DATE RECEIVED: 3/30/12 ©

DATE APPROVED:

a _PLAN APPROVE

MW/2W12 =ONE cory ATTACHED

19.

EFFECTIVE DATE OF ‘APPROVED MATERIAL: WA/L2

; "90, "SIGNATURE OF: REGIONAL! OFF ICAL:

21.

TYPED NAME: Richard R. ‘McGreal - ss

ne 22. . TITLE: Associate Regional ‘Administrator, Division of Medicaid and

23.

REMARKS:

Children's 's Health Operations. Boston Regional Office

The State and CMS agreed to the following pen ‘and ink changes i in an email dated i0/a/ 12: - Added Supplement 12 to Attachment 2.6-A, page 3 to Box 8 and 9 to the Form 179. - Added parentheses in the last part of the citations of the Social Security Act on Supplement 8a to Attachment

2.6-A page I1; also added “Pregnant Women Only" after the I902@)LOXAYIDDS) citation on this page. FORM HUFA-179 (U7-92) Pe . : 3

Attachment 2.6-A Supplement 12 Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Connecticut ELIGIBILITY UNDER 1931 OF THE ACT

Dependent Child Earnings: Earned income of a dependent child who is a student, either part-time or full-time, is disregarded in determining eligibility.

Disregard of Awards: Financial awards received by a recipient for educational attendance, attaining certain grade levels, or attainment levels (e.g., increased reading level) is disregarded as income or as a resource in determining eligibility.

Gross Income Test: Eligibility is determined without regard to the 185 percent gross income test.

Earned Income Deductions: Deductions are allowed for employment expenses and day care costs. The amount allowed for employment expenses is $90 per month per employed person. The amount allowed for day care is the amount obligated up to a maximum of $200 for a child under age one and $175 for all others needing day care. Day care is allowed as a deduction whether paid by the family or by a state agency.

Income Disregard: Otherwise countable Income between the CNIL and the 185% of the federal poverty level is disregarded.

Increased Income Disregard: For families receiving benefits under section 1931, all income is disregarded for six months from the date the family would otherwise become ineligible provided the family has income at that time.

Increased Child Support Disregards: For families receiving benefits under section 1931 that do not have earned income and become otherwise ineligible due to increased child support payments, all income is disregarded for eight months from the date the family would otherwise become ineligible.

Census Income Disregard: All wages paid by the Census Bureau for temporary employment related to any decennial census activities are excluded.

Connecticut Earned Income Tax Credit: The Department will exclude this tax credit when determining eligibility.

Resource Methodologies

All resources are disregarded.

TN No.: _ 12-015 Approval Date _ 11/21/12 Effective Date:_1-1-12 Supercedes TN No.: 09-015

SUPPLEMENT 8A TO Attachment 2.6- A Page 11

State of __ Connecticut

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

METHODOLOGIES FOR TREATMENT OF INCOME THAT ARE LESS RESTRICTIVE THAN THOSE OF THE AFDC OR SSI PROGRAMS PURSUANT TO SECTION 1902(r)(2) OF THE ACT

X Section 1902(f) State ___Non-Section 1902(f) State

The Department will exclude the Connecticut Earned Income Tax Credit when determining eligibility for the following groups pursuant to Section 1902(r)(2) of the Social Security Act.

Qualified children and pregnant women under 1902(a)(10)(A)(i) (III)

Poverty level pregnant women and infants(133-185%FPL) under 1902(a) (10) (A)(i)(IV) Poverty level children aged 1 up to age 6 (133% FPL) under 1902(a)(10)(A)(i) (VI) Poverty level children aged 6 up to age 19 (100%FPL) under 1902(a)(10)(A)(i) (VII) Low Income Adults under 1902(a)(10)(A)(i) (VIII)

Family Planning under 1902(a)(10)(A) (ii) (XX!)

Optional categorically needy groups under 1902(a)(10)(A)(ii) as listed

IX ID< ID< I< I< I< DX

1902(a) (10) (A) (ii)(I)

1902(a) (10) (A) (ii)(II)

1902(a) (10) (A) (ii) (IV)

1902(a) (10) (A) (ii) (IX) - Pregnant Women Only 1902(a) (10) (A) (ii) (XIII)

1902(a) (10) (A) (ii) (XV)

1902(a) (10) (A) (ii) (XVI)

eoceeeee

Note: The Special Income Level group under 1902(a)(10)(A)(ii)(V), the individuals who would be eligible if in an institution Group under 1902(a)(10)(A)(ii)(VI) and the Hospice Group under 1902(a) (10) (A) (ii) (VII) cannot be included in this disregard.

X Medically needy under 1902(a)(10)(C)(i)(III) X_ All aged, blind or disabled groups in 209(b) states under 1802(f) X QMBs, SLMBs and Qls under 1905(p)

TN# 12-015 Approval Date 11/21/12 Effective Date 1-1-12 Supersedes: New

Table of Contents (Cover Page) for one PDF to post on Medicaid.gov

Sample Template is below this line. Do not print the wording above this line.

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: CT 12-022 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

RVICES

Division of Medicaid and Children's Health Gperations / Boston Regional Office

September 21, 2012

Roderick L. Bremby. Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

Dear Commissioner Bremby:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 12-022 with an effective date of May 1, 2012. as requested by your Agency.

This proposed SPA transmitted an amendment to Connecticut's approved ‘Title XIX State plan to disregard the cash surrender value of life insurance policies when the death benefits are assigned

to funeral homes to fund funeral home contracts.

If there are questions. please contact Robert Cruz. He can be reached at (617) 563-1257.

Sincerely. /s/ Richard R. MeGreal Associate Regional Administrator Enclosure ce: Claudette J. Beaulieu, Deputy Commissioner

Mare Shok Stephen Markoski

STMENT OD HAL SH AND HUMAN SERV! S OF MEDICARE AND Mi-DICAID SERVIC

TRANSMITTAL AND NOTICE OF APPROVAL

FORM APPROVEL OME NO 0938-0195

| TRANSMITTAL NUMBER 2. STATE: CT

12-022

OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

» PROGRAM IDENTIFICATION TITLE XU OF THE SOCIAL SECURITY ACT (MEDICAID)

TO. REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

PROPOSED EFFECTIVE DATE

S$ ivi OF STATE PLAN MA

TAE (Cheek Ones

CINEW STATE PLAN

[ AMFNDMFNI TO Bi CONSIDERED AS KEW PLAN

&S AME NDMENI

COMPLETE BLOCKS 6 THRU 10 1) THIS IS AN AMENOMENT

‘Separate Transinittal for cach amendmenyy

T FEDERAL STATUTE REGULATION CITATION ‘

Section 1902(r)2)

7 FEDLRAL BUDGE 7 IMPACT a FFY, 2013 s 0 > FFY___2014 $0

PAG! NUMBER OF TIL PLAN SECTION OR ATTACHMENT

Supplement 8b to Attachment 2.6-A Page 12 : H

VAGE NUMBER OF THE SUPERSI.DED PLAN SECTION OR ATTACHMENT (If applicables

9

10, SUBIECT OF AMENDMENT bh surrenaer value of

a funeral contract

Disregard the

Ife insurance pohcics when Geath eenetits are assignee to Junesal homes to fund

ii GOVERNOR'S REVIEW (Check Ones BJ GOVERNOR'S OFFICE REPORTED NO COMMENT (O COMMi NTS OF GOVERNOR'S OFFICE INC! OSP.D (No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

TT OTHER. AS SPECIEIND.

SIGNATURE OF STAT! AGENCY OFFICIAL

16 RETURN TO

State of Connecticus

W300 TYPED SAMS Deparment of Social Services Claudérte 1. Beaulieu 2* Steaumes Sucet Harttord, CT 06106-5033 wo THIET Depun Commissioner Attsntion: James Wo Starr 18. DATE SUBMIJ} 11 June 2%, 2042 FOR REGION AL OFFICE USE ONLY 1% DATERTCEIVED: 6/29/12 18 DATE APPROVED: 794/49 PLAN APPROVED - ONE COVY ATLACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SI TURY OF JONAL. 5/1/12 2). TYPEUNAME. Richard R. McGreal 9. TITLE: Associate Regional Administrator, Division of Medicaid and Children's Health Operations, Boston Reglonal Office 23. RLMARKS:

The State and CMS agreed to the following pen and ink changes in an email dated 9/6/12:

- Box 8 of the 179: changed 8a to 8b and page 11 to page 12

- On the Plan page itself, page 11 was changed to page 12 and the TN No at the bottom left was changed from 09-024 to 12-022

FORM CMS-179 (07/92)

OFFICIAL SUPPLEMENT 8b to ATTACHMENT 2.6-A

Page 12

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: CONNECTICUT

MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902 {r) (2) OF THE ACT

SS Section 1902 (f) State | = Non-Section 1902 (f State The more liberal resource methodologies described below apply to the following coverage groups. For individuals who are described in

1902{a)(10)(A)(ii){1) 4902(a){10}(A)(ii) (IV) 4902(a)(70)(A) iV) 4902(a)(40)(A)(ii)(VI) *902(a}(40)(A)(i){X) 41902(a)(10)(A)(ii)(X1) 4902(a)(1OMA)(1i)(XV) 1902(a)(10)(A)(1i)(XVE}

Disregard of the casn surrender value of life insurance policies when deatn benefit are assigned to funeral home to fund funeral contract.

TN No 12-022 Supersedes TN No N/A

Approval Date 9/21/12 Effective Date 5-1-12

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations / Boston Regional Office

May 9, 2013

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

Dear Commissioner Bremby:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 12-023 with an effective date of July 1, 2012, as requested by your Agency.

This proposed SPA transmitted an amendment to Connecticut’s approved Title XIX State plan to no longer count Aid and Attendance benefits as available income in determining eligibility for Medicaid.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosure

ce: Claudette J. Beaulieu, Deputy Commissioner Mare Shok Vanessa Soares Bowden

Revision: HCFA-PM-91-4 (BPD) Supplement 4TO ATTACHMENT 2.6-—A Page 1] OMB No.: —-0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: CONNECTICUT

METHODS FOR TREATMENT OF INCOME THAT DIFFER FROM THOSE OF THE SS] PROGRAM

(Section 1902 (f) more restrictive methods and criteria and State supplement criteria in SSI criteria State without section 1634 agreements and in section 1902 (f) States. Use to reflect more liberal methods only if you limit to State supplement recipients. DO NOT USE this supplement to reflect more liberal policies that you elect under the authority of section 1902 (r) (2) of the Act. Use Supplement 8a for section 1902 (r) (2) methods.)

1. Home Equity Conversion Plans are countable income if there are no repayment agreements.

2. Allowances for Unusual Medical Expenses from the Veteran’s Administration are countable income.

TN No. 12-023 Supersedes Approval Date TN No. 96-005

5/9/13 Effective Date. 7/1/2012

/s/

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 13-019 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

/s/

/s/ /s/

Revision: ATTACHMENT 2.2-A Page 9b3

State: CONNECTICUT

Agency* Citation(s) Groups Covered

A. Mandatory Coverage — Categorically Needy and Other Required Special Groups (Continued)

1902(a)(10)(A)(i)(VINI) 29. State Option to Provide Coverage to 1902(k)(2) the Lowest Income Population the Becomes Mandatory in 2014.

Individuals who are under 65 years of age, not pregnant, not entitled to, or enrolled for, benefits under Part A of title XVII, or enrolled for benefits under Part B of title XVIII, and not described in 1902(a)(10)(A)(i)(I) through 1902(a)(10)(A)(i)(VII) of the Act.

_X_ The agency elects to make individuals described above eligible under the early option set forth in section 1902(k)(2) of the Act. The effective date for coverage of this group under the early option is April 1, 2010 (cannot be earlier than April 1, 2010).

The Income Standard applicable to individuals eligible under this early option is 53% of FPL

(cannot exceed 133 percent of FPL).

NOTE: No resource test is applicable to this group.

TN No. 13-019 Approval Date 6-19-13 Effective Date 3-1-2013

Supersedes TN No. 12-016

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 13-042 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

/s/

/s/ /s/

Revision: ATTACHMENT 2.2-A Page 9b3

State: CONNECTICUT

Agency* Citation(s) Groups Covered

A. Mandatory Coverage — Categorically Needy and Other Required Special Groups (Continued)

1902(a)(10)(A){i)(VIN) 29. State Option to Provide Coverage to 1902(k)(2) the Lowest Income Population the Becomes Mandatory in 2014.

individuals who are under 65 years of age, not pregnant, not entitled to, or enrolled for, benefits under Part A of title XVII|, or enrolled for benefits under Part B of title XVIIl, and not described in 1902(a)(10)(A)(i)(I) through 1902(a)(10)(A)(i)(VI) of the Act.

_X_ The agency elects to make individuals described above eligible under the early option set forth in section 1902(k)(2) of the Act. The effective date for coverage of this group under the early option is April 1, 2010 (cannot be earlier than April 1, 2010).

The Income Standard applicable to individuals eligible under this early option is 54% of FPL

(cannot exceed 133 percent of FPL).

NOTE: No resource test is applicable to this group.

TN No. 13-042 Approval Date__11/12/1 Effective Date 7-1-2013

Supersedes TN No. 13-019

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 13-043 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

/s/

/s/ /s/

Addendum Page 2 to Supplement 6 to Attachment 2.6- A

State Connecticut

For domiciliary living arrangements, the standard includes a fixed amount for personal needs of $29.51 and an allowance for the charge to the individual for room and board set by the Department in accordance with State law. The maximum standards of assistance for domiciliary living arrangements are $1,908.30 for an individual, $4,038.30 for a couple with one eligible member, and $3,816.60 for a couple with two eligible members.

These limits are the maximum standards, except in unusual circumstances where certain special needs are included in the need standard. These special needs are generally authorized on a non-recurrent basis. The eligibility requirements and limitations of the special needs are set forth in detail in the Uniform Policy Manual, Chapter 4525.

The following special needs have fixed amounts:

Meals on Wheels $4.43 per diem (1) meal per day $8.09 per diem (2) meals per day

Purchase of Essential Clothing; As described in Chapter 4500,

Purchase, Repair or Replacement Appendix | of the Uniform Policy

of Essential Household Items Manual

Restaurant and Congregate Meals $36.20 per mo. per person residing in

permanent housing in the community

$7.80 per day per person residing in emergency housing

Security Deposit - Heating Service Amount charged to the person up to a maximum of $200.00 for equipment only

Telephone Installation Standard residential line service connection charge; one-time product charge for telephone rental up to a maximum of $5.00; cost of labor up to a maximum of $23.00; cost of one telephone jack, up to a maximum of $4.00

Therapeutic Diet $36.20 per month per person

11/12/13 ‘ TN No. 13-043 Approval Date Effective Date 7-1-13 Supersedes

TN No. 13-017

Addendum Page 1 to SUPPLEMENT 6 TO

Attachment 2.6- A State CT

Net Income Level Maximums Standards of Assistance Optional State Supplement

Living Arrangement Individual Couple Independent Level 1 $567.55 n/a Level 2 $368.57 $737.14 New Horizons Unshared $1,816.00 N/A Shared with unrelated $1,748.10 N/A person Shared with related $1,816.00 $3,946.00, one person eligible member $3,632.00, two eligible members Domiciliary $1,908.30 $4,038.30, one

eligible member

$3,816.60, two eligible members

For independent living arrangements, the standard of assistance includes a fixed amount for personal needs of $167.55 for a single person, $168.57 for a married person living with his or her spouse and an

allowance for shelter. The shelter component of the standard is the actual cost, as paid, up to the specific maximums of $400.00 for Level 1 and $200.00 for Level 2.

For the New Horizons living arrangement, the standard of assistance includes a fixed amount for personal needs of $133.14, and an allowance for the charge to the individual for shelter set by the Department in accordance with State law. The maximum standards of assistance for the New Horizons living arrangement are $1,816.00, for an individual living alone or with a related person, $1,748.10 for an

individual living with an unrelated person, $3,946.00 for a couple with one eligible member, and $3,632.00 for a couple with two eligible members.

TN#__ 13-043 Approval Date TM2n3 Supersedes TN# __ 13-017

Effective Date __7-1-13

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 14-0001MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

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

JFK Federal Building, Government Center

Room 2275

Boston. Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES.

