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

(ct-11-004)(approval-document)(page-2)Page 2#

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 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If applicable)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

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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-

(ct-11-033)(approval-document)(page-5)Page 5#

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

(ct-12-003)(approval-document)(page-3)Page 3#

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)

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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

(ct-12-010)(approval-document)(page-2)Page 2#

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 4.19P x: {

e Attachment 4./9B vage Hey

® Addenduin page 4dq) to 4

e Addendum page 4d to Atiach

(ct-12-010)(approval-document)(page-4)Page 4#

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)

(ct-12-010)(approval-document)(page-5)Page 5#

’

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

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

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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

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

b. Occupational Therapy

TN # 12-010 Supersedes TN # 09-013

ii.

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

(ct-12-010)(approval-document)(page-9)Page 9#

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

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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

(ct-12-010)(approval-document)(page-11)Page 11#

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.

i. Licensed Marital and Family Therapists Services

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

TN# 07-013

(ct-12-010)(approval-document)(page-12)Page 12#

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.

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

(ct-12-013)(approval-document)(page-3)Page 3#

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

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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

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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

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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

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

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

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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

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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

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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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:

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

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

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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

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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:

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

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

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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

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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

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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:

□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

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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)

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

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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:

_________________ 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

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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)

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

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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

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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

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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

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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

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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

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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

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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.

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

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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

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

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.

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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

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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

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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

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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

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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

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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

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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.

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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

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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.

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- 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.

TN# 14-027 Approval DateMAY 14 201% Effective Date July 1, 2014 Supersedes

TN# New

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Attachment 4.19A

; Page 2d

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

TN# 14-027 Approval Dateyay -4-4-94te Effective Date July 1, 2014 Supersedes

TN# New

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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

January 27, 2017

Roderick L. Bremby, Commissioner Department of Social Services

55 Farmington Avenue

Hartford, CT 06105

RE: CT SPA 17-0001/Section 1915(i) Home and Community-Based Services (HCBS) Renewal

Dear Commissioner Bremby:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 17-0001 with an effective date of February 1, 2017 as requested by your Agency.

This SPA is an amendment to Connecticut’s approved Title XIX Medicaid State plan to renew the home and community-based services benefit under Section 1915(i) of the Social Security Act for individuals 65 and older who meet the needs-based and financial eligibility criteria in the approved SPA.

This SPA has an expiration date of January 31, 2022. Since the state has elected to target the population who can receive Section 1915(i) State Plan HCBS, CMS approves this SPA for a five-year period, in accordance with Section 1915(i)(7) of the Act. To renew the 1915(i) State Plan HCBS benefit for an additional five-year period, the state must provide a written request for renewal to CMS at least 180 days prior to the end of the approval period. CMS approval of a renewal request is contingent upon state adherence to federal requirements and the state meeting its objectives with respect to quality improvement and beneficiary outcomes.

Per 42 CFR §441.745(a)(i), the state will annually provide CMS with the projected number of individuals to be enrolled in the benefit and the actual number of unduplicated individuals enrolled in this 1915(i) benefit in the previous year. Additionally, at least 18 months prior to the end of the five-year approval period, the state must submit to CMS a report with the results of the state’s quality monitoring, including an analysis of state data, findings, any remediation, and systems improvement for each of the 1915(i) requirements in accordance with the state’s quality improvement strategy in the approved SPA.

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001

1915(i) State plan Home and Community-Based Services

Administration and Operation

The state implements the optional 1915(i) State plan Home and Community-Based Services (HCBS) benefit for elderly and disabled individuals as set forth below.