Division of Medicaid and Children's Health Operations / Boston Regional Office

June 11, 2014

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

Dear Commissioner Bremby: We are pleased to enclose a copy of approved State plan amendment (SPA) No. 14-0001MMI1 with an effective date of January 1, 2014, as requested by your Agency. This SPA incorporates

the MAGI-Based Eligibility Groups into Connecticut’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosure ce:

Raymond Singleton Jr., Deputy Commissioner Marc Shok, Adult Services Program Manager

State/Territory name: Connecticut Submitted By: Marc Shok Last Revision Date: Jun 6, 2014 Submit Date: Dec 18, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-001 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Affordable Care Act; 42 CFR Part 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment MAGI-Based Eligibility Groups Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 CT.0622.R00.00 - Jan 01, 2014 06/12/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp Date Received: 12/18/13 Effective Date of Approved Materials: 1/1/14 Typed Name: Richard R. McGreal Plan Approved - One Copy Attached Date Approved: 6/11/14 Signature of Regional Official: Division of Medicaid and Children's Health Operations, Boston Regional Office /s/

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

14-0001MM1

STATE:

Connecticut

Pages or sections of pages being superseded by S25, S28, S30, S32, S51, S52, S53, S54, S55, S57, S59 and S14 and related pages or sections of pages being deleted as obsolete

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

Page 1 Page 3 Page 3a Page 4 Page 4a Page 9b3 Page 9b4 Page 9d Page 9e Page 12 Page 13 Page 13a Page 14 Page 14a Page 23 Page 23b Page 23e (from TN 04-010)

Page 2, A.2.b Page 2, A.2.c Page 2a, A.3 Page 5, A.10 Page 9c, B.1 remove “Caretaker relatives” and “Pregnant women” Page 20, B.14 Page 23c, B.20 Page 23c, B.22 Page 25, C.4

Supplement 1 to Attachment 2.2-A

Page 1

Attachment 2.6-A

Page 3b Page 11a Page 19 Page 19a Page 19b Page 21

Page 1, A.2.a(i) and (iii) Page 6 related to AFDC recipients, pregnant women, infants, and children Page 7, 1.a(1) and (2) Page 12, C.1.e(2) Page 18, 5.e Page 25, 11.a(3)

Supplement 1 to Attachment 2.6-A

Pages 1, 2, 2a, 3

Supplement 2 to Attachment 2.6-A

Pages 1-5

2

Supplement 8a to Attachment 2.6-A

Page 1 Page 2 Page 3 Page 5 Page 6 Page 7 Page 10

Page 8, delete all of the AFDC-related group references Page 11, delete all of the AFDC-related group references Supplement 8b to Attachment 2.6-A

Page 5

Page 7, delete adopted individuals and Independent foster care adolescents

Supplement 12 to Attachment 2.6-A

Pages 1-5 Addendum

Supplement 14 to Attachment 2.6-A Page 1

Page 1 of 8 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Region A Description Regions are based on cost of living. Household size Standard ($) + 1 470 x + 2 604 x + 3 751 x + 4 881 x + 5 1,001 x + 6 1,124 x + 7 1,255 x + 8 1,383 x TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S14-1 Effective Date: 1/1/14

Page 2 of 8 Medicaid Eligibility + 9 1,493 x + 10 1,631 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region Region B Description Regions are based on cost of living. Household size Standard ($) + 1 397 x + 2 530 x + 3 653 x + 4 772 x + 5 887 x + 6 1,007 x + 7 1,135 x + 8 1,257 x + 9 1,365 x + 10 1,492 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region Region C Description Regions are based on cost of living. Household size Standard ($) + 1 397 x + 2 530 x TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S14-2 Effective Date: 1/1/14

Page 3 of 8 Medicaid Eligibility + 3 646 x + 4 756 x + 5 866 x + 6 984 x + 7 1,107 x + 8 1,227 x + 9 1,336 x + 10 1,480 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Region A Description Regions are based on cost of living. Household size Standard ($) TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S14-3 Effective Date: 1/1/14

Page 4 of 8 Medicaid Eligibility + 1 402 x + 2 513 x + 3 636 x + 4 741 x + 5 835 x + 6 935 x + 7 1,040 x + 8 1,143 x + 9 1,228 x + 10 1,341 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region Region B Description Regions are based on cost of living. Household size Standard ($) + 1 333 x + 2 443 x + 3 543 x + 4 639 x + 5 731 x + 6 827 x + 7 933 x + 8 1,031 x + 9 1,116 x TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S14-4 Effective Date: 1/1/14

Page 5 of 8 Medicaid Eligibility + 10 1,220 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region Region C Description Regions are based on cost of living. Household size Standard ($) + 1 333 x + 2 443 x + 3 536 x + 4 622 x + 5 708 x + 6 805 x + 7 904 x + 8 1,001 x + 9 1,086 x + 10 1,209 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S14-5 Effective Date: 1/1/14

Page 6 of 8 Medicaid Eligibility Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S14-6 Effective Date: 1/1/14

Page 7 of 8 Medicaid Eligibility Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S14-7 Effective Date: 1/1/14

Page 8 of 8 Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S14-8 Effective Date: 1/1/14

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives S25 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. ■ The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative (select any that apply): The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. Definition of domestic partner: The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: great grandparent, great great grandparent great aunt or uncle, great great aunt or uncle half siblings half siblings of either parents (equivalent of aunt or uncle) Legal guardian Individual who has applied for legal guardianship Partners in same-sex civil unions established in states that recognize civil unions The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. Options relating to the definition of dependent child (select the one that applies): TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S25-1 Effective Date: 1/1/14

Page 2 of 4 Medicaid Eligibility The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard ■ The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S25-2 Effective Date: 1/1/14

Page 3 of 4 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other dollar amount % 198 Income standard chosen: ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. Another income standard in-between the minimum and maximum standards allowed The state's AFDC payment standard in effect as of July 16, 1996, not converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, not converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other income standard in-between the minimum and the maximum standards allowed. The amount of the income standard for this eligibility group is: A percentage of the federal poverty level: A dollar amount % 196 There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S25-3 Effective Date: 1/1/14

Page 4 of 4 Medicaid Eligibility Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S25-4 Effective Date: 1/1/14

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Pregnant Women S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I), (IV) and (IX) 1931(b) and (d) 1920 Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. ■ Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. Yes No MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 185 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S28-1 Effective Date: 1/1/14

Page 2 of 4 Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL The amount of the maximum income standard is: 258 % FPL Income standard chosen ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard Another income standard in-between the minimum and maximum standards allowed. There is no resource test for this eligibility group. ■ Benefits for individuals in this eligibility group consist of the following: ■ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. Presumptive Eligibility ■ The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes No The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. There may be no more than one period of presumptive eligibility per pregnancy. ■ A written application must be signed by the applicant or representative. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S28-2 Effective Date: 1/1/14

Page 3 of 4 Medicaid Eligibility Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: ■ The woman must be pregnant ■ Household income must not exceed the applicable income standard at 42 CFR 435.116. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. ■ List of Qualified Entities S17 A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan 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 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 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 Affairs Is a 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 Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S28-3 Effective Date: 1/1/14

Page 4 of 4 Medicaid Eligibility 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 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description + An entity that receives funds under one of the following: the Migrant Health Centers, Community Health Centers, or Public Health Service primary care research and demonstration projects (see §329, 330 and 340 of the Public Health Service Act) x + An entity that receives funds under othe Maternal and Child Health Services Block Grant Program (see Title V of the Social Security Act); x + An entity that participates in a program established under the Commodity Supplemental Food Program (see §4(a) of the Agriculture and Consumer Protection Act of 1973) x + An entity that participates in a State perinatal program x The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included. ✔ 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 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S28-4 Effective Date: 1/1/14

Page 1 of 8 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 185 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S30-1 Effective Date: 1/1/14

Page 2 of 8 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Enter the amount of the maximum income standard: 196 % FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age one through age five, inclusive ■ Minimum income standard ■ TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S30-2 Effective Date: 1/1/14

Page 3 of 8 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 196 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S30-3 Effective Date: 1/1/14

Page 4 of 8 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Enter the amount of the maximum income standard: 196 % FPL Income standard chosen ■ TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S30-4 Effective Date: 1/1/14

Page 5 of 8 Medicaid Eligibility The state's income standard used for children age six through eighteen is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No Presumptive Eligibility for Children S16 1902(a)(47) 1920A 42 CFR 435.1101 42 CFR 435.1102 The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions: ■ TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S30-5 Effective Date: 1/1/14

Page 6 of 8 Medicaid Eligibility If the state has elected to cover Optional Targeted Low-Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR 435.118), for that child’s age. If the state has not elected to cover Optional Targeted Low Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child’s age. Children under the following age may be determined presumptively eligible: ■ Under age 19 The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: Name of limitation Description + No more than two periods within a calendar year. x The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: ■ Household income must not exceed the applicable income standard described above, for the child's age. ■ State residency Citizenship, status as a national, or satisfactory immigration status TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S30-6 Effective Date: 1/1/14

Page 7 of 8 Medicaid Eligibility The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. ■ List of Qualified Entities S17 A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan 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 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 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 Affairs Is a 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 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 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description + Any other entity approved by the Secretary of Health and Human Services at the request of the Commecticut Department of Social Services x TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S30-7 Effective Date: 1/1/14

Page 8 of 8 Medicaid Eligibility The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training 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 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S30-8 Effective Date: 1/1/14

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. ■ The state attests that it operates this eligibility group under the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under age 26. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ■ Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. ■ The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S33-1 Effective Date: 1/1/14

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals above 133% FPL S50 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S50-1 Effective Date: 1/1/14

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives S51 42 CFR 435.220 1902(a)(10)(A)(ii)(I) Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S51-1 Effective Date: 1/1/14

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 S52 42 CFR 435.222 1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S52-1 Effective Date: 1/1/14

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ■ Are under the following age (see the Guidance for restrictions on the selection of an age): ■ Under age 21 Under age 20 Under age 19 Under age 18 MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. ■ The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S53-1 Effective Date: 1/1/14

Page 2 of 2 Medicaid Eligibility No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this eligibility group under (check all that apply): ■ The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age: This eligibility group does not use an income test (all income is disregarded). There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S53-2 Effective Date: 1/1/14

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Targeted Low Income Children S54 1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S54-1 Effective Date: 1/1/14

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis S55 1902(a)(10)(A)(ii)(XII) 1902(z) Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are infected with tuberculosis. ■ Are not otherwise eligible for mandatory coverage under the Medicaid state plan. ■ Have household income under a standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Maximum income standard ■ First indicate the maximum income standard that could be used for this group and then indicate the income standard the state uses for the group. The state elects to convert the effective income level for coverage of this eligibility group in effect in the Medicaid state plan as of March 23, 2010 and December 31, 2013 to MAGI-equivalent standards. Yes No The state's maximum income standard for this eligibility group is: The break-even point for earned income under the SSI program. The effective income level for this eligibility group under the Medicaid state plan in effect as of March 23, 2010, not converted to a MAGI-equivalent standard. The effective income level for this eligibility group under the Medicaid state plan in effect as of December 31, 2013, not converted to a MAGI-equivalent standard. The amount of the maximum income standard for this eligibility group is: A percentage of the federal poverty level: A dollar amount % Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S55-1 Effective Date: 1/1/14

Page 2 of 3 Medicaid Eligibility Standard varies by living arrangement Standard varies in some other way Enter the standard by some other way Remove Name Description Disregard all income for all household members. Household size Standard ($) + 1 x Additional incremental amount Yes No Increment amount $ Add The dollar amounts increase automatically each year Yes No Income standard chosen ■ The state's income standard used for this eligibility group is: The maximum income standard. If not chosen as the maximum income standard, the break-even point for earned income under the SSI program. Another income standard less than the maximum standard allowed. Individuals qualifying under this group are eligible only for the following services, provided the service is related to the diagnosis, treatment or management of the individual's tuberculosis. ■ Prescribed drugs, described in 42 CFR 440.120 ■ Physician services, described in 42 CFR 440.50 ■ Outpatient hospital and rural health clinic described in 42 CFR 440.20 and Federally-qualified health center services ■ Laboratory and x-ray services (including services to confirm the presence of the infection), described in 42 CFR 440.30 ■ Clinic services, described in 42 CFR 440.90 ■ Case management services defined in 42 CFR 440.169 ■ Services other than room and board designed to encourage completion of regimens of prescribed drugs by out-patients, including services to observe directly the intake of prescription drugs. ■ Limitations related to tuberculosis-related services may be found in the Benefits section. ■ PRA Disclosure Statement TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S55-2 Effective Date: 1/1/14

Page 3 of 3 Medicaid Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 S55-3 Effective Date: 1/1/14

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents S57 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under the following age ■ Under age 21 Under age 20 Under age 19 Were in foster care under the responsibility of a state on their 18th birthday. ■ Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. ■ Have household income at or below a standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013): ■ All children under the age selected A reasonable classification of children under the age selected: Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

Page 2 of 2 Medicaid Eligibility Maximum income standard ■ No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this eligibility group under (check all that apply): ■ The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 demonstration as of March 23, 2010. A Medicaid 1115 demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard: This eligibility group does not use an income test (all income is disregarded). There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services S59 1902(a)(10)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ The individual may be a male or a female. ■ Income standard used for this group ■ Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is the highest of the following: The state's current effective income level for the Pregnant Women eligibility group (42 CFR 435.116) under the Medicaid state plan. The state's current effective income level for pregnant women under a Medicaid 1115 demonstration. The state's current effective income level for Targeted Low-Income Pregnant Women under the CHIP state plan. The state's current effective income level for pregnant women under a CHIP 1115 demonstration. The amount of the maximum income standard is: 258 % FPL Income standard chosen ■ The state's income standard used for this eligibility group is: The maximum income standard Another income standard less than the maximum standard allowed. MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

Page 2 of 4 Medicaid Eligibility In determining eligibility for this group, the state uses the following household size: ■ All of the members of the family are included in the household Only the applicant is included in the household The state increases the household size by one In determining eligibility for this group, the state uses the following income methodology: ■ The state considers the income of the applicant and all legally responsible household members (using MAGI-based methodology). The state considers only the income of the applicant. Benefits for this eligibility group are limited to family planning and related services described in the Benefit section. ■ Presumptive Eligibility ■ The state makes family planning services and supplies available to individuals covered under this group when determined presumptively eligible by a qualified entity. Yes No The state also covers medical diagnosis and treatment services that are provided in conjunction with a family planning service in a family planning setting during the presumptive eligibility period. Yes No The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: Name of limitation Description + No more than two periods in a calendar year. x TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

Page 3 of 4 Medicaid Eligibility The state requires that a written application be signed by the applicant or representative. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: ■ The individual must not be pregnant. ■ Household income must not exceed the applicable income standard specified for this group. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state uses entities, as defined in section 1920C, to determine eligibility presumptively for this eligibility group. These entities must be eligible to receive payment for services under the state's approved Medicaid state plan and determined by the state to be capable of determining presumptive eligibility for this group. ■ The types of entities used to determine presumptive eligibility for this eligibility group are: Name of entity Description + Entities that provides services of the type provided by: (a) outpatient hospitals (§1905(a)(2) (A)); (b) rural health clinics (§1905(a)(2)(B)); or (c) clinics furnished by, or under, the direction of a physician (§1905(a) (9)) x + Entities that receives funds under the Migrant Health Centers, Community Health Centers, or Public Health Service primary care research and demonstration projects (see §329, 330 and 340 of the Public Health Service Act). x + Entities that receives funds underthe Maternal and Child Health Services Block Grant Program (see Title V of the Social Security Act). x + Entities that receives funds under the Urban Indian Health Program (see Title V of the Indian Health Care Improvement Act) x TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

Page 4 of 4 Medicaid Eligibility Name of entity Description + Entities that participate in a program established under the Special Supplemental Food Program for Women, Infants and Children (see §17 of the Child Nutrition Act of 1966). x + Entities that participate in a program established under the Commodity Supplemental Food Program (see §4(a) of the Agriculture and Consumer Protection Act of 1973). x + Entities that participate in a program established under the Indian Health Service or a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act. x + Entities that participate in a State perinatal program. x The state assures that it has communicated the requirements for entities, at 1920C of the Act, and has 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 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20131009 TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

FORM HCFA-179 (07-92)

INDIVIDUALS ELIGIBLE FOR FAMILY PLANNING SERVICES (Attachment to S59)

TRANSMITTAL NUMBER: 14-001

STATE:

Connecticut

The state is covering the following categorical population listed under section 1902(a)(10)(A)(ii)(XXI) of the Social Security Act and 42 CFR 435.214: Individuals described in clause (i) of 1905(a) (i.e., individuals under age 21).

The elections made in S59 apply to the group covering individuals under age 21 who also are described in section 1902(ii) except that, in determining eligibility for this group, the state considers only the income of the applicant.

TN No. 14-0001MM1 Approval Date: 6/11/14 Effective Date: 1/1/14 Connecticut

TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

/s/

TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14

TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14 population/type citation unit size original standard converted standard AFDC 5/1/1988 (region A) AFDC 5/1/1988 (region A) 1 $381 $470 2 $485 $604 3 $601 $751 4 $701 $881 5 $790 $1,001 6 $883 $1,124 7 $983 $1,255 8 $1,080 $1,383 9 $1,160 $1,493 10 $1,267 $1,631 addon N/A N/A AFDC 5/1/1988 (region B) AFDC 5/1/1988 (region B) 1 $315 $397 2 $419 $530 3 $514 $653 4 $604 $772 5 $691 $887 6 $782 $1,007 7 $882 $1,135 8 $975 $1,257 9 $1,055 $1,365 10 $1,153 $1,492 addon N/A N/A AFDC 5/1/1988 (region C) AFDC 5/1/1988 (region C) 1 $315 $397 2 $419 $530 3 $507 $646 CT: converted thresholds date: 21-JUN-2013

TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14 4 $588 $756 5 $670 $866 6 $760 $984 7 $854 $1,107 8 $946 $1,227 9 $1,026 $1,336 10 $1,142 $1,480 addon N/A N/A AFDC 5/1/1996 (region A) AFDC 5/1/1996 (region A) 1 $402 $496 2 $513 $640 3 $636 $795 4 $741 $933 5 $835 $1,059 6 $935 $1,192 7 $1,040 $1,329 8 $1,143 $1,465 9 $1,228 $1,582 10 $1,341 $1,728 addon N/A N/A AFDC 5/1/1996 (region B) AFDC 5/1/1996 (region B) 1 $333 $418 2 $443 $557 3 $543 $686 4 $639 $812 5 $731 $933 6 $827 $1,058 7 $933 $1,193 8 $1,031 $1,321 9 $1,116 $1,435 10 $1,220 $1,568 addon N/A N/A

TN No. 14-0001MM1 Connecticut Approval Date: 6/11/14 Effective Date: 1/1/14 AFDC 5/1/1996 (region C) AFDC 5/1/1996 (region C) 1 $333 $417 2 $443 $557 3 $536 $679 4 $622 $794 5 $708 $909 6 $805 $1,035 7 $904 $1,164 8 $1,001 $1,290 9 $1,086 $1,404 10 $1,209 $1,556 addon N/A N/A Family 1931 1931 mandatory parents & other caretaker relatives (also used for full coverage of pregnant women) 185% FPL 198% FPL Pregnant women 1902(a)(10)(A)(ii)(IX) optional poverty-level related pregnant women covered for pregnancy- related services 250% FPL 258% FPL Children <19 1902(a)(10)(A)(i)(IV/VI/VII) mandatory poverty-level children < 19 185% FPL 196% FPL Uninsured children <19 (under 1 >185%; age 1-5 >185%; age 6-18 >185%) S-CHIP state plan children 300% FPL 318% FPL Children age 14-18 Pre-CHIP Medicaid 100% FPL 111% FPL S-CHIP premium children < 19 235-300% lower bound 235% FPL 249% FPL 235-300% upper bound 300% FPL 318% FPL

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 14-0002MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion Letter 3) CMS 179 Form/Summary Form 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the State Plan

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

Boston Regional Office

JFK Federal Building

15 New Sudbury Street, Room 2325

Boston, MA 02203-0003 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 24, 2014

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

RE: $94 — Eligibility Process State Plan Amendment (SPA), CT-14-0002MM2 Dear Commissioner Bremby:

Enclosed is an approved copy of Connecticut’s State plan amendment (SPA) CT-14-0002MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 26, 2014. SPA CT-14-0002MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Connecticut’s Medicaid State plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014.

The approval of SPA CT-14-0002MM2 includes full approval of your State’s alternative paper application. The State is using an interim alternative single streamlined online application and by July 25, 2014 will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following S94 State plan pages and attachments:

e $94, pages $94-1 and S94-2

e Attachment 1 — State of Connecticut's alternative paper application for individuals

e Attachment 2 — State of Connecticut's alternative paper application for families

e Attachment 3 — Statement of use with respect to the alternative single streamlined online

application

In addition, enclosed is a summary of State plan pages which are superseded by SPA CT-14- 0002MM2.

CMS appreciates the significant amount of work your staff dedicated to preparing this SPA. If you have any questions concerning this SPA, please contact Robert Cruz at (617) 565 — 1257 or via e-mail at Robert.Cruz@cms.hhs.gov.

Page 2 — Roderick L. Bremby, Commissioner

Sincerely, /s/

Richard McGreal Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures ce:

Raymond Singleton Jr., Deputy Commissioner Marc Shok, Adult Services Program Manager

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

Boston Regional Office JFK Federal Building 15 New Sudbury Street, Room 2325

Boston, MA 02203-0003 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 24, 2014

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

RE: $94 — Eligibility Process State Plan Amendment (SPA), CT-14-0002MM2 Dear Commissioner Bremby:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Connecticut’s State plan amendment (SPA) transmittal CT-14-0002MM2, which was submitted to CMS on March 26, 2014. Our review of this submission included a review of the online alternative single streamlined application developed by the State.

Until July 25, 2014, the State is using an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following changes.

1. The State will not request citizenship and immigration information from non- applicants.

2. The State will provide language explaining that non-applicants are not required to provide their Social Security Number.

3. The State will ensure that an applicant is able to indicate he/she is an American Indian or Alaska Native without requiring an attestation of federally recognized tribe membership.

4. The State will allow American Indian and Alaska Native household members to identify income that is not countable for Medicaid/CHIP determinations.

5. As previous year’s tax return information is not relevant for eligibility purposes, Connecticut will adopt the approach of asking about current annual income and whether a change in income is expected during the following coverage year.

6. Connecticut will allow individuals who cannot pass identification proofing initially to proceed with the application, as appropriate. Eligibility results should only be provided once the applicant successfully passes the identification proofing.

7. Connecticut will review the contents of the summary page as non-applicants show up as U.S. citizens, which may not be accurate.

8. On the Citizenship page, under Individual Details, applicants are asked if they are U.S. citizens. If “no” is selected, the names of non-applicants also show up. Connecticut will not show the names of non-applicants.

/s/

State/Territory name: Connecticut Submitted By: Marc Shok Last Revision Date: Mar 26, 2014 Submit Date: Mar 26, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-0002 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Affordable Care Act; 42 CFR Part 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Eligibility Process Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 CT.0828.R00.00 - Jan 01, 2014 05/27/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp Date Received: 3/26/14 Effective Date of Approved Material: 1/1/14 Typed Name: Richard R. McGreal Plan Approved - One Copy Attached Date Approved: 6/24/14 Signature of Regional Official Division of Medicaid and Children's Health Operations, Boston Regional Office /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

CT-14-0002-MM2 STATE:

Connecticut

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 Eligibility Process

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

Section 2, Page 10, section 2.1(a), TN 91-15 Section 2, Page 11a, section 2.1(d), TN 92-3

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. 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 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 S94 - 1 Effective Date: 1/1/14

Page 2 of 2 Medicaid Eligibility The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ 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. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 S94 - 2 Effective Date: 1/1/14

call us at 1-855-805-4325. Para obtener una copia de este formulario en Español, llame 1-855-805-4325. If you need help in a language other than English, call 1-855-805-4325 and the customer service representative will connect you with your preferred language. We will get you help at no cost to you. TTY users should call

Types of Coverage Available: - HUSKY Health • Medicaid - Subsidized and Un-Subsidized Health Insurance Application for Individual Health Coverage and Cost Savings Programs Apply Faster Online Apply faster online at accesshealthct.com. Use this application to see what coverage you qualify for • Affordable private healthcare plans that offer comprehensive coverage to help you stay well. • New tax credits that can provide immediate help paying a portion of your premiums for healthcare coverage. • Free healthcare coverage from Medicaid. Who can use this application? Single adults who: • Aren’t offered healthcare coverage from their employer. • Don’t have any dependents and can’t be claimed as a dependent by someone else and are expecting to file a tax return. NOTE: If any of the following apply, you need to fill out form AH3 (Family) instead to make sure you get the most benefits possible. Visit accesshealthct.com. • Married or have dependent children. • Were in Connecticut foster care and you’re under age 26. • Have items that can be deducted from your income. If your only deduction is student loan interest, you can use this form. • Want help paying for medical bills from the last 3 months. • Are an American Indian or Alaska native. What you may need to apply • Social Security number (or document number for any legal immigrants who need insurance). • Employer and income information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements). • Policy numbers for any current healthcare coverage. What happens next? • Send your completed, signed application to the address on page 4. Please use the enclosed envelope. • We’ll follow up with you within 2 weeks by mail and you’ll get instructions on the next steps to obtain health coverage. • If you don’t have all the information required, sign and submit your application anyway. If necessary, we will contact you by phone or mail to complete the application. • If you don’t hear from us and it’s been 2 weeks, please call 1-855-805-4325. Filling out this application doesn’t mean you have to buy healthcare coverage. Why do we ask for this information? • We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We’ll keep all the information you provide private and secure, as required by law. Get free help with this application • Online: accesshealthct.com • Phone: 1-855-805-4325. • In person: There may be counselors certified by Access Health CT in your area who can help. Visit accesshealthct.com or call 1-855-805-4325 for more information. • En Español: Llame a nuestro centro de ayuda gratis al 1-855-805-4325. • For Telecommunications Device for the Deaf (TDD or TTY) please call 1-855-789-2428. If someone is helping you fill out this application, you will need to complete Appendix C. Form AH2 TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 1 - Application for Individuals Effective Date: 1/1/14

call us at 1-855-805-4325. Para obtener una copia de este formulario en Español, llame 1-855-805-4325. If you need help in a language other than English, call 1-855-805-4325 and the customer service representative will connect you with your preferred language. We will get you help at no cost to you. TTY users should call

STEP 1 Tell us about yourself 1. First name, Middle name, Last name, & suffix

2. Home address (If you do not have a Home address, please provide at least the city and state where you are seeking healthcare coverage) 3. Apartment or suite number 4. City 5. State 6. Zip code 7. County 8. Mailing address (if different from home address) 9. Apartment or suite number 10. City 11. State 12. Zip code 13. County 14. Phone number ( ) – 15. Other phone number ( ) – 16. Do you want to get information about this application by email? □Yes □No

Email address:

17. Preferred spoken or written language (if not English)

18. Date of birth (mm/dd/yyyy) 19. Sex

□Male □Female 20. Social Security Number (SSN)

-

-

We need your SSN if you want healthcare coverage and have an SSN. We use SSNs to check income and other information to see if you are eligible for help with healthcare coverage costs. If you need help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. 21. Are you a U.S. Citizen or U.S. National? □Yes □No 22. If you are not a U.S. Citizen or U.S. National, do you have eligible immigration status? □Yes. Fill in your document type and ID number below.

a. Immigration document type

b. Document ID number

c. Have you lived in the U.S. since 1996? □Yes □No

d. Are you a veteran or an active-duty member of the U.S. military? □Yes □No 23. Are you pregnant? □Yes □No If yes, what is your due date? How many babies are expected during this pregnancy?

24. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? □Yes □No

25. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) □Mexican □Mexican American □Chicano/a □Puerto Rican □Cuban □Other:

26. Race (OPTIONAL—check all that apply)

□Caucasian □Black or African American □American Indian or Alaska Native □Asian Indian □Chinese □Filipino □Japanese □Korean □Vietnamese □Other Asian □Native Hawaiian □Guamanian or Chamorro □Samoan □Other Pacific Islander □Other: TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 1 - Application for Individuals Effective Date: 1/1/14

STEP 2 Current job & income information

□Employed – if you’re currently employed, tell us about your income. Start with question 1.

□Not Employed – skip to question 11. □Self Employed – skip to question 10. CURRENT JOB 1:

1. Employer name and address 2. Employer phone number ( ) – 3. Average hours worked each week 4. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

CURRENT JOB 2: if you have more jobs and need more space, attach another sheet of paper.

5. Employer name and address 6. Employer phone number ( ) – 7. Average hours worked each week 8. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

9. In the past year, did you: □Change jobs □Stop working □Start working fewer hours □None of these 10. If self-employed, answer the following questions: a. Type of work:

b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? $ 11. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI) □Unemployment $ How often? □Pensions $ How often? □Social Security $ How often? □None □Retirement accounts $ How often? □Alimony received $ How often? □Net farming/fishing $ How often? □Net rental/royalty $ How often? □Other income $ How often? Type: 12. Do you pay student loan interest (not the amount of the loan) that can be deducted on a federal income tax return? □Yes If yes, how much? $ How often? □No 13. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to step 3. Your total income (before taxes) this year $ Your total income next year (if you think it will be different) $ STEP 3 Your healthcare coverage 1. Are you enrolled in healthcare coverage now from any of the following? □YES. If yes, check which coverage you have. □NO □Medicaid □CHIP □Medicare □TRICARE (don’t check if you have Direct Care or Line of Duty) □Peace Corps □VA health care programs □Other Name of healthcare coverage: Policy number:

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 1 - Application for Individuals Effective Date: 1/1/14

STEP 4 Read & sign this application • I am signing this application under penalty of perjury, which means I have provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under state and federal law if I intentionally provide false or untrue information. • I know that I must tell Access Health CT if anything changes (and is different than) what I wrote on this application. I can visit accesshealthct.com or call 1-855-805-4325 to report any changes. I understand that a change in my information could affect my eligibility. • Do you need a reasonable accommodation or help to fill out your application because of a disability or impairment? □Yes □No • If yes, what kind do you need? ______________________________________________ • I know that under state and federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, disability, or because of genetic information. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file or Connecticut Commission on Human Rights and Opportunities (CHRO) www.ct.gov/chro/site/default.asp • I confirm that I am not incarcerated (detained or jailed). • I confirm that next year I expect to file a federal income tax return, won’t claim dependents on that return, and can’t be claimed as a dependent on anyone else’s federal income tax return. • I confirm that I’m not offered health coverage from an employer. We need this information to check your eligibility for help paying for healthcare coverage if you choose to apply. We will check your answers using information from federal data sources, Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information does not match, we may ask you to send us proof. Renewal of coverage in future years To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow Access Health CT to use income data verified by federal data sources. Access Health CT will send me a notice, let me make any changes, and I can opt out at any time. Yes, renew my eligibility automatically for the next: □5 years (the maximum number of years allowed), or for a shorter number of years: □4 years □3 years □2 years □1 year □Don’t use information from tax returns to renew my coverage. If I am eligible for Medicaid (HUSKY Health) If I enroll in Medicaid, I am giving the Medicaid agency my rights to pursue and get any money from other health insurance, legal settlements, or other third parties. My right to appeal If I think Access Health CT or Medicaid/Children’s Health Insurance Program (CHIP) has made a mistake, I can appeal its decision. To appeal means to tell someone at Access Health CT or Medicaid/CHIP that I think the action is wrong, and ask for a fair review of the action. I know that I can find out how to appeal by contacting Access Health CT at 1-855-805-4325. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. Sign this application. The person who filled out step 1 should sign this application. If you are an authorized representative, you may sign here as long as you have provided the information required in Appendix C. Signature

Date (mm/dd/yyyy) STEP5 Mail completed application to: Access Health CT PO BOX # 670 Manchester, CT 06045-0670 What happens next? We will follow up with you within 2 weeks. You will get instructions on how to take the next steps to get your health coverage. If you do not hear from us within 2 weeks, visit accesshealthct.com or call 1-855-805-4325. TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 1 - Application for Individuals Effective Date: 1/1/14

Para obtener una copia de este formulario en Español, llame 1-855-805-4325. If you need help in a language other than English, call 1-855-805-4325 and the customer service representative will connect you with your preferred language. We will get you help at no cost to you. TTY users should call APPENDIX C: Authorized Representative Assistance with Completing this Application You can choose an authorized representative to assist in completing the application (Certified application counselors, in-person assisters, navigators and brokers please see below). You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the Access Health CT 1-855-805-4325. If you are a legally appointed representative for someone on this application, submit proof with the application. Select the type of representative: □ Court Appointed Representative and/or Power of Attorney □ Responsible Adult 1. Name of authorized representative (First Name, Middle Name, Last Name) 2. Address

3. Apartment or Suite number 4. City 5. State 6. ZIP code 7. Phone number ( ) - 8. Organization name (if applicable) 9. ID number (if applicable) By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency. 10. Your signature 11. Date (mm/dd/yyyy)

For certified application counselors, in-person assisters, navigators, and brokers only 1. Application start date (mm/dd/yyyy) 2. First Name, Middle name, Last name, & Suffix 3. Organization name 4. ID/License number (if applicable)

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 1 - Application for Individuals Effective Date: 1/1/14

Types of Coverage Available: - HUSKY Health • Medicaid • CHIP - Subsidized and Un-Subsidized Health Insurance Application for Family Health Coverage and Cost Saving Programs Apply Faster Online Apply faster online at accesshealthct.com. Use this application to see what coverage you qualify for • Affordable private healthcare plans that offer comprehensive coverage to help you stay well. • A new tax credit that can immediately help pay a portion of your premiums for healthcare coverage. • Free or low-cost healthcare programs from Medicaid or the Children’s Health Insurance Program (CHIP) You may qualify for a low-cost program even if you earn as much as $94,000 a year (for a family of 4). Who can use this application? • Apply even if you or your child already has healthcare coverage. You could be eligible for lower-cost or free coverage. • If you’re single, you may be able to use the AH2 form. Visit accesshealthct.com • Families that include immigrants can apply. You can apply for your child even if you aren’t eligible for coverage. Applying won’t affect your immigration status or chances of becoming a permanent resident or citizen. • Married couples or those with dependent children. • Individuals in CT foster care between the ages of 18 and 26 • People who have items that can be deducted from your income. If your only deduction is student loan interest you can use this form. • American Indians or Alaska Natives. What you may need to apply • Social Security numbers (or document numbers for any legal immigrants who needinsurance) • Date of birth for all applicants • Employer and income information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements) • Policy numbers for any current healthcare insurance • Information about any employer-related healthcare insurance available to your family. What happens next? • Send your completed and signed application to the address on page 12. • We’ll follow up with you within 2 weeks by mail and you’ll get instructions on the next steps to obtain health coverage. • If you don’t have all the information required, sign and submit your application anyway. If necessary, we will contact you by phone or mail to complete the application. • If you don’t hear from us and it’s been 2 weeks, please call 1-855-805-4325. Filling out this application doesn’t mean you have to buy health coverage. Why do we ask for this information? • We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We’ll keep all the information you provide private and secure, as required by law. Get free help with this application • Online: accesshealthct.com • Phone: 1-855-805-4325. • In person: There may be counselors certified by Access Health CT in your area who can help. Visit accesshealthct.com or call 1-855-805-4325 for more information. • En Español: Llame a nuestro centro de ayuda gratis al 1-855-805-4325. • For Telecommunications Device for the Deaf (TDD or TTY) please call 1-855-789-2428 If someone is helping you fill out this application, you will need to complete Appendix C. Form AH3 TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 1 Tell us about yourself (Please be sure to fill in all applicable information. We need one adult in the family to be the contact person for your application. The contact person will sign the application.) 1. First Name, Middle Name, Last Name, & Suffix

2. Home address (If you do not have a Home address, please provide at least the City and State where you are seeking healthcare coverage) 3. Apartment or suite number 4. City 5. State 6. Zip code 7. County 8. Mailing address (if different from home address) 9. Apartment or suite number 10. City 11. State 12. Zip code 13. County 14. Phone number ( ) – 15. Other phone number ( ) – 16. Do you want to get information about this application by email? □Yes □No

Email address:

17. Preferred spoken or written language (if not English)

STEP 2 Tell us about your family * If you have more than 4 people to include, make a copy of Step 2:Person 4 (pages 9 and 10) and complete. * Who do you need to include on this application? Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. (You do not need to file taxes to get healthcare coverage). Include: • Yourself • Your spouse • Your children under 19 who live with you • Your unmarried partner who needs healthcare coverage • Anyone you include on your tax return, even if they don’t live with you • Anyone else under 19 who you take care of and lives with you You do not have to include: • Your unmarried partner who does not need healthcare coverage • Your unmarried partner’s children • Your parents who live with you, but file their own tax return (if you are over 19) • Other adult relatives who file their own tax return The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can. Complete Step 2 for each person in your family. Start with yourself, and then add other adults and children. If you have more than 4 people in your family, you will need to make a copy of the pages and attach them. You don’t need to provide immigration status or a Social Security Number (SSN) for family members who do not need healthcare coverage. We will keep all the information you provide private and secure as required by law. We will use personal information only to check if you are eligible for healthcare coverage. TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

1-855-805-4325 Para obtener una copia de este formulario en Español, llame 1-855-805-4325. If you need help in a language other than English, call 1-855-805-4325 and the customer service representative will connect you with your preferred language. We’ll get you help at no cost to you. TTY users should call 1-855-789-2428

STEP 2: PERSON 1

(Start with yourself) Complete step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you do not file a tax return, remember to still add family members who live with you. 1. First Name, Middle Name, Last Name, & Suffix 2. Relationship to you? SELF 3. Date of birth (mm/dd/yyyy) 4. Sex

□Male □Female 5. Social Security Number (SSN) - - We need your SSN if you want healthcare coverage and have an SSN. We use SSNs to check income and other information to see who is eligible for help with healthcare coverage costs. Providing your SSN can also be helpful since it can speed up the application process. If you or someone in your family wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. 6. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for healthcare coverage even if you do not file a federal income tax return.) □YES. If yes, please answer questions a–c.

□NO. If no, skip to question c. a. Will you file jointly with a spouse? □Yes

□No If yes, name of spouse: b. Will you claim any dependents on your tax return? □Yes

□No If yes, list full name(s) of dependents: c. Will you be claimed as a dependent on someone’s tax return? □Yes

□No If yes, please list the name of the tax filer: How are you related to this tax filer? 7. Are you pregnant? □Yes □No If yes, what is your due date? How many babies are you expecting during this pregnancy?

8. Do you need healthcare coverage? (Even if you have healthcare coverage, there might be a program with better coverage or lower costs.) □YES. If yes, answer all the questions below.

□NO. If no, SKIP to the income questions on page 4.