1. Services. (Specify the state's service title(s) for the HCBS defined under “Services” and listed in Attachment 4.19-B):

Adult Day health, Care Management, Homemaker, Companion, Chore, Respite, Assisted Living, Assistive Technology, Environmental Accessibility Adaptations, Home Delivered Meals, Adult Family Living/Foster Care, Mental Health Counseling, Personal Emergency Response Systems, Transportation, Bill Payer, Transitional Care Management/Care Transitions, Chronic Disease Self-Management Programs, Recovery Assistant, Personal Care Assistant

2. Concurrent Operation with Other Programs. (/ndicate whether this benefit will operate concurrently with another Medicaid authority):

Select one: O | Not applicable © | Applicable

Check the applicable authority or authorities:

O1 | Services furnished under the provisions of §1915(a)(1)(a) of the Act. The State contracts with a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act for the delivery of 1915(i) State plan HCBS. Participants may voluntarily elect to receive program and other services through such MCOs or prepaid health plans. Contracts with these health plans are on file at the State Medicaid agency. Specify:

(a) the MCOs and/or health plans that furnish services under the provisions of §1915(a)(1); (b) the geographic areas served by these plans;

(d) how payments are made to the health plans; and

(e) whether the 1915(a) contract has been submitted or previously approved.

¥ | Program(s) authorized under §1915(b) of the Act.

Specify the $1915(b) program and indicate whether a §1915(b) program application has been submitted or previously approved:

Ct Home Care Programs Freedom of Choice Waiver approved from 7/1/15-6/30/20

Specify the §1915(b) authorities under which this program operates (check each that

applies): O | §1915(b)(1) (mandated enrollment to 0 | §1915(b)(3) (employ cost savings managed care) to furnish additional services) O | §1915(b)(2) (central broker) Y | §1915(b)(4) (selective contracting/limit number of

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 17-0001 ee Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

4. Distribution of State plan HCBS Operational and Administrative Functions.

¥ (By checking this box the state assures that): When the Medicaid agency does not directly conduct an administrative function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. When a function is performed by an agency/entity other than the Medicaid agency, the agency/entity performing that function does not substitute its own judgment for that of the Medicaid agency with respect to the application of policies, rules and regulations. Furthermore, the Medicaid Agency assures that it maintains accountability for the performance of any operational, contractual, or local regional entities. In the following table, specify the entity or entities that have responsibility for conducting each of the operational and administrative functions listed (check each that applies):

(Check all agencies and/or entities that perform each function):

Other State Medicaid Operating Contracted Local Non-

Function Agency Agency Entity State Entity 1 Individual State plan HCBS enrollment M Oo oOo oO 2 Eligibility evaluation Mu oO va Oo 3 Review of participant service plans M4 Oo v | 4 Prior authorization of State plan HCBS uM Oo O Oo 5 Utilization management M oO Oo Oo 6 Qualified provider enrollment M Oo v Oo 7 Execution of Medicaid provider agreement M Oo Oo Oo 8 Establishment of a consistent rate methodology for each State plan HCBS a 2 2 o 9 Rules, policies, procedures, and information development governing the State 4] Oo O Oo plan HCBS benefit 10Quality assurance and quality improvement wi oO ay oO activities

(Specify, as numbered above, the agencies/entities (other than the SMA) that perform each function):

Access Agencies defined in CT Statutes 17b-342 provide care management functions. These entities are selected as a result of a competitive procurement. This was most recently procured in 2013. This service is limited to selected contractors and was approved in the state’s 1915(b)- 4 application. The care managers perform multidimensional assessments to determine functional eligibility for HCBS. The Access Agency care manager is required to review the plan of care with the HCBS participant every 60 days or more frequently if identified needs changed. The fiscal intermediary, also selected as the result of a competitive procurement does provider credentialing and facilitates enrollment with the department’s MMIS contractor.

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

TN: 17-0001 Page 4 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL SFT t TT

(By checking the following boxes the State assures that):

5. Y Conflict of Interest Standards. The state assures the independence of persons performing evaluations, assessments, and plans of care. Written conflict of interest standards ensure, at a minimum, that persons performing these functions are not:

e related by blood or marriage to the individual, or any paid caregiver of the individual

e financially responsible for the individual

e providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HCBS; except, at the option of the state, when providers are given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified entity in a geographic area, and the state devises conflict of interest protections. (Ifthe state chooses this option, specify the conflict of interest protections the state will implement):

6. ¥ Fair Hearings and Appeals. The state assures that individuals have opportunities for fair hearings and appeals in accordance with 42 CFR 431 Subpart E.