Leave the rest of this page blank. 9. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? □Yes □No 10. Are you a U.S. Citizen or U.S. National? □Yes □No 11. If you are not a U.S. Citizen or U.S. National, do you have eligible immigration status? □Yes. Fill in your document type and ID number below. a. Immigration document type c. Have you lived in the U.S. since 1996? □Yes □No

b. Document ID number d. Are you or your spouse or parent a veteran or an active-duty member of the U.S. military? □Yes □No 12. Do you want help paying for medical bills from the last 3 months? □Yes □No 12a. If yes, was your income in the last 3 months equal to your current month’s income? □Yes □No 13. List the names of the children under age 19 for whom you are the primary person responsible for taking care of them. _________________________________________________________________________________________________ 14. Were you in Connecticut foster care at age 18 or older? □Yes □No 15. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) □Mexican □Mexican American □Chicano/a □Puerto Rican □Cuban □Other:

16. Race (OPTIONAL—check all that apply) □Caucasian □Black or African American □American Indian or Alaska Native □Asian Indian □Chinese □Filipino □Japanese □Korean □Vietnamese □Other Asian □Native Hawaiian □Guamanian or Chamorro □Samoan □Other Pacific Islander □Other: TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 2: PERSON 1

(Continue with yourself) Current Job & Income Information □Employed – if you’re currently employed, tell us about your income. Start with question 17.

□Not Employed – skip to question 27. □Self Employed – skip to question 26. CURRENT JOB 1:

17. Employer name and address 18. Employer phone number ( ) – 19. Average hours worked each week 20. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)

21. Employer name and address 22. Employer phone number ( ) – 23. Average hours worked each week 24. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

25. In the past year, did you: □Change jobs □Stop working □Start working fewer hours □None of these 26. If self-employed, answer the following questions: a. Type of work:

b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? $ 27. OTHER INCOME: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI) □None □Unemployment $ How often? □Pensions

$ How often? □Social Security $ How often? □Retirement accounts $ How often? □Alimony received $ How often? □Net farming/fishing $ How often? □Net rental/royalty $ How often? □Other income $ How often? Type: 28. DEDUCTIONS: Check all that apply, and give the amount and how often you pay it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You should not include a cost that you already considered in your answer to net self-employment (question 26b). □Alimony paid

$ How often? □Student loan interest $ How often? □Other deductions

$ How often? Type:

29. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. Your total income (before taxes) this year $ Your total income next year (if you think it will be different) $ TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 2: PERSON 2 Complete step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you do not file a tax return, remember to still add family members who live with you. 1. First Name, Middle Name, Last Name, & Suffix 2. Relationship to Person 1? 3. Date of birth (mm/dd/yyyy) 4. Sex □Male □Female 5. Social Security Number (SSN) - - We need this SSN if this person wants healthcare coverage and has an SSN. 6. Does Person 2 live at the same address as you? □Yes □No If no, list Person 2’s address: 7. Does Person 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for healthcare coverage even if you do not file a federal income tax return.) □YES. If yes, please answer questions a–c.

□NO. If no, skip to question c. a. Will Person 2 file jointly with a spouse? □Yes

□No If yes, name of spouse: b. Will Person 2 claim any dependents on his or her tax return? □Yes

□No If yes, list name(s) of dependents: c. Will Person 2 be claimed as a dependent on someone’s tax return? □Yes

□No If yes, please list the name of the tax filer: How is Person 2 related to this tax filer? 8. Is Person 2 pregnant? □Yes □No If yes, what is the due date? How many babies is person 2 expecting during this pregnancy?

9. Does Person 2 need healthcare coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) □YES. If yes, answer all the questions below.

□NO. If no, SKIP to the income questions on page 6.

Leave the rest of this page blank. 10. Does Person 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? □Yes □No 11. Is Person 2 a U.S. Citizen or U.S. National? □Yes □No 12. If Person 2 is not a U.S. Citizen or U.S. National, do they have eligible immigration status? □Yes. Fill in their: a. Immigration document type b. Document ID number c. Has Person 2 lived in the U.S. since 1996? □Yes □No d. Is Person 2 or their spouse or parent a veteran or an active- duty member of the U.S. military? □Yes □No 13. Does Person 2 want help paying for medical bills from the last 3 months? □Yes □No 13a. If yes, is Person 2’s income in the last 3 months equal to their current month’s income? □Yes □No 14. List the names of the children under the age of 19 for whom Person 2 is the primary person responsible for taking care of them.

____________________________________

____________________________________ 15. Was Person 2 in Connecticut foster care at age 18 or older? □Yes □No 16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply) □Mexican □Mexican American □Chicano/a □Puerto Rican □Cuban □Other:

17. Race (OPTIONAL—check all that apply)

□Caucasian □Black or African American □American Indian or Alaska Native □Asian Indian □Chinese □Filipino □Japanese □Korean □Vietnamese □Other Asian □Native Hawaiian □Guamanian or Chamorro □Samoan □Other Pacific Islander □Other: TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 2: PERSON 2

Current Job & Income Information □Employed – if you’re currently employed, tell us about your income. Start with question 18.

□Not Employed – skip to question 28. □Self Employed – skip to question 27. CURRENT JOB 1:

18. Employer name and address 19. Employer phone number ( ) – 20. Average hours worked each week 21. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

CURRENT JOB 2: (If Person 2 has more jobs and need more space, attach another sheet of paper.)

22. Employer name and address 23. Employer phone number ( ) – 24. Average hours worked each week 25. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

26. In the past year, did Person 2: □Change jobs □Stop working □Start working fewer hours □None of these 27. If self-employed, answer the following questions: a. Type of work:

b. How much net income (profits once business expenses are paid) will Person 2 get from this self-employment this month? $ 28. OTHER INCOME: Check all that apply, and give the amount and how often Person 2 gets it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI) □None □Unemployment $ How often? □Pensions $ How often? □Social Security $ How often? □Retirement accounts $ How often? □Alimony received $ How often? □Net farming/fishing $ How often? □Net rental/royalty $ How often? □Other income $ How often? Type: 29. DEDUCTIONS: Check all that apply, and give the amount and how often Person 2 pays it. If Person 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: person 2 should not include a cost that they already considered in their answer to net self-employment (question 27b). □Alimony paid

$ How often? □Student loan interest $ How often? □Other deductions

$ How often? Type:

30. YEARLY INCOME: Complete only if Person 2’s income changes from month to month. Person 2’s total income (before taxes) this year $ Person 2’s total income next year (if you think it will be different) $ Thanks! This is all we need to know about person 2.

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 2: PERSON 3 Complete step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you do not file a tax return, remember to still add family members who live with you. 1. First Name, Middle Name, Last Name, & Suffix 2. Relationship to Person 1? 3. Date of birth (mm/dd/yyyy) 4. Sex □Male □Female 5. Social Security Number (SSN) - - We need this SSN if this person wants healthcare coverage and has an SSN. 6. Does Person 3 live at the same address as you? □Yes □No If no, list Person 3’s address: 7. Does Person 3 plan to file a federal income tax return NEXT YEAR? (You can still apply for healthcare coverage even if you do not file a federal income tax return.) □YES. If yes, please answer questions a–c.

□NO. If no, skip to question c. a. Will Person 3 file jointly with a spouse? □Yes

□No If yes, name of spouse: b. Will Person 3 claim any dependents on his or her tax return? □Yes

□No If yes, list name(s) of dependents: c. Will Person 3 be claimed as a dependent on someone’s tax return? □Yes

□No If yes, please list the name of the tax filer: How is Person 3 related to this tax filer? 8. Is Person 3 pregnant? □Yes □No If yes, what is the due date? How many babies is Person 3 expecting during this pregnancy?

9. Does Person 3 need healthcare coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.) □YES. If yes, answer all the questions below.

□NO. If no, SKIP to the income questions on page 8.

Leave the rest of this page blank. 10. Does Person 3 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? □Yes □No 11. Is Person 3 a U.S. Citizen or U.S. National? □Yes □No 12. If Person 3 is not a U.S. Citizen or U.S. National, do they have eligible immigration status? □Yes. Fill in their: a. Immigration document type b. Document ID number c. Has Person 3 lived in the U.S. since 1996? □Yes □No d. Is Person 3 or their spouse or parent a veteran or an active- duty member of the U.S. military? □Yes □No 13. Does Person 3 want help paying for medical bills from the last 3 months? □Yes □No 13a. If yes, is Person 3’s income in the last 3 months equal to their current month’s income? □Yes □No 14. List the names of the children under the age of 19 for whom Person 3 is the primary person responsible for taking care of them.

____________________________________

____________________________________ 15. Was Person 3 in Connecticut foster care at age 18 or older? □Yes □No 16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply) □Mexican □Mexican American □Chicano/a □Puerto Rican □Cuban □Other:

17. Race (OPTIONAL—check all that apply)

□Caucasian □Black or African American □American Indian or Alaska Native □Asian Indian □Chinese □Filipino □Japanese □Korean □Vietnamese □Other Asian □Native Hawaiian □Guamanian or Chamorro □Samoan □Other Pacific Islander □Other: TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 2: PERSON 3

Current Job & Income Information □Employed – if you’re currently employed, tell us about your income. Start with question 18.

□Not Employed – skip to question 28. □Self Employed – skip to question 27. CURRENT JOB 1:

18. Employer name and address 19. Employer phone number ( ) – 20. Average hours worked each week 21. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

CURRENT JOB 2: (If Person 3 has more jobs and need more space, attach another sheet of paper.)

22. Employer name and address 23. Employer phone number ( ) – 24. Average hours worked each week 25. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

26. In the past year, did Person 3: □Change jobs □Stop working □Start working fewer hours □None of these 27. If self-employed, answer the following questions: a. Type of work:

b. How much net income (profits once business expenses are paid) will Person 3 get from this self-employment this month? $ 28. OTHER INCOME: Check all that apply, and give the amount and how often Person 3 gets it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI) □None □Unemployment $ How often? □Pensions $ How often? □Social Security $ How often? □Retirement accounts $ How often? □Alimony received $ How often? □Net farming/fishing $ How often? □Net rental/royalty $ How often? □Other income $ How often? Type: 29. DEDUCTIONS: Check all that apply, and give the amount and how often Person 3 pays it. If Person 3 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: Person 3 should not include a cost that they already considered in their answer to net self-employment (question 27b). □Alimony paid

$ How often? □Student loan interest $ How often? □Other deductions

$ How often? Type:

30. YEARLY INCOME: Complete only if Person 3’s income changes from month to month. Person 3’s total income (before taxes) this year $ Person 3’s total income next year (if you think it will be different) $ Thanks! This is all we need to know about person 3.

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 2: PERSON 4 Complete step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you do not file a tax return, remember to still add family members who live with you. 1. First Name, Middle Name, Last Name, & suffix 2. Relationship to Person 1? 3. Date of birth (mm/dd/yyyy) 4. Sex □Male □Female 5. Social Security Number (SSN) - - We need this SSN if this person wants healthcare coverage and has an SSN. 6. Does Person 4 live at the same address as you? □Yes □No If no, list Person 4’s address: 7. Does Person 4 plan to file a federal income tax return NEXT YEAR? (You can still apply for healthcare coverage even if you do not file a federal income tax return.) □YES. If yes, please answer questions a–c.

□NO. If no, skip to question c. a. Will Person 3 file jointly with a spouse? □Yes

□No If yes, name of spouse: b. Will Person 4 claim any dependents on his or her tax return? □Yes

□No If yes, list name(s) of dependents: c. Will Person 4 be claimed as a dependent on someone’s tax return? □Yes

□No If yes, please list the name of the tax filer: How is Person 4 related to this tax filer? 8. Is Person 4 pregnant? □Yes □No If yes, what is the due date? How many babies is Person 4 expecting during this pregnancy?

9. Does Person 4 need healthcare coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) □YES. If yes, answer all the questions below.

□NO. If no, SKIP to the income questions on page 10.

Leave the rest of this page blank. 10. Does Person 4 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? □Yes □No 11. Is Person 4 a U.S. Citizen or U.S. National? □Yes □No 12. If Person 4 is not a U.S. Citizen or U.S. National, do they have eligible immigration status? □Yes. Fill in their: a. Immigration document type b. Document ID number c. Has Person 4 lived in the U.S. since 1996? □Yes □No d. Is Person 4 or their spouse or parent a veteran or an active- duty member of the U.S. military? □Yes □No 13. Does Person 4 want help paying for medical bills from the last 3 months? □Yes □No 13a. If yes, is Person 4’s income in the last 3 months equal to their current month’s income? □Yes □No 14. List the names of the children under the age of 19 for whom Person 4 is the primary person responsible for taking care of them.

____________________________________

____________________________________ 15. Was Person 4 in Connecticut foster care at age 18 or older? □Yes □No 16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply) □Mexican □Mexican American □Chicano/a □Puerto Rican □Cuban □Other:

17. Race (OPTIONAL—check all that apply)

□Caucasian □Black or African American □American Indian or Alaska Native □Asian Indian □Chinese □Filipino □Japanese □Korean □Vietnamese □Other Asian □Native Hawaiian □Guamanian or Chamorro □Samoan □Other Pacific Islander □Other: TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 2: PERSON 4

Current Job & Income Information □Employed – if you’re currently employed, tell us about your income. Start with question 18.

□Not Employed – skip to question 28. □Self Employed – skip to question 27. CURRENT JOB 1:

18. Employer name and address 19. Employer phone number ( ) – 20. Average hours worked each week 21. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

CURRENT JOB 2: (If Person 4 has more jobs and need more space, attach another sheet of paper.)

22. Employer name and address 23. Employer phone number ( ) – 24. Average hours worked each week 25. Wages/tips (before taxes) □Hourly □Weekly □Every 2 weeks □Twice a month □Monthly □Yearly $

26. In the past year, did Person 4: □Change jobs □Stop working □Start working fewer hours □None of these 27. If self-employed, answer the following questions: a. Type of work:

b. How much net income (profits once business expenses are paid) will Person 4 get from this self-employment this month? $ 28. OTHER INCOME: Check all that apply, and give the amount and how often Person 4 gets it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI) □None □Unemployment $ How often? □Pensions $ How often? □Social Security $ How often? □Retirement accounts $ How often? □Alimony received $ How often? □Net farming/fishing $ How often? □Net rental/royalty $ How often? □Other income $ How often? Type: 29. DEDUCTIONS: Check all that apply, and give the amount and how often Person 4 pays it. If Person 4 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: Person 4 should not include a cost that they already considered in their answer to net self-employment (question 27b). □Alimony paid

$ How often? □Student loan interest $ How often? □Other deductions

$ How often? Type:

30. YEARLY INCOME: Complete only if Person 4’s income changes from month to month. Person 4’s total income this year $ Person 4’s total income next year (if you think it will be different) $

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 3 American Indian or Alaska Native (AI/AN) family member(s) 1. Are you or is anyone in your family American Indian or Alaska Native? □YES If yes, be sure to complete Appendix B.

□NO If no, skip to Step 4. STEP 4 Your Family’s Healthcare Coverage Answer these questions for anyone who needs healthcare coverage. 1. Is anyone enrolled in healthcare coverage now from any of the following? □YES If yes, check the type of coverage and write the person(s) name(s) next to the coverage that they have.

□NO □Medicaid □HUSKY (CHIP) □Medicare □TRICARE (don’t check if you have Direct Care or Line of Duty) □VA health care programs □Peace Corps

□Employer insurance

Name of health insurance:

Policy number:

Is this COBRA coverage? □Yes □No

Is this a retiree health plan? □Yes □No □Other

Name of health insurance:

Policy number: Is this a limited-benefit plan (like a school accident policy)? □Yes □No 2. Is anyone listed on this application offered healthcare coverage from a job? Check yes even if the coverage is from someone else’s job, such as a parent or spouse. □YES If yes, you will need to complete and include Appendix A. Is this a state employee benefit plan? □Yes □No □NO If no, continue to Step 5.

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 0938-1193. The time required to complete this information collection is estimated to average 60 minutes per application, 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 21244-185

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

STEP 5 Read & sign this application • I am signing this application under penalty of perjury, which means I have provided true and correct answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under state and federal law if I provide false and/or untrue information. • I know that I must inform Access Health CT if anything changes (and is different than) what I wrote on this application. I can visit accesshealthct.com or call 1-855-805-4325 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household. • Do you need a reasonable accommodation or help to fill out your application because of a disability or impairment? □Yes □No • If yes, what kind do you need? ______________________________________________ • I know that under state and federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, disability, or because of genetic information. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file or Connecticut Commission on Human Rights and Opportunities (CHRO) www.ct.gov/chro/site/default.asp • By signing below I confirm that no one applying for health healthcare coverage on this application is incarcerated (detained or jailed). If not,

is incarcerated.

(Name of person) We need this information to check your eligibility for help paying for health coverage if you choose to apply. We will check your answers using information from the federal data sources, Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information does not match, we may ask you to send us proof. Renewal of coverage in future years To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow Access Health CT to use income data verified by federal data sources. Access Health CT will send me a notice, let me make any changes, and I can opt out at any time. Yes, renew my eligibility automatically for the next: □5 years (the maximum number of years allowed), or for a shorter number of years: □4 years □3 years □2 years □1 year □Do not use information from tax returns to renew my coverage. If anyone on this application is eligible for Medicaid or CHIP (HUSKY) • I am giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent. • List the names of any children who have a parent living outside of the home.

• If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate. My right to appeal If I think Access Health CT or Medicaid/Children’s Health Insurance Program (CHIP) has made a mistake, I can appeal its decision. To appeal means to tell someone at Access Health CT or Medicaid/CHIP that I think the action is wrong, and ask for a fair review of the action. I know that I can find out how to appeal by contacting Access Health CT at 1-855-805-4325. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. Sign this application. The person who filled out step 1 should sign this application. If you are an authorized representative, you may sign here as long as you have provided the information required in Appendix C. Signature Date (mm/dd/yyyy) STEP 6 Mail completed application to: Access Health CT PO BOX # 670 Manchester, CT 06045-0670 TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

Visit accesshealthct.com or call us at 1-855-805-4325. Para obtener una copia de este formulario en Español, llame 1-855-805-4325. If you need help in a language other than English, call 1-855-805-4325 and the customer service representative will connect you with your preferred language. We’ll get you help at no cost to you. TTY users should call 1-855-789-2428.

APPENDIX A: Health Coverage from Jobs You Do Not need to answer these questions unless someone in the household is eligible for healthcare coverage from a job. Attach a copy of this page for each job that offers coverage. Tell us about the job that offers coverage. Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to include this page when you send in your application, not the Employer Coverage Tool. EMPLOYEE Information 1. Employee name (First, Middle, Last) 2. Employee Social Security Number - - EMPLOYER Information 3. Employer name 4. Employer Identification Number (EIN) - 5. Employer address 6. Employer phone number ( ) – 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) ( ) – 12. Email address

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? □Yes (Continue) 13a. If you are in a waiting or probationary period, when can you enroll in coverage?

(mm/dd/yyyy) List the names of anyone else who is eligible for coverage from this job. Name:

Name:

Name:

□No (Stop here and go to Step 5 in the application) Tell us about the health plan offered by this employer. 14. *Does the employer offer a health plan that meets the minimum value standard? □Yes □No 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $

b. How often? □Weekly □Every 2 weeks □Twice a month □Quarterly □Yearly 16. What change will the employer make for the new plan year (if known)? □Employer won’t offer healthcare coverage □Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $

b. How often? □Weekly □Every 2 weeks □Twice a month □Quarterly □Yearly Date of change? (mm/dd/yyyy)

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

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

Visit accesshealthct.com or call us at 1-855-805-4325. Para obtener una copia de este formulario en Español, llame 1-855-805-4325. If you need help in a language other than English, call 1-855-805-4325 and the customer service representative will connect you with your preferred language. We’ll get you help at no cost to you. TTY users should call 1-855-789-2428.

EMPLOYER COVERAGE TOOL Use this tool to help answer questions in Appendix A about any employer healthcare coverage that you’re eligible for (even if it’s from another person’s job, like a parent or spouse). The information in the numbered boxes below matches the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A. Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for each employer that offers health coverage. EMPLOYEE Information The employee needs to fill out this section. 1. Employee name (First, Middle, Last) 2. Employee Social Security Number - - EMPLOYER Information Ask the employer for this information. 3. Employer name 4. Employer Identification Number (EIN) - 5. Employer address (Access Health CT will send notices to this address) 6. Employer phone number ( ) – 7. City 8. State 9. ZIP code 10. Who can we contact about employee healthcare coverage at this job? 11. Phone number (if different from above) ( ) – 12. Email address

13. Is the employee currently eligible for coverage offered by this employer, or will the employee become eligible in the next 3 months? □Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage?

(mm/dd/yyyy) (Continue) □No (Stop and return this form to the employee) Tell us about the health plan offered by this employer. Does the employer offer a health plan that covers an employee’s spouse or dependents? □Yes. Which people? □Spouse □Dependent(s) □No (Go to question 14) 14. Does the employer offer a health plan that meets the minimum value standard*? □Yes (Go to question 15) □No (Stop and return this form to the employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $

b. How often? □Weekly □Every 2 weeks □Twice a month □Quarterly □Yearly If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee. 16. What change will the employer make for the new plan year (if known)? □Employer won’t offer healthcare coverage □Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for that plan? $

b. How often? □Weekly □Every 2 weeks □Twice a month □Quarterly □Yearly Date of change? (mm/dd/yyyy)

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

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

Visit accesshealthct.com or call us at 1-855-805-4325. Para obtener una copia de este formulario en Español, llame 1-855-805-4325. If you need help in a language other than English, call 1-855-805-4325 and the customer service representative will connect you with your preferred language. We’ll get you help at no cost to you. TTY users should call 1-855-789-2428.

Appendix B American Indian or Alaska Native (AI/AN) family member(s) Complete this appendix if you or a family member is American Indian or Alaska Native. Submit this with your Application for healthcare Coverage and help paying Costs. Tell us about your American Indian or Alaska Native family member(s). American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. NOTE: If you have more people to include, make a copy of this page and attach. 1. Names.

AI/AN Person 1 AI/AN Person 2 AI/AN Person 3 AI/AN Person 4 First First First First Middle Middle Middle Middle Last Last Last Last 2. Member of federally recognized tribe?

AI/AN Person 1 AI/AN Person 2 AI/AN Person 3 AI/AN Person 4 □Yes. If yes, tribe name:

_________________ □Yes. If yes, tribe name:

_________________ □Yes. If yes, tribe name:

_________________ □Yes. If yes, tribe name:

_________________ Name of state that tribe is located in:

_________________ □No Name of state that tribe is located in:

_________________ □No Name of state that tribe is located in:

_________________ □No Name of state that tribe is located in:

_________________ □No 3. Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? AI/AN Person 1 AI/AN Person 2 AI/AN Person 3 AI/AN Person 4 □Yes □No □Yes □No □Yes □No □Yes □No If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? □Yes □No If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? □Yes □No If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? □Yes □No If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? □Yes □No 4. Certain money received may not be counted for Medicaid or the Children’s Health Insurance Program (CHIP). List any income (amount and how often) reported on your application that includes money from these sources: • Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties. • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations). • Money from selling things that have cultural significance. AI/AN Person 1 AI/AN Person 2 AI/AN Person 3 AI/AN Person 4 $ _________________ How often? _______________________ $ _________________ How often? _______________________ $ _________________ How often? _______________________ $ _________________ How often? _______________________

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

Para obtener una copia de este formulario en Español, llame 1-855-805-4325. If you need help in a language other than English, call 1-855-805-4325 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call APPENDIX C: Authorized Representative Assistance with Completing this Application You can choose an authorized representative to assist in completing the application (Certified application counselors, in-person assisters, navigators and brokers please see below). You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the Access Health CT 1-855-805-4325. If you are a legally appointed representative for someone on this application, submit proof with the application. Select the type of representative: □ Court Appointed Representative and/or Power of Attorney □ Responsible Adult 1. Name of authorized representative (First Name, Middle Name, Last Name) 2. Address 3. Apartment or Suite number 4. City 5. State 6. ZIP code 7. Phone number ( ) - 8. Organization name 9. ID number (if applicable) By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency. 10. Your signature 11. Date (mm/dd/yyyy)

For certified application counselors, in-person assisters, navigators, and brokers only 1. Application start date (mm/dd/yyyy) 2. First Name, Middle name, Last name, & Suffix 3. Organization name 4. ID number (if applicable)

TN No. 14-0002MM2 Connecticut Approval Date: 6/24/14 Attachment 2 - Application for Families Effective Date: 1/1/14

TN No. 14-0002MM2 Approval Date: 6/24/14 Effective Date: 1/1/14 Connecticut Attachment 3

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

 Paper Application  Online Application

TRANSMITTAL NUMBER:

CT-14-0002-MM2

STATE:

Connecticut

Through July 25, 2014, the state is using an interim alternative single streamlined application. After July 25, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

Table of Contents

State/Territory Name: Connecticut State Plan Amendment (SPA) #: 14-0003MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages

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

JFK Federal Building. Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations / Boston Regional Office

August 25, 2014

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

Dear Commissioner Bremby:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 14-0003MM3 with an effective date of January 1, 2014, as requested by your Agency. This SPA describes how the state will apply Modified Adjusted Gross Income (MAGI)-based methodologies consistent with 42 CFR §435.603.

The state selected the option to include available cash support as household income, exceeding nominal amounts, provided by the person claiming an individual described at 42 CFR §435.603(f)(2)(1) as a tax dependent. The state originally proposed a nominal amount of $30 per quarter which is current state policy. CMS recommends changing this policy to a nominal amount of at least $30 per month. The state has agreed to modify this amount subsequent to the approval of this SPA.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

ec? Raymond Singleton Jr., Deputy Commissioner Marc Shok, Adult Services Program Manager

State/Territory name: Connecticut Submitted By: Marc Shok Last Revision Date: Aug 18, 2014 Submit Date: Dec 18, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-003 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Affordable Care Act; 42 CFR Part 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment MAGI Income Methodology Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 CT.0623.R00.00 - Jan 01, 2014 09/03/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp Date Received: 12/18/13 Effective Date of Approved Material: 1/1/14 Typed Name: Richard McGreal Plan Approved - One Copy Attached Date Approved: 8/25/14 Signature of Regional Official: Division of Medicaid and Children's Health Operations, Boston Regional Office /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

CT 14-0003MM3 STATE: Connecticut

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

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

Notwithstanding any other provisions of the Connecticut Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment TN 14-003MM3 will apply to all MAGI-based eligibility groups covered under Connecticut Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. ■ In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: The pregnant woman is counted just as herself. The pregnant woman is counted as herself, plus one. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: Current monthly household income and family size Projected annual household income and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Yes No TN No. 14-0003MM3 Connecticut Approval Date: 8/25/14 S10-1 Effective Date: 1/1/14

Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: ■ Age 19 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0003MM3 Connecticut Approval Date: 8/25/14 S10-2 Effective Date: 1/1/14

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 14-0004MM4 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

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

JFK Federal Building. Government Center Room 2275 Boston, Massachusetts 02203

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations / Boston Regional Office

June 18, 2014

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford. CT 06106-5033

Dear Commissioner Bremby: We are pleased to enclose a copy of approved State plan amendment (SPA) No. 14-0004MM4 with an effective date of January 1, 2014, as requested by your Agency. This SPA establishes the

single state agency and entities responsible for determinations of eligibility and appeals/fair hearings in accordance with the Affordable Care Act.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosure

ce: Raymond Singleton Jr., Deputy Commissioner Mare Shok,. Adult Services Program Manager

State/Territory name: Connecticut Submitted By: Marc Shok Last Revision Date: Mar 31, 2014 Submit Date: Mar 31, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-0004 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Affordable Care Act; 42 CFR Part 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Single State Agency Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 CT.0883.R00.00 - Jan 01, 2014 05/27/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp Date Received: 3/31/14 Effective Date of Approved Material: 1/1/14 Typed Name: Richard R. McGreal Plan Approved - One Copy Attached Date Approved: 6/18/14 Signature of Regional Official: Division of Medicaid and Children's Health Operations, Boston Regional Office /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

CT-14-0004 STATE:

Connecticut

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

A1 – A3

COMPLETE PAGES SUPERSEDED:

Section 1, pages 1-8 Attachment 1.1-A Attachments 1.2A-C

PARTIAL PAGES SUPERSEDED:

Section 1; page 8a and 9

Section 1, page 9

Section 1, page 8a and 9 A2 Notwithstanding any other provisions of the Medicaid State Plan, the agencies designated in A2 will determine eligibility for coverage to the extent specified in A2 – Not applicable.

Page 1 of 8 Medicaid Administration OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 State Plan Administration Designation and Authority A1 42 CFR 431.10 Designation and Authority State Name: Connecticut As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Connecticut Department of Social Services Type of Agency: Title IV-A Agency Health Human Resources Other Type of Agency Both the Title IV-A Agency and Human Resources Agency The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: Conn. General Statutes Section 17b-260 and 17b-264 The single state agency supervises the administration of the state plan by local political subdivisions. Yes No The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided. ✔ An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). Yes No TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 A1-A3 - 1 Effective Date: 1/1/14

Page 2 of 8 Medicaid Administration The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes No State Plan Administration Organization and Administration A2 42 CFR 431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency. The Department of Social Services (DSS) administers and delivers a wide variety of services to children, families, adults, people with disabilities and the elderly. DSS' services include health care coverage, child care, child support, long-term care and supports, energy assistance, food and nutrition aid, and program grants. DSS administers myriad state and federal programs and one-third of the state budget, currently serving more than 825,000 individuals in nearly 525,000 households (March 2014 data). By statute, DSS is the state agency responsible for administering a number of programs under federal legislation, including the Food Stamp Act, the Older Americans Act, and the Social Security Act.

The Department of Social Services is part of the Executive Branch of Connecticut state government. Pursuant to state law, the Commissioner of Social Services, like other state agency heads, is appointed by the Governor, with the advice and consent of the Connecticut General Assembly. The department also has two deputy commissioners for administration and programs. The agency delivers most of its programs through 12 field offices (including three benefits centers available by phone) located throughout the state, with central administrative offices located in Hartford. In addition, many services funded by the agency are available through community-based agencies and partner contractors. The agency has outstationed employees at hospitals to expedite Medicaid/ TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 A1-A3 - 2 Effective Date: 1/1/14

Page 3 of 8 Medicaid Administration HUSKY applications, and also works with community service providers to facilitate program applications.

Divisions Within the Department

-Affirmative Action -Aging Services Division -Economic Security -Eligibility Policy and Program Support (see description in Integrated Services, below) -Energy, Refugee and Community Services -Family Services -Field Operations - This Division supports the Department’s modernized approach to providing services to clients, including the establishment of benefit centers and other service delivery upgrades as described in “Modernization – Eligibility and Service Delivery” below. -Finance and Administration - This Division supports the Department through a full range of financial oversight and operational functions. These financial management activities are provided through the following four key service groups: the Budget Group, the Federal Reporting and Accounting Services Group, the Fund Management and Reporting (FMR) Group, the Actuarial Research and Analytical Support Unit. -Division of Health Services and Health Management (see description below) -Human Resources -Integrated Services (see description below) -MIS-IT Support -Office of Legal Counsel, Regulations and Administrative Hearings (see hearings description below) -Office of Public Affairs -Organizational and Skill Development -Quality Assurance - This Office is responsible for ensuring the fiscal and programmatic integrity of all programs administered by the Department. It includes four divisions each with unique program integrity functions: Fraud & Recoveries, Provider Audit/ Grants & Contracts, Quality Control, and Special Investigations. -SNAP -Social Work & Prevention Services -Strategic Planning

Division of Health Services and Health Management - Overview

The Division oversees administration of the Medicaid program with the exception of eligibility policy. The Division is made up of 10 units, including:

o Alternate Care Unit (ACU): manages the Connecticut Home Care Program for Elders, the Connecticut Home Care Program for Adults with Disabilities, the Katie Beckett waiver, Ascend level of care determination process for Medicaid payment of nursing facility stays, and the 1915(i) State Plan home and community-based services option and provides administrative oversight of Medicaid waivers operated by DDS and DMHAS.

o Behavioral Health Unit: manages behavioral health services for Medicaid eligible individuals. The unit is responsible for the behavioral health Administrative Services Organization (ASO) and staffs the Behavioral Health Partnership Oversight Council

o Dental Unit: manages the dental ASO, helps to coordinate dental benefits among different providers, reviews clinical materials for administrative hearings, staffs the Dental Policy Advisory Committee as well as provides oversight of the lead abatement and healthy homes programs

o Enrollment Unit: acts as liaison on Health Insurance Exchange activities and replacement of the Eligibility Management System (EMS) and manages Husky B (CHIP)

o Money Follows the Person Unit (MFP): leads the state’s “re-balancing” efforts to shift the focus of spending on long-term services and supports from institutional settings to home and community-based options

o Medical Care Management Unit: manages the medical ASO, Person-Centered Medical Home (PCMH) initiative, NEMT and TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 A1-A3 - 3 Effective Date: 1/1/14

Page 4 of 8 Medicaid Administration Rewards to Quit

o Pharmacy Unit: manages the pharmacy benefits for all clients enrolled in Connecticut Medical Assistance programs. This includes management of the preferred drug list, pharmacy prior authorization, drug rebate invoicing/collection, coordination with Medicare Part D, processing of eligibility/enrollment in the Connecticut AIDS Drug Assistance Program (CADAP) and more.

o Certificate of Need (CON) and Rate Setting Unit: establishes payment rates for medical and residential services covered under the Medicaid and State Supplement/Aged, Blind and Disabled (SSABD) programs, performs cost report auditing, and performs certificate of need (CON) reviews for nursing facility, residential care home and ICF-MR development, facility renovation projects and capacity expansions/contractions. The unit is also instrumentally involved with nursing facility receiverships and bankruptcies (restructuring, transfers to new owners, closures).

o Medical Operations Unit: manages how all medical programs are operationalized to reimburse providers via the Medicaid Management Information System (MMIS), including fiscal agent services provided through a contract with HP Enterprise Services (HP). These services include credentialing and enrollment of providers, coding and rule configuration in the MMIS to govern how claims for services are processed (including rules to prevent inappropriate payments), financial and other reporting on such processing, and management of processes that support these functions (e.g., call centers, provider communication, provider relations, etc.) A large component of Med Ops’ work revolves around implementing new initiatives; specifically, supporting other units in the work of documenting program details and directing HP in how such details must be aligned to support payment for new services or changes to existing services. In addition, Med Ops is responsible for the Medicaid Electronic Health Record (EHR) Incentive program and related Health Information Technology (HIT) initiatives which complement other health care reform efforts.

o Medical Policy Unit: interprets federal and state statutes and regulations toward development of Department policies and procedures; creates and updates fee schedules; determines Department health program coverage guidelines; provides staff support to the State Plan Amendment process.

o Medical and Clinical Review Team: Provides clinical consultation to all DSS activities as well as assists clinical review of the medical ASO.

Division of Integrated Services - Overview

The Division is responsible for providing residents of Connecticut with coordinated and comprehensive access to social services and programs. The Division is comprised of the following teams:

-Eligibility Policy and Program Support; -Economic Security; -Child Support; and -Social Work and Community Services

The Eligibility and Program Support team is responsible for the administration of Medicaid eligibility policy.

Modernization – Eligibility and Service Delivery

To improve access for Connecticut residents, DSS has undertaken a major initiative to modernize and upgrade service delivery. The ConneCT initiative allows clients real-time access to their case information through online and interactive voice-response systems, including an online service eligibility pre-screening tool. Streamlined document management and modernized service centers are also key elements of the initiative.

The Department also implemented a new business model. All eligibility work is getting processed in one of three types of centers: 1) service centers - dedicated staff in 12 Service Centers providing face-to-face services with walk-in clients; 2) processing centers - processors in the 12 centers processing work that comes in via the web and the mail via the workflow; and 3) benefits centers – representatives in three Benefits Centers available to clients and processing eligibility work via the phone.

In addition, the Department is planning for the replacement of the agency’s outdated eligibility management system and is working in partnership with Access Health CT, the state’s new health insurance exchange. The Department has developed systems, TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 A1-A3 - 4 Effective Date: 1/1/14

Page 5 of 8 Medicaid Administration policies, and procedures to support the requirements for the various insurance affordability programs in the federal Affordable Care Act (ACA).

MAGI-related eligibility determinations (parent and caretakers, pregnant women, single adults, children) and former foster care coverage group determinations are made in the Access Health CT System. The system is shared by the Department and Access Health CT and uses a shared rules engine.

Any questions or discrepancies on determinations made by the AHCT system are addressed by a DSS employee, either an eligibility worker in one of the Department’s service, processing or benefits centers or a member of the Eligibility and Program Support team. Also, DSS uses a contractor for data entry of eligibility information for MAGI Medicaid, but any determination or action that requires the exercise of discretion would be either sent to a DSS employee in one of the service or benefit centers for action. Also, the Eligibility and Program Support team maintains an onsite presence at the contractor’s office.

Eligibility determinations for non-MAGI Medicaid populations are made by the workers in the 3 types of centers described above. In 2013, the Department launched four Long-Term Care Application Centers. The Centers will receive and process nursing home and Medicaid waiver applications from within their designated catchment areas.

Hearings Process

Applicants for and recipients of benefits provided under Department of Social Services programs may contest actions taken by the Department, including actions (denial, termination, suspension, reduction) related to Medicaid and CHIP eligibility and benefits. The Office of Legal Counsel, Regulations and Administrative Hearings established a separate MAGI hearings unit that also has jurisdiction over eligibility determinations related to Advance Payments of Premium Tax Credits and Cost Sharing Reductions for Qualified Health Plans.

Administrative hearings are conducted by hearing officers, who are impartial employees of the Department of Social Services and are designees of the Commissioner of Social Services. A hearing officer conducts the hearing, reviews the hearing record, researches the law and issues written decisions based on the facts and applicable state and federal law.

The MAGI hearings unit normally holds hearings by telephone, but clients may request a hearing by video conference. While relatively informal in nature, the hearing process affords clients an opportunity to explain on the record why they disagree with the Department’s action. Once the hearing has been held and the record has been closed, the hearing officer issues a written decision and sends it to the client by certified mail.

If the client does not agree with the hearing officer’s decision, the client has the right to ask the Department to reconsider it. A reconsideration request must be made within 15 days of the mailing date of the hearing officer’s decision. The client may also appeal the hearing officer’s decision to the Superior Court within 45 days. The client may appeal the hearing officer’s decision to Superior Court without first asking for reconsideration.

Upload an organizational chart of the Medicaid agency. An attachment is submitted. Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. Executive Branch - Overview

Connecticut’s Governor heads the Executive branch. In addition to the Governor and Lieutenant Governor, there are four other elected offices established in the Connecticut Constitution: Secretary of State, Comptroller, Treasurer and Attorney General. There are several executive departments: Administrative Services, Agriculture, Banking, Children and Families, Consumer Protection, Correction, Economic and Community Development, Developmental Services, Construction Services, Education, Emergency Management and Public Protection, Energy & Environmental Protection, Higher Education, Insurance, Labor, Mental TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 A1-A3 - 5 Effective Date: 1/1/14

Page 6 of 8 Medicaid Administration Health and Addiction Services, Military, Motor Vehicles, Public Health, Public Utility Regulatory Authority, Public Works, Revenue Services, Social Services, Transportation, and Veterans Affairs. In addition to these departments, there are other independent bureaus, offices and commissions. While the Department of Social Services is the single state agency for administration of the Medicaid program, the Department works closely with other executive branch health and human services agencies, including the Department of Children and Families, the Department of Developmental Services, the Department of Mental Health and Addiction Services and the Department of Public Health.

The Department collaborates with these agencies on a number of Medicaid waivers for their children and adult populations. DSS also collaborates with the Departments of Children and Families and Mental Health and Addiction Services on the Connecticut Behavioral Health Partnership. The CT BHP is a Partnership that consists: of the Department of Children and Families (DCF), the Department of Social Services (DSS), the Department of Mental Health and Addiction Services (DMHAS), a contracted Administrative Services Organization and a legislatively mandated Oversight Council. Expanded in 2011 to include DMHAS, the partnership is designed to create an integrated behavioral health service system for Connecticut’s Medicaid populations that provides access to a more complete, coordinated, and effective system of community based behavioral health services and support. DCF, DMHAS, and DDS also provide certain services such as targeted case management, inpatient psychiatric services for individuals under age twenty-one, and ICF/IIDs through state-operated and/or privately contracted providers that are covered under Medicaid, some of which are funded using a certified public expenditure methodology. DSS also works closely with the Department of Public Health, which administers Connecticut’s Title V program, the WIC program and many other public health programs.

Access Health CT - Connecticut’s State Based Marketplace

The Connecticut Health Insurance Exchange was established by Connecticut Public Act 11-53. The Exchange is a quasi-public agency created to fulfill the requirements of the federal Affordable Care Act. The Exchange does business under the name “Access Health CT.” The power of the Exchange is vested in a 14 member board. Under the Exchange’s statutory authority, the Governor and legislative leadership have responsibility for the appointment of several board members with differing backgrounds and expertise. The statutory authority also provides that several Executive Branch officials, including the Commissioner of Social Services, serve as Ex-Officio voting members of the Board.

MAGI-related eligibility determinations (parent and caretakers, pregnant women, single adults, children) and former foster care coverage group determinations are made in the Access Health CT System. The system is shared by the Department and Access Health CT and uses a shared rules engine.

Access Health CT and the Department maintain a very close working relationship in order to achieve the goals of the ACA. The Department of Social Services and AHCT entered into a Memorandum of Agreement to address a number of issues, including but not limited to cost allocation, system integration, responsibility for hearings and appeals, data sharing and security.

Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 A1-A3 - 6 Effective Date: 1/1/14

Page 7 of 8 Medicaid Administration Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) Remove Type of entity that conducts fair hearings: An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Add Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? Yes No State Plan Administration Assurances A3 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. ✔ All requirements of 42 CFR 431.10 are met. ✔ There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12. ✔ The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. ✔ Assurance for states that have delegated authority to determine eligibility: There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 A1-A3 - 7 Effective Date: 1/1/14

Page 8 of 8 Medicaid Administration When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 A1-A3 - 8 Effective Date: 1/1/14

TN #: 14-0004MM4 Approval Date:___6/18/14_______ Effective Date 1/1/14 Supersedes TN #: 10-21

8a

State: CONNECTICUT

Tribal Consultation Requirements

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) 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.

The State uses the following process 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. The State includes information about the frequency, inclusiveness and process for seeking such advice below:

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. Prior to submission of a State Plan Amendment, waiver, waiver amendment or other change, or demonstration project proposal to CMS, the Department sends a copy of the public notice for the amendment or other submission. If the amendment or submission does not require public notice, the State sends a brief summary of the proposed change.

The State sends the notices via e-mail. If the State has not received comments or questions concerning the State Plan Amendment, waiver or other submission within 2 (two) weeks, the State determines that the tribe does not have any questions or concerns regarding the proposal. In addition to this 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 a requirement or provision, the State will also arrange for a meeting or teleconference with the tribal representatives to discuss the proposed change.

9 TN #: 14-0004MM4 Approval Date:___6/18/14_______ Effective Date: 1/1/14 Supersedes TN #: 10-21 In addition to the ongoing consultation process on SPAs and waivers, the State tribal leads for the HUSKY and CHIP programs also 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 consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved is described below.

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 State met with the health directors for the two federally recognized tribes. At the meetings, the Department’s tribal leads described the Medicaid State Plan Amendment process and discussed the method of consultation and communication that would best serve the tribal representatives’ needs. The tribal representatives agreed to a process in which the Department sends copies of the public notice for proposed State Plan Amendments via e- mail prior to submission to CMS.

TN NO. 14-0004MM4 Connecticut Supersedes TN No. 08-003 Approval Date: 6/18/14 Effective Date: 1/1/14 /s/

TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 Effective Date: 1/1/14

TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 Effective Date: 1/1/14

TN No. 14-0004MM4 Connecticut Approval Date: 6/18/14 Effective Date: 1/1/14

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 14-0005MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

JFK Federal Building. Government Center

Room 2275

Boston. Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES,

Division of Medicaid and Children's Health Operations / Boston Regional Office

May 23, 2014

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

Dear Commissioner Bremby: We are pleased to enclose a copy of approved State plan amendment (SPA) No. 14-0005MM5 with an effective date of January 1, 2014, as requested by your Agency. This SPA affirms state

residency regulations and addresses interstate agreements and temporary absence in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014.

If there are questions, please contact Robert Cruz. He can be reached at (617) 565-1257.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosure ce:

Raymond Singleton Jr., Deputy Commissioner Marc Shok, Adult Services Program Manager

State/Territory name: Connecticut Submitted By: Marc Shok Last Revision Date: May 15, 2014 Submit Date: Mar 26, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-0005 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Affordable Care Act; 42 CFR Part 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Residency Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 CT.0829.R00.00 - Jan 01, 2014 05/27/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp Date Received: 3/26/14 Effecive Date of Approved Materials: 1/1/14 Typed Name: Richard McGreal Plan Approved - One Copy Attached Date Approved: 5/23/14 Signature of Regional Official

Division of Medicaid and Children's Health Operations, Boston Regional Office /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

14-0005 MM5 STATE:

Connecticut

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S88 Non-Financial Eligibility- State Residency

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

Section 2, Page 13, Item 2.3, TN 87-58 Attachment 2.6-A: Page 3, TN 14-0006 MM6

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ TN No. 14-0005MM5 Connecticut Approval Date: 5/23/14 S88-1 Effective Date: 1/1/14

Page 2 of 4 Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ TN No. 14-0005MM5 Connecticut Approval Date: 5/23/14 S88-2 Effective Date: 1/1/14

Page 3 of 4 Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual The state has a policy related to individuals in the state only to attend school. Yes No Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No TN No. 14-0005MM5 Connecticut Approval Date: 5/23/14 S88-3 Effective Date: 1/1/14

Page 4 of 4 Medicaid Eligibility Provide a description of the definition: The State complies with 42 CFR 435.403(j)(3). Temporary absences do not affect eligibility if individuals have the intent to return to Connecticut when the purpose of their absence is completed. Residence is considered abandoned if another state grants Medicaid. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No. 14-0005MM5 Connecticut Approval Date: 5/23/14 S88-4 Effective Date: 1/1/14

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 14-0006MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

/s/

State/Territory name: Connecticut Submitted By: Marc Shok Last Revision Date: May 15, 2014 Submit Date: Mar 26, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-0006 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Affordable Care Act; 42 CFR Part 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Citizenship and Immigration Status Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 CT.0830.R00.00 - Jan 01, 2014 05/27/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp Date Received: 3/26/14 Effective date of Approved Material: 1/1/14 Typed Name: Richard R. McGreal Plan Approved - One Copy Attached Date Approved: 6/3/14 Signature of Regional Official Division of Medicaid and Children's Health Operations, Boston Regional Office /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

TN CT-14-0006

STATE:

Connecticut

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S89 Non-Financial Eligibility- Citizenship and Non-Citizen Eligibility

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

Attachment 2.6-A: Page 2, Item 3, Subparagraphs (a), (b), and (c), TN 09-016 Attachment 2.6-A: Page 2a, TN 09-016 Attachment 2.6-A, Page 2b, TN 09-016 Attachment 2.6-A, Page 3, Item 3, Subparagraphs (d) and (e), TN 91-15

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ✔ The state provides Medicaid eligibility to otherwise eligible individuals: ■ Who are citizens or nationals of the United States; and

■ Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and ■ Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: The first day of the month in which the person meets Medicaid eligibility requirements pending verification of citizenship or satisfactory immigration status. The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: TN No. 14-0006MM6 Connecticut Approval Date: 6/3/14 S89-1 Effective Date: 1/1/14

Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No Pregnant women Individuals under age 21: Individuals under age 21 Individuals under age 20 Individuals under age 19 An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ TN No. 14-0006MM6 Connecticut Approval Date: 6/3/14 S89-2 Effective Date: 1/1/14

Page 3 of 3 Medicaid Eligibility 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0006MM6 Connecticut Approval Date: 6/3/14 S89-3 Effective Date: 1/1/14

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 14-0007MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203

CENTERS FOR MEDICARE & MEDICAID SERVICES Division of Medicaid and Children's Health Operations / Boston Regional Office

June 3, 2014

Roderick L. Bremby, Commissioner Department of Social Services

25 Sigourney Street

Hartford, CT 06106-5033

Dear Commissioner Bremby:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 14-O007MM7 with an effective date of January |, 2014, as requested by your Agency.

This SPA transmits an amendment to Connecticut’s approved Title XIX State plan to indicate that hospitals in the State determine eligibility presumptively under the option at 42 CFR 435.1110, and that the State provides Medicaid coverage for individuals determined presumptively eligible under this provision.

During the SPA review, CMS recommended a number of changes to the online version of the presumptive eligibility application which are reflected here. The following questions will be marked as optional for presumptive eligibility:

living arrangement status place of birth

educational status

current medical insurance inheritance

all asset questions

receipt of SSI

We are approving this SPA with the understanding that the State agrees to have these system changes implemented by the end of August 2014.

/s/

State/Territory name: Connecticut Submitted By: Marc Shok Last Revision Date: Mar 26, 2014 Submit Date: Mar 26, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-0007 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Affordable Care Act; 42 CFR Part 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Hospital Presumptive Eligibility Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 CT.0831.R00.00 - Jan 01, 2014 05/27/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp Date Received: 3/26/14 Effective Date of Approved Material: 1/1/14 Typed Name: Richard McGreal Plan Approved - One Copy Attached Date Approved: 6/3/14 Signature of Regional Official Division of Medicaid and Children's Health Operations, Boston Regional Office /s/

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ A qualified hospital is a hospital that: ■ Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. ■ Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. ■ Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: ■ Pregnant Women ■ Infants and Children under Age 19 ■ Parents and Other Caretaker Relatives ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. TN No. 14-0007MM7 Connecticut Approval Date: 6/3/14 S21 - 1 Effective Date: 1/1/14

Page 2 of 3 Medicaid Eligibility Yes No The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: Name of limitation Description + No more than two periods within a calendar year. x The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: ■ The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) ■ Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. ✔ TN No. 14-0007MM7 Connecticut Approval Date: 6/3/14 S21 - 2 Effective Date: 1/1/14

Page 3 of 3 Medicaid Eligibility 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 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0007MM7 Connecticut Approval Date: 6/3/14 S21 - 3 Effective Date: 1/1/14

Presumptive Eligibility for Hospitals Eff. Jan 1, 2014 Dec 4, 2013, Lois Filek, DSS/UCONN SSW Presented at CT Hospital Association Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Agenda • What is Presumptive Eligibility and when would you use it? • Affordable Care Act Changes • PE Process • Break • MAGI Medicaid and the move from presumptive to ongoing Medicaid Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Objectives • Differentiate between HUSKY groups A,B,D and who can do what. • Learn steps necessary to successfully make referrals to DSS for Presumptive Eligibility. • Given scenarios, determine Medicaid/CHIP presumptive eligibility using non-filer rules • Given scenarios, determine Medicaid/CHIP eligibility for ongoing Medicaid coverage using MAGI methodology

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

What is Presumptive Eligibility? • Presumptive eligibility provides temporary coverage until the person has applied and had his or her eligibility fully determined. • PE may be used twice in a calendar year and once per pregnancy.

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Affordable Care Act Changes • Expansion of Medicaid to adults (HUSKY D) • More groups eligible for PE (All the MAGI groups) – HUSKY D Adults (hospitals only) – Parent/Caretakers on HUSKY A) (hospitals only) • All hospitals may utilize Presumptive Eligibility for MAGI groups • No asset test for any MAGI group

• AHCT processes Medicaid applications for MAGI Medicaid groups for coverage effective January 1, 2014. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Who can apply using PE? NEW! • Parents and caretaker relatives of dependent children under 19 – HA • MLIPs – Medicaid low income population – HD (Hospitals only) • DCF Former Foster Care kids under 26

Note - Hospitals may use PE for the HUSKY groups included in their contracts with DSS. Not all hospitals will do PE for HUSKY B. Existing

• Pregnant Women – HA • Kids under age 19 – HA • Kids under age 19 HB • Family Planning • Breast and Cervical

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

MAGI Medicaid/CHIP Eligibility & New Income Limits • HUSKY A* – Children - 196% of FPL (201%)* – Parent and/or Caretakers - 196% of FPL (201%)* – Pregnant Woman - 258% of FPL (263%)* • HUSKY B/CHIP* – Band 1 <= 249% of FPL (254%)* – Band 2 between 250% (255%) and 318% (323%) – Band 3 > 318% of FPL (323%)* • HUSKY D* - Medicaid for the Lowest-Income Population – MLIP (former LIA) – 133% of FPL (138%)* Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 *There is a 5% FPL Income Disregard added to all standard limits.

When to consider Presumptive Eligibility • When your client needs immediate access to medical provider and it cannot be provided otherwise, PE will provide same day service via a voucher followed up with expedited service. • When major eligibility systems are down • When time prevents a full Medicaid application from being processed Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Certification Process and Requirements • DSS Requirements for certification – Signed contract – Attend training • Benchmarks for success – Assisting clients with complete Medicaid applications via AHCT – Referring eligible Medicaid participants

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Presumptive Eligibility Application Process • Current way -Paper – W-1PE. Fax Referral to DSS. • New and preferred way – ConneCT online application

Remember - You can use AHCT’s SSA online application and bypass PE altogether. Results are instantaneous. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Presumptive Process • Entity must check AEVS (Automated eligibility verification system) to make sure applicant is not already in receipt of HUSKY. • HHCE interviews and helps client complete application. – One page W-1PE • Determine eligibility for Medicaid/CHIP using DSS rules. DSS will allow non-filer rules for income test. • If eligible, give client voucher (W-538) good for ten days. Voucher is guarantee of payment. • New way - Key application into ConneCT • Old way - Fax referral packet to DSS within 48 hrs. (Signed, completed application form and copy of voucher with correct FastLink cover) • Entity must assist client by ensuring completion of the SSA application with AHCT. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

DSSmap/AEVS Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

ConneCT Online Application Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Presumptive Eligibility Time Frames • PE period begins on date determination is made • End date of PE period is earlier of: – Date eligibility determination for regular Medicaid is made, if application for Medicaid is filed by last day of the month following the month in which determination of PE is made or – Last day of month following month in which determination of PE is made if no application for Medicaid is filed by that date – Example: Client applies January 12. • If client doesn’t follow through with completed AHCT application, PE ends Feb 28. • Completed, signed PE application required. Incomplete or unsigned referral will not guarantee payment. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

More on Process • Regional Processing Unit (RPU) grants PE using expedited process. • If using fax process, PE Fast-Link forms are for PE only – do not send materials for other DSS programs using that phone #. • If using online process, try not to apply for multiple programs for PE purposes. • Order vouchers W-538 from DSS Public Internet site. Register for account on DSS Internet site. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Order forms from DSS Internet Site

http://www.catalog.state. ct.us/dss/eduplicating/def ault.asp Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Regional Processing Unit The 3 RPUs currently act as one workflow. They are no longer geographic. There is a special fax number for the HHCEs that expedites the work item creation at DSS Scanning Center. 1-860-812-0006 is the new fax number on the PE Fast-Link form. ****************************************** Online applications thru ConneCT for PE purposes are not to be confused with AHCT’s Medicaid application. DSS is currently piloting the ConneCT online application and there will be a checkbox that indicates the application is coming from a certified entity. You are encouraged to apply online January 1.

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

PE Application Fax Process • All paper applications faxed in will go to DSS Scanning Center via use of a Fast Link form • PE entities have a special Fast link PE form and the materials will go directly to the RPU (Regional Processing Unit) – a dedicated unit at DSS. • Fast Link form faxed to 860-812-0006 • Send each application separate to avoid problems with scanning. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Determining Eligibility for PE • Complete and signed application • Self attestation for Residency • Self attestation for Non-Citizen status • Self attestation for Pregnancy • Self attestation for Income • Income test – Non-filer rules under MAGI methodology • In general, applicant plus spouse plus kids under 19 • Compare household gross income to appropriate standards • No asset test Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

When using online ConneCT application for Presumptive Eligibility: • PE applicants must be told which questions are mandatory for PE if using a multi-program application. • DSS ConneCT online application is being re-programmed currently to ask only those questions necessary. • These questions are not required on the on-line ConneCT application: – living arrangement status pg 9, – place of birth pg 10, – educational status pg 10, – current medical insurance, pg 17 – inheritance, pg 18 – all asset questions on pgs,19,20,21 – SSI income, pg 25

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Meeting the non-citizen requirement • Qualified non-citizens who entered before 8/96. • Qualified Immigrants who reach end of five year waiting period(i.e. LPR’s/green card holders) • Qualified Immigrants exempt from 5-year waiting period (e.g., Refugees, Cuban/Haitian entrants, Trafficking Victims, Veteran families. Pregnant women and kids under 21 exempt from five year wait rule. • *No federal funding to cover undocumented immigrants, except for payment for limited emergency services.

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Review Immigrant Chart Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

HUSKY A Children under 19 • Children whose household income is below 196% +5% FPL • Children under 21 are exempt from the five year ban for lawfully present non-citizens. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

HUSKY A Parent/Caretaker Relative • Parent or caretaker relative of child under 19 whose household income is below 196% +5% FPL • These adults are subject to the five year residency rule for non-citizens.

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

HUSKY B May not be an option for all hospitals. • The Affordable Care Act give all hospitals the right to determine Medicaid for HUSKY A and D groups. • It does not give hospitals the right to determine eligibility for HUSKY B. • DSS would have to give authority via the contract. • Some hospitals had HUSKY B in prior contracts. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

PE for Kids under HB (CHIP)

• The ACA did not give hospitals authorization to do HUSKY B PE grants. If a hospital wants to do PE for HUSKY B, they will need a separate contract. Write to patricia.mccooey@ct.gov • PE process may be used for kids under 19 whose income exceeds Medicaid limits (over 201% and up to 318% +5% FPL) • Do not refer applicant for PE when household income exceeds 318% + 5%FPL. • When the child being referred for PE is HB, fax packet to Xerox using Xerox fax # • Additional rules for HB – please see HUSKY B procedures. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

PE for Pregnant Women HUSKY A • Unborn counts as household member for pregnant woman only • Exempt from five year residency rule for lawfully present non-citizens • Uses higher income limit – 258% +5% FPL • PE may be used with each pregnancy

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

PE for Medicaid Lowest Income Population - HUSKY D HOSPITALS ONLY • Adults 19-64 • This group uses 133% +5% FPL • This group is for healthy adults but: – Disabled adults on SSDI/SSI (or found disabled by Colonial Cooperative at DSS) may opt for this group as it has a higher income limit and no asset test. The individual must not me on Medicare. • Medicare recipients must not use MLIPS. (one exception is caretaker/parent on Medicare) Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

PE for Family Planning HUSKY E • Child bearing age • Family Planning is a limited coverage benefit. • HUSKY E client must get other coverage that satisfies minimal essential coverage requirements or face tax penalty • Family Planning uses 258% +5% FPL • Family Planning is unique in confidentiality aspect. Kids under 21 won’t have parent’s income counted and any private insurance will not be billed if found to be confidential • TPL exemption process isn’t limited to minors. • Federal law prohibits an age cutoff for family planning, but services are only for clients who need family planning services Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

PE Breast and Cervical • Must have been found eligible by CDC approved hospital or not eligible • No income or asset rules apply if found eligible in CDC approved entity and without insurance • Check CDC (Center for Disease Control) site for list of approved facilities • AHCT does not currently screen for this program. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Former DCF kids up to age 26 • For young adults leaving foster care system, mirrors ACA provision allowing children to stay on parent’s policy • Once identified as former DCF, there are no income or asset tests applied. • Coverage is up to age 26.

• * Until DSS ConneCT system includes a question on this population, please submit paper application W-1PE. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Common Errors • Do not give undocumented non-citizens PE • Undocumented parent’s income counts but they are not part of the household size. • Do not give lawfully present non-citizens here less than five years PE unless pregnant or under age 21. • Do not give PE to a HUSKY B applicant whose household income exceeds 318% + 5% FPL Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

The Income Test for Presumptive Eligibility Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Use Non-Filer Rules Using Non-filer rules – determine household size For individuals living together, include: • applicant • spouse • dependent children under 19 • if applicant is child under 19, count parents and siblings under 19 • Natural, adopted and step Household size determines: • Whose income counts • What size if the family for purposes of comparing to FPL Chart? Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Income Calculation • Determine frequency of each type of income. • Convert to a monthly amount using the following formulas: – Weekly – multiply by 4.3 – Bi-weekly – multiply by 2.15 – Semi-monthly – multiply by 2 – Monthly – no conversion required – Annually – divide by 12 If gross amount not provided, probe further about hourly rate of pay and number of hours worked per week or pay period Hourly rate x number of hours/week or pay period Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Countable Income

Income sources used in determining the adjusted gross income include but are not limited to:

• Wages/tips • Unemployment • Pension and annuities • Income from business or personal services • Interest • Alimony received • Social Security benefits (RSDI) • Foreign earned • Lump sum in the month received • Self-employment • Military-retirement/pension Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Non-Countable Income

• Child support • Veterans’ benefits • Gifts and inheritances • Worker’s compensation • Supplemental Security Income (SSI) • Scholarships, awards, or fellowship grants used for educational expenses. Any amount used for living expenses is countable income (room and board). • Lump sums, except in the month received • Certain Native American and Alaska Native income Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Example • 35 yr old father applies. He resides with his girlfriend and their two common children. • He earns $28,000 a yr. She earns $40,000.

• Whose income counts under non-filer rules? – Just his. They’re not married. – What size is the family? 3 – Make the PE referral – Income is below HUSKY A for parent group. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Assisting the client in establishing ongoing Medicaid is a benchmark of success. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Assisting your client with AHCT application for Medicaid/CHIP • Complete SSA application form AH2 (individual) or AH3 (family) for AHCT • Access Health CT will verify and determine eligibility for – Medicaid – CHIP – Offer health plans on exchange and notify if eligible for advanced premium tax subsidy (APTC) • Consumer will receive instantaneous decision on eligibility. • Access Health CT will grant to the 1st of the month found eligible under Medicaid rules. (including 3 month retro if requested) • Once found eligible for Medicaid, AHCT communicates with DSS to place client on DSS eligibility system (EMS)

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Access Health CT CT Health Exchange/Marketplace • http://www.accesshealthct.com/ • The following MAGI Medicaid populations will apply via AHCT: – HUSKY A (Kids under 19) – HUSKY A (parent/caretaker relatives) – HUSKY B (Kids under 19 over income for Medicaid) – HUSKY D – Adults -19-64 (Medicaid Lowest Income Populations) If they begin on DSS ConneCT site, will be re- directed to AHCT Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

AHCT • AHCT will determine eligibility for Medicaid, CHIP. • If over income for Medicaid/CHIP, AHCT will notify the consumer if they qualify for a subsidy in the form of tax credits. • Client can then compare and enroll in a qualified health plan QHP. • AHCT will give 90 day reasonable opportunity periods for client/consumer to provide verifications. Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

AHCT • Applying via AHCT ensures client pursues ongoing coverage beyond PE period. • Applying via AHCT allows for verification via Federal Data Services Hub • AHCT will use Federal Hub to verify: – Citizenship and Non-Citizen status – Income – Identity – Social Security number Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Names of PE groups on DSS computer

– F06 – Kids under 19 – F06 – Pregnant Woman (some offices use P02) – M07 – Family Planning – M09 = no income limit = Former Foster Care – M10 = PE MLIP – M11 = PE Parent/Caretaker

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Review of Presumptive Eligibility Process • Complete W-1PE form. • Determine eligibility for PE using non-filer rules to establish household composition. Once you know whose income to count, compare gross household income to appropriate standard. • If eligible, give client W-538 voucher for same day use. Follow directions on voucher fax to RPU, copy to Central Office and your records. Voucher is good for ten days. • Fax packet materials (completed application, copy of voucher to RPU using special FastLink fax cover sheet.) This fax will go to the DSS Scanning Center and end up as a work item in the RPU work flow.

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Modified Adjusted Gross Income (MAGI) Based on Federal Income Tax Rules Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

What is MAGI? • A methodology for how income is counted and how household composition and household size are determined. • Based on federal rules for determining Adjusted Gross Income (with some modifications) Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 MAGI is not just a number on a tax return!

How is MAGI Calculated? • MAGI = Adjusted Gross Income (AGI) plus: – Excluded foreign income – Tax-exempt interest – Tax-exempt Social Security Income • Additional modifications for Medicaid only: – Certain scholarships, awards or fellowship income are excluded. – Certain Native American/Alaska Native income is excluded. – Lump sum income counted only in month received.

Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

MAGI does not include: • Child support income • Worker’s Compensation • Veteran’s Benefits • SSI

Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Other changes for Medicaid/CHIP using MAGI Methodology • Uses TAXABLE income • Non-taxable income not counted • For earned income – “pre-tax” payroll deductions may be used to reduce the individual’s gross income and determine “countable” income • Other allowable deductions – alimony paid, student loan interest

Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Types of “Pre-Tax” Payroll Deductions • The types of payroll deductions that can be subtracted from the gross pay include: – Most health insurance premiums paid by the employee – Employee contributions to 401(k) and 403(b) retirement plans – Employee contributions to the State Retirement system – Contributions to Deferred Compensation plans – Flexible spending accounts Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Programs that Use MAGI Methodology • Public health programs; HUSKY A, HUSKY B (CHIP) and HUSKY D, and; • Federal affordability subsidies to reduce the cost of obtaining private insurance and accessing care: – Cost Sharing Reductions (CSR) that will lower out of pocket cost (250% FPL) – Advanced Premium Tax Credits (APTC) that will lower cost of monthly premiums (400% FPL) Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

MAGI Medicaid/CHIP Eligibility & New Income Limits • HUSKY A* – Children - 196% of FPL (201%)* – Parent and/or Caretakers - 196% of FPL (201%)* – Pregnant Woman - 258% of FPL (263%)* • HUSKY B/CHIP* – Band 1 <= 249% of FPL (254%)* – Band 2 between 250% (255%) and 318% (323%) – Band 3 > 318% of FPL (323%)* • HUSKY D* - Medicaid Coverage for the Lowest-Income Population – MCLIP (former LIA) – 133% of FPL (138%)* Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 *There is a 5% FPL Income Disregard added to all standard limits.

MAGI Excluded Populations • Will be referred to as ‘classic’ Medicaid – HUSKY C (S-Track) • Aid to the Aged, Blind and Disabled (AABD) – Long-Term Care – Community Based Waivers – People eligible for Medicare Buy-In • Continue to be processed by DSS computer • Same income limits • Same asset test

Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Modified Adjusted Gross Income (MAGI) • Modified Adjusted Gross Income (MAGI) is a methodology that uses federal income tax rules and concepts to: – Construct the MAGI household for each applicant and determine household size; – Determine countable income for each household; and – Determine eligibility for MAGI Medicaid/CHIP. Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

MAGI Determination based on Tax Filing Questions • Will need to know: – How an individual expects to file federal income taxes for the year in which they seek health care coverage/benefits; and – Relationship between applicants. • If seeking coverage for 2014: – Filing status and 2013 income (usually filed by 4/15/14) – Projected income for 2014 • If applying during open enrollment in October 2014: – Filing status and 2014 income (usually filed by 4/15/15) – Projected income for 2015 Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

MAGI Household Composition • Uses Tax Rules: – Tax Filers; – Tax Dependents – Exceptions; and – Non-Filers; An individual who: • Does not expect to file taxes; • Meets exception as a tax dependent; or • Does not expect to be a tax dependent. • Each individual will have their own determination for Household size.

Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

MAGI Household Size: Tax Filers • A tax filer is an individual who expects to file taxes and not be claimed as a tax dependent. • Household Size always includes: – The tax filer; – Their spouse, if living together; and – All persons whom the taxpayer expects to claim as a tax dependent. Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

What is a Tax Dependent o Expects to be claimed as a tax dependent; o Must consider exceptions for dependents; and o Household Size depends on whether individual meets an exception. Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Exceptions for Tax Dependents • Claimed as a tax dependent by someone other than a spouse, biological, adopted or step-parent, or • If under 19: – Lives with both parents, but the parents do not file a joint tax return, or – Claimed as a tax dependent by a non-custodial parent. Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Household Size: Tax Dependents • Tax Dependent – With no exception – Same household size as tax payer claiming them, and – If married, their spouse, if they live together. • Tax Dependent – With exception – Use Non-Filer Rules Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

MAGI Household Size – Non-Filers • Always includes: – The individual; – Spouse, if living together; and – Their children under the age of 19 (natural, adopted, and step)

• For Individuals under 19, include parents and siblings under 19 (natural, adopted, and step)

Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

MAGI Medicaid Examples Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Medicaid Eligibility Example - #1 Determine Household Size Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Mary and Bob are a Married couple with two children, Mark (8) and Melissa (10). They file taxes jointly and claim both children as tax dependents. Household Size for each individual = 4. In this example, household composition is constructed the way we currently would under classic Medicaid rules.

Medicaid Eligibility Example - #1 Determine Countable Income Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Household Size for each individual = 4. Mary work part-time and has countable income of $8,500/y. Bob works full- time and has countable income of $35,000/y. Mark and Melissa have no income. Total income counted for each individual = $43,500.

Medicaid Eligibility Example - #1 Determining Eligibility Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 MAGI Medicaid Income Limit for HUSKY A - 196% of the FPL. Total Countable Income = $43,500 196% of the FPL (for 4) = $46,158 Mary and Bob are eligible for HUSKY A as Parents/Caretakers. Mark and Melissa are eligible for HUSKY A as Children.

Medicaid Eligibility Example - #2 Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Peter is divorced and has custody of his two children, Max (23) and Theresa (15). Peter will file taxes and claim both children on his tax return. Max and Theresa do not expect to file taxes. Max Tax Dependent Child - 23 Theresa Tax Dependent Child - 15 Peter Parent

Peter is a tax filer and will claim both children. Peter’s household size = 3 Max is a tax dependent who does not meet an exception. Therefore, Max’s household size is the same as the tax filer (Peter) who is claiming him = 3. Theresa is also a tax dependent who does not meet an exception. Therefore, Theresa’s household size is the same as the tax filer (Peter) who is claiming her = 3. Medicaid Eligibility Example - #2 Determine Household Size Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Medicaid Eligibility Example - #2 Determine Countable Income • Peter works full-time and reports $37,550 of countable income per year. • Max does not work and has no other income. • Theresa does not work and has no other income.

Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Total income for each individual is $37,550

Peter is a parent. His annual income ($37,550) is less than 196% FPL for HH of 3 ($38,279). He is eligible for HUSKY A. Max is over 19 and not eligible for HUSKY A. So, his countable income ($37,550) is compared to 133% of the FPL for 3 – HUSKY D. He is over-income. Theresa is a child under 19. Her countable income ($37,550) is less than 196% of FPL for HH of 3. She is eligible for HUSKY A. Medicaid Eligibility Example - #2 Determine Medicaid Eligibility Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Practice Scenario • Determine the household size, amount of countable income for each household and eligibility for health care coverage: – Thomas and Mary are married. They are applying for health care coverage for themselves, their 22 year old son (Christopher) and their 16 year old son (Steven).

– Thomas and Mary will file taxes jointly and will claim both Christopher and Steven as tax dependents.

– Thomas is employed at ABC Corp and makes $31,000 per year. Mary is recently unemployed and not eligible for UCB. Christopher and Steven also do not have any income.

Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Practice Results Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Thomas Mary Christopher Steven Household Size 4 4 4 4 Countable Income 31,000 31,000 31,000 31,000 Eligible for: HUSKY A HUSKY A HUSKY D HUSKY A

Medicaid Eligibility Example - # 3 Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Jeff and Lisa are an engaged couple who live together and have two children in common. Lisa is pregnant expecting 1 child. Each parent claims one child on their separate tax returns. Angie Dependent Child claimed by Jeff Lewis Dependent Child claimed by Lisa Jeff Lisa

Medicaid Eligibility Example - # 3 Determine Household Size (Jeff) Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Angie Tax Dependent Jeff’s Household Size = 2 • Jeff is a tax filer = 1 • Jeff will claim Angie as a tax dependent = 1

Medicaid Eligibility Example - # 3 Determine Household Size (Lisa) Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Lisa Lisa’s Household Size = 3 • Lisa is a tax filer = 1 • Lisa will claim Lewis as a tax dependent = 1 • Lisa is pregnant with one child = 1 Lewis Tax Dependent

Angie’s (Lewis’) Household Size = 4 Medicaid Eligibility Example - # 3 Determine Household Size (Angie/Lewis) Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Angie (Lewis) is a tax dependent = 1 each Angie (Lewis) lives with both parents who will not file a joint return; therefore meet an exception. Count parents & sibling = 3 each Meet an exception?

Medicaid Eligibility Example - # 3 Determine Income Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 Angie Dependent Child claimed by Jeff Lewis Dependent Child claimed by Lisa Lisa works full time, and earns $45,000. Angie and Lewis have no income Jeff works full-time and earns $25,000.

Medicaid Eligibility Example - # 3 Determine Eligibility (Jeff/Lisa) Connecticut TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 • Jeff’s household size = 2. • Jeff’s income is $25,000. • Based on the annual FPL chart for 2 ($30,400), he is below 196% FPL. • Eligible for HUSKY A (Parent). • Lisa’s household size = 3. • Lisa’s income is $45,000. • Based on the annual FPL chart for 3 ($50,388), she is below 258% FPL. • Eligible for HUSKY A (Pregnant).

Medicaid Eligibility Example - # 3 Determine Eligibility (Angie/Lewis) Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14 • Angie and Lewis’ household size = 4. • Total countable income is $70,000. • Based on the annual FPL chart, they are above 196% FPL ($46,158) • Eligible for CHIP (HUSKY B).

Example #4 - Scenario • Use same family as example #3 • Parents get married, file taxes jointly. • Child is born. Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Example #4 - Results • Household size for each individual is 5 • Total countable income = $70,000 • Eligibility – Mom and Dad • Not eligible for HUSKY A - Over Income • Eligible for Advanced Premium Tax Credit (APTC) – Children • Eligible for HUSKY B (Band 2) Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Questions and Next Steps Connecticut TN No. 14- 0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Connecticut

W-1PE (Rev 4/14)

Name: ______________________ __________ ______________________________________

First Middle Initial Last

Residential Address: _________________________________________________________________

Telephone Number (optional) : ______________________

Do you need a translator to help you fill out your application? No ______Yes______ If “yes,” what language? _____________________

Were you in Connecticut Foster Care at the age of 18 and receiving Medicaid at that time? No ______ Yes______

Are you pregnant? No ______ Yes _____ If yes, what is your due date? ______________________

How many babies are you expecting with this pregnancy? ____________

Section 1. Household Composition Please list all family members (spouse, children, parents, siblings) living in your household. Name Relationship to Applicant Date of Birth Social Security # (optional) Gender

Yourself

M F

M F

M F

M F

M F Section 2. Income Please list Taxable Gross Income for you and anyone else in your household. Please include any gross taxable wages from employment, gross Social Security (including your Medicare Part B premium), pensions, annuities, disability benefits, alimony, interest, Unemployment Compensation, dividends, rental property income, self-employment income. Name of Person Receiving Income Source (List name of employer if working) Taxable Gross Monthly Amount

Self

$

$

$

$

Total Taxable Gross Monthly Income $

Notice to Presumptive Eligibility applicant: Presumptive Eligibility provides HUSKY coverage for a limited period of time: coverage will expire at the end of the month which follows the month of State of Connecticut Department of Social Services

Application for HUSKY Presumptive Eligibility DSS Use Only

CLID: ___________________

App. Date: _______________

TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Connecticut

application approval. YOU MUST SUBMIT ANOTHER APPLICATION for ongoing Medicaid/CHIP coverage.

Citizenship/Immigration Status

Please check the applicable status:

________ Yes, I am a U.S. Citizen.

OR,

________ No, I am not a U.S. Citizen.

If not a U.S. Citizen, provide status below:

_________ Lawful Permanent Resident (Green Card Holder).

Date of U.S. Entry (if available)*(see below)____________ Immigration # (if available)__________________________

OR ,

_________ Asylee, Refugee, Cuban/Haitian Entrant

Immigration # (if available)___________________________

OR,

_________ Other Immigration status not listed above

Please specify type ________________________________

*Most green card holders must live in the U.S. for five (5) years before they can get Medicaid/CHIP. The five (5) year rule does not apply to pregnant women or children under 21 years of age.

If you are not lawfully present in the U.S. and do not have any eligible immigration status, you may only be eligible for coverage of emergency services. You cannot use this application. You may apply on-line at our website www.connect.ct.gov or by the W-1E General Application, which can be obtained by calling 1-877-284-8759.

TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Connecticut

I certify I have read and understand this form. I declare that the information I have provided is true, correct and complete. I may be required to document my Citizenship/Immigration status when I submit a full application for Medicaid/CHIP.

________________________________________________ __________________________ Applicant or Authorized Representative’s Signature

Date

Fax To: Department of Social Services, Scanning Center Fax Number: 860-812-0006

DO YOU WANT TO REGISTER TO VOTE?

Federal and state laws require the Department of Social Services (DSS) to give you the chance to register to vote. Please answer the questions below and print and sign your name in the space provided.

Are you registered to vote?  Yes I am already registered  No

To be completed by the Presumptive Eligibility site

PE Site Name: ______________________________________________

PE Site Representative: ______________________________________

Telephone Number: _________________________________________

Notice: Applications for on-going Medicaid/CHIP may be submitted on-line at AccessHealthCT.com or by calling 1-855-805-4325.

Department of Social Services strongly encourages use of the Presumptive Eligibility On-line application available on the DSS ConneCT site: https://connect.ct.gov/access/.

TN No. 14-0007MM7 Approval Date: 6/3/14 Effective Date: 1/1/14

Connecticut

If you are not registered to vote where you live now, would you like to apply to register to vote

here today?  Yes  No

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.

To register, complete a voter registration application form and leave it at DSS or mail it in. The form is included with DSS applications that we mail to you, and you can also get one at all DSS offices. You can mail your completed form to DSS in the enclosed envelope or send it directly to your Town Hall. If you need help, please call 1-855-626-6632.

_______________________ ___________________________ ______________ Print Your Name

Your Signature

Date

Address_____________________________________________________________________ Number Street City State

For Worker’s Use Only Date__________________  No check boxes checked  Voter Registration Card Sent Worker Name________________________ Worker DMC Number___________________ --------------------------------------------------------------------------------------------------------------------- (Tear Here and Keep) If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose you own political party or other political preferences, you may file a complaint with: State Elections Enforcement Commission, 20 Trinity Street, Hartford, CT 06106; 860-256-2940, toll-free 866-733-2463, TDD: 1-800-842-9710;SEEC@ct.gov.

Table of Contents State/Territory Name: Connecticut State Plan Amendment (SPA) #: 14-015MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN ST.]RVICES Centers for Medicare & Mcdicaid Scniccs JFK Federal Building. Govemment Centcr Room 2275 Boston. Massachusetts 02203 Division of Medicaid and Children's Health Operations / Boston Regional Office January 31. 2014 Roderick L. Bremby, Commissioner Depanment of Social Services 25 Sigoumey Street Hartford, CT 061 06-5033 Dear Commissioner Bremby: We are pleased to enclose a copy of approved State plan amendment (SPA) No. 14-015MMl with an effective date of January l,20l4,as requested by your Agency. This proposed SPA transmitted an amendment to Connecticut's approved Title XIX State plan to cover the new Adult Group as described in Section 42 CFR 43 5.1 I 9 and Section 1902(a)( l0)(A)(i)(VIII) ofthe Social Security Act. we reviewed this SPA for compliance with 91902(a)(73) of the Social Security Act, as added by $5006(e) of the American Recovery and Reinvestment Act of2009, Public Law l1l-5. This SpA was also reviewed in conjunction with provisions of the Affordable Care Act, public Law I I t-148. If there are questions, please contact Marie Montemagno. She can be reached at (617) s65-9157. Sincerely, /s/ Richard R. McGreal Associate Regional Administrator Enclosure Raymond Singleton Jr., Deputy Commissioner Marc Shok, Adult Services Program Manager curs ctNTtas foR MtDtcAxt & MtDtcAtD s[{vtcts

State/Territory name: Connecticut Submitted By: Marc Shok Last Revision Date: Jan 22, 2014 Submit Date: Jan 22, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-015 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Affordable Care Act; 42 CFR Part 435 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 770284714.00 Second Year 2015 $ 1226908712.00 Subject of Amendment S32 - Individuals Below 133% of FPL Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 CT.0746.R00.00 - Jan 01, 2014 02/24/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp Date Received: 1/22/14 Effective date of Appoved Material: 1/1/14 Typed Name: Richard McGreal Plan Approved - One Copy Attached Date Approved: 1/31/14

Signature of Regional Official:

Division of Medicaid and Children's Health Operations, Boston Regional Office /s/

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Adult Group S32 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. Yes No Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Have attained age 19 but not age 65. ■ Are not pregnant. ■ Are not entitled to or enrolled for Part A or B Medicare benefits. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B. ■ Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. Have household income at or below 133% FPL. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ There is no resource test for this eligibility group. ■ Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. ■ Under age 19, or A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: Under age 20 Under age 21 Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No TN No. 14-0015MM1 Connecticut Approval Date: 1/31/14 S32 - 1 Effective Date: 1/1/14

Page 2 of 2 Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No. 14-0015MM1 Connecticut Approval Date: 1/31/14 S32 - 2 Effective Date: 1/1/14

Table of Contents

State/Territory Name: CT

State Plan Amendment (SPA) #: 14-0027

This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

7500 Security Boulevard, Mail Stop S2-26-12

Baltimore, MD 21244-1850

(CENTER FOR MEDICAID & CHIP SERVICES:

Financial Management Group MAY 14 2015 Roderick L. Bremby, Commissioner Department of Social Services 25 Sigourney Street Hartford, CT 06106-5033

RE: Connecticut 14-027

Dear Mr. Bremby:

We have reviewed the proposed amendment to Attachments 4.19-A, of your Medicaid State plan submitted under transmittal number (TN) 14-027. This amendment replaces the existing plan language with a comprehensive description of the reimbursement methodology for the state’s public chronic disease hospital (CDH) owned and operated by the Department of Veterans’

Affairs (DVA).

°

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447. We are pleased to inform you that Medicaid State plan amendment 14-027 is approved effective July 1, 2014. We are enclosing the CMS-179

and the amended plan pages.

If you have any questions, please call Novena James-Hailey at (617) 565-1291.

Sincerely,

Timothy Hill Director

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO, 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: CT TRANSMITTAL AND NOTICE OF APPROVAL 14-027 OF STATE PLAN MATERIAL 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE .

FOR: HEALTH CARE FINANCING ADMINISTRATION ; SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE:

CENTERS FOR MEDICARE AND MEDICAID SERVICES July 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE.OF STATE PLAN MATERIAL (Check One):

__NEW STATE PLAN ___AMENDMENT TO BE CONSIDERED AS NEW PLAN _X_ AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS ISAN AMENDMENT (Sepajate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 7, FEDERAL BUDGET IMPACT: " "Section 1905 (a)(1) of the Social Security Act a FEY 2014 $0 42 CFR 440.10 and 42 CFR 447.253(a)(b)and(c) b.FFY 2015 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT;| 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR . . ATTACHMENT (if applicable) Attachment 4.19-A Page 2a, 2b, 2c, 2dy ae New

10. SUBJECT OF AMENDMENT: Effective July 1, 2014, this SPA proposes to amend Attachment 4.19-A of the Medicaid State Plan to revise the reimbursement language for public:chronic disease hospitals to set forth a reimbursefnent methodology for establishing payment rates. No fiscal impact is associated with this change.

11, GOVERNOR’S REVIEW (Check One):

X_GOVERNOR’S OFFICE REPORTED NO COMMENT __OTHER, AS SPECIFIED: __COMMENTS OF GOVERNOR'S OFFICE ENCLOSED __NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12, SIGNATURE OF STATE.AGENCY OFFICIAL: 16. RETURN TO: sae ges State of Connecticut ——._—, _. | Department of Social Services - 9" floor 13. TYPED NAME: Roderick Lypifemby 55 Farmington Avenue Hartford, CT 06105 14. TITLE: Commissioner ne . a : } Attention: Ginny Mahoney

is. DATE SUBMITTED. September 26, 2014

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: ; 18. DATE APPROVED: MAY 14 2019 PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIA: 01 2014 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: : j 22. TITLE? 5 ot vustin Ean Deputy Director, PMG

23. REMARKS: Pen and ink change in box B per Stare regues* and CMS approval.

- Attachment 4.19A Page 2a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Connecticut Methods for Establishing Payment Rates for Public Chronic Disease Hospitals

1) Public Chronic Disease Hospital Services: a. Definition of Public Chronic Disease Hospital (CDH) Services

The CDH services provided by the State of Connecticut Department of Veteran’s Affairs (CT DVA) includes hospital-based professional and facility services, both routine and ancillary services. A public CDH billing will be triggered when a Medicaid-eligible client had a recorded inpatient day in a public CDH. A Medicaid public chronic disease hospital service “Unit” is defined when a client is present at midnight for the census count. Costs of the facilities are determined in accordance with the Medicare cost identification principles described in PRM-15-2 and 45 CFR 95. Documentation of a recorded inpatient day shall be maintained in facility’s records. A payment for CDH services will not duplicate payments made under Medicaid for other services covered under the program. CDH costs identified are Medicaid covered services provided to Medicaid eligible recipients.

b. Interim Rates

Interim rates for public CDH services provided by CT DVA shall be updated annually. Interim rates for public CDH services will be computed using settled costs from the prior state fiscal year for public CDH services provided to Medicaid clients in a public CDH rounded up to the nearest $10. The prescribed methodology for the calculation of the interim rates is described below in section “d. Cost Reimbursement Methodology” and the timing of settlement is described below in section “e. Settlement.” Interim rates are provisional in nature, pending the completion of cost reconciliation and cost settlement for the rate period, as noted below in section “e. Settlement.” Payments for public CDH services provided by CT DVA will not duplicate payments made under Medicaid for other covered services.

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Page 2b STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

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Methods for Establishing Payment Rates for Public Chronic Disease Hospitals

c

iCostCenter#| Description

. Cost Reports

Final reimbursement is based on the Public CDH Per Capita Rate Calculation which is a CT DVA certified cost report that is completed by the Connecticut Office of the State Comptroller. Cost reports will include detailed cost data, including direct costs, operating expenses related to direct services, indirect costs, and general and administrative costs in support of public chronic disease hospital services. The Public CDH Per Capita Rate Calculation prepared by the Office of the State Comptroller shall utilize Form CMS-2552-10 and adhere to the Medicare cost reporting guidelines. The Public CDH Per Capita Rate Calculation is due to the Department of Social Services no later than 8 months following the close of the state fiscal year during which costs were incurred. Cost reports are subject to desk review by

the Department of Social Services or its designee. Desk review will be completed within 8 months following the receipt of the cost reports.

°

Cost Reimbursement Methodology

In determining Medicaid allowable costs for providing services at a public CDH, the following elements are included and calculations made:

i. Direct costs of providing public CDH services shall include salary, wage, fringe benefits and worker’s compensation that are directly identified as public CDH services, including costs that are integral to the delivery of public CDH services. For purposes of this subsection, allowable direct costs include costs from the

__ inpatient cost center and ancillary cost centers.

inpatient 30. |UP Routine Senices, 54 67 Occupational Therapy 68 [Speech Therapy | 69 —Electrocardiology — TN# 14-027 Approval DateMAY 14 2019 Effective Date July 1, 2014 \ Supersedes

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

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Methods for Establishing Payment Rates for Public Chronic Disease Hospitals

iv.

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Other direct costs, purchases and supplies necessary for CDH services, are determined using PRM 15-2 guidelines as used to identify allowable costs included in Form CMS 2552-10. These costs are. directly attributable to activities performed by personnel who deliver public CDH services and costs necessary to support the delivery of public CDH services.

Total direct costs include the sum of items i. and ii. above. Total direct costs are reduced by any federal payments for those costs, resulting in adjusted direct costs for public CDH services.

A proportional amount of administrative costs will be allocated to the direct service inpatient and ancillary cost centers. Administrative costs are captured in the following general service Medicare cost centers:

Medicare Cost Center #

4 Employee Benefits 5 Administrative and General 6 Maintenance and Repairs 7 Operation of Plant 8 Laundry and Linen Senice 9 Housekeeping 10 Dietary 12 Maintenance of Personnel 13 Nursing Administration 15 Pharmacy 16 Medical Records & Medical Records Library 17 Social Serice

Indirect costs shall include a portion of the Statewide Cost Allocation Plan (SWCAP) allocation, building and equipment depreciation, and bond interest, which are recorded on Worksheet A-8.

The general service administrative costs and indirect costs shall be allocated

using PRM 15-2 guidelines and in accordance with Form CMS 2552-10 and cost report instructions.Following are the allocation methodologies used in the

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Connecticut

Methods for Establishing Payment Rates for Public Chronic Disease Hospitals

CMS-2552 Cost Report: Capital Related Costs for Building and Fixtures, Capital Related Costs for Moveable Equipment, Maintenance and Repairs, Operation of Plant, and Housekeeping, are allocated using square footage; Employee Benefits using salaries; Administrative and General using accumulated costs; Laundry using pounds of laundry; Dietary using number of meals; Maintenance of Personnel by number of employees housed onsite; and Nursing Administration, Pharmacy, Medical Records and Library, and Social Service using time allocations. SWCAP is allocated as part of Employee Benefits and Administrative and General and Building and Equipment depreciation and Bond Interest are allocated as part of Capital Related to Building and Fixtures.

vii. | The Medicaid reimbursable costs are recorded on Schedule B Part I of the CMS-2552 Cost Report, Column 26, lines 30,54, 60, 65, 66, 67, 68, and 69.

Medicare |

__Cost Center Description _ {Medicare Cost Report Reference

"30 linpationt Routine Services (Worksheot 8, Part (Line 30, Column 25 54 Radiology Worksheet B,, ine 54, Column 21

$0. {Laboratory We Par 26.

5 ____ Respiratory Therapy . 26 66 Physical Therapy Part |, Line 66, Column 26 &7 Occupational Therapy Worksheet 8, Part |, Line 67, Column 26

__... 68 [Speech Therapy [Worksheet 8, Part |, Line 68, Column 26 69 Electrocardiclogy Worksheet B, Part |, Line 69, Column 26

Additional Medicaid allowable costs are Physician services, Clinical and APRN services, and Dental services reduced from the Medicare Part A costs on the CMS-2552 CR. These cost items are reduced on Worksheet A-8-2 and Worksheet A-8 and are added back for Medicaid purposes.

viii. | The per diem rate for public CDH services is calculated by dividing the Medicaid reimbursable public CDH costs under item vii. by the total available days for the same period, as recorded on Worksheet S-3, Part I, Line 1, column 3. The Medicaid allowable costs are calculated by the per diem rate multiplied by the Medicaid days for the same period, as recorded on Worksheet S-3, Part I, Line 1, column 7.

Settlement Public CDH claims paid at the interim rate for public CDH services delivered by CT

DVA during the reporting period, as documented in the MMIS, will be compared to the total Medicaid reimbursable cost based on the Cost Reimbursement Methodology

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Methods for Establishing Payment Rates for Public Chronic Disease Hospitals

identified in subsection (d) above. CT DVA’s interim rate claims for public CDH services will be adjusted in aggregate. This process results in cost reconciliation.

Reconciliation will occur within 24 months of the end of.the reporting period contained in the submitted cost report. Connecticut will not modify the CMS-approved scope of costs or the annual cost report methodology without CMS approval. If it has been determined that an overpayment has been made, the Department of Social Services will return the federal share of the overpayment pursuant to 42 CFR 433, Subpart F. If the actual, certified Medicaid reimbursable costs of a public CDH exceed the interim Medicaid rates, the Department of Social Services will submit claims to CMS for the underpayment. Cost settlement will occur within the timelines set forth in 42 CFR 433, Subpart F.

Audit

All supporting accounting records, statistical data and all other records related to the provision of public CDH services delivered by CT DVA may be subject to audit. Ifan audit discloses discrepancies in the accuracy and/or allowances of actual direct or indirect costs or statistical data as submitted for each fiscal year by CT DVA, the Department of Social Services’ payment rate for such period shall be adjusted as necessary.

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