7. ¥No FFP for Room and Board. The state has methodology to prevent claims for Federal financial participation for room and board in State plan HCBS.

8. vO Non-duplication of services. State plan HCBS will not be provided to an individual at the same time as another service that is the same in nature and scope regardless of source, including Federal, state, local, and private entities. For habilitation services, the state includes within the record of each individual an explanation that these services do not include special education and related services defined in the Individuals with Disabilities Education Improvement Act of 2004 that otherwise are available to the individual through a local education agency, or vocational rehabilitation services that otherwise are available to the individual through a program funded under §110 of the Rehabilitation Act of 1973.

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 17-0001 Page 5 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

Number Served

1. Projected Number of Unduplicated Individuals To Be Served Annually. (Specify for year one. Years 2-5 optional):

Annual Period | From To Projected Number of Participants Year | 2HAT 131/18 TE Year 2 2HA 131/19 825 Year 3 2HN9 131/20 875 Year 4 2/1/20 1/31/71 925 Year 5 QAI 131/92 975

2. ¥Y Annual Reporting. (By checking this box the state agrees to): annually report the actual number of unduplicated individuals served and the estimated number of individuals for the following year.

Financial Eligibility

1. ¥Medicaid Eligible. (By checking this box the state assures that): Individuals receiving State plan HCBS are included in an eligibility group that is covered under the State’s Medicaid Plan and have income that does not exceed 150% of the Federal Poverty Line (FPL). (This election does not include the optional categorically needy eligibility group specified at §1902(a)(10)(A)(ii)(X XII) of the Social Security Act. States that want to adopt the §1902(a)(10)(A)(ii)(X XID) eligibility category make the election in Attachment 2.2-A of the state Medicaid plan.)

2. Medically Needy (Se/ect one): ¥ The State does not provide State plan HCBS to the medically needy.

O The State provides State plan HCBS to the medically needy. (Select one):

O The state elects to disregard the requirements section of 1902(a)(10)(C)(i)(II]) of the Social Security Act relating to community income and resource rules for the medically needy. When a state makes this election, individuals who qualify as medically needy on the basis of this election receive only 1915(i) services.

O The state does not elect to disregard the requirements at section 1902(a)(10)(C)(i)CI) of the Social Security Act.

Evaluation/Reevaluation of Eligibility

1. Responsibility for Performing Evaluations / Reevaluations. Eligibility for the State plan HCBS benefit must be determined through an independent evaluation of each individual). Independent evaluations/reevaluations to determine whether applicants are eligible for the State plan HCBS benefit are performed (Select one):

O | Directly by the Medicaid agency

O | By Other (specify State agency or entity under contract with the State Medicaid agency):

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i:

TN: 17-0001 Page 6 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 ; —~— BG IAL | | Contracted entity-Access Agency care managers

2. Qualifications of Individuals Performing Evaluation/Reevaluation. The independent evaluation is performed by an agent that is independent and qualified. There are qualifications (that are reasonably related to performing evaluations) for the individual responsible for evaluation/reevaluation of needs- based eligibility for State plan HCBS. (Specify qualifications):

The care manager who conducts the assessments, develops care plans and provides ongoing monitoring shall be either a registered nurse licensed in the state where care management services are provided or a social services worker who is a graduate of an accredited four-year college or university. The nurse or social services worker shall have a minimum of two years of experience in health care or human services. A bachelor’s degree in nursing, health, social work, gerontology or a related field may be substituted for one year of experience.

Care managers shall have the following additional qualifications:

demonstrated interviewing skills which include the professional judgment to probe as

necessary to uncover underlying concerns of the applicants; demonstrated ability to establish

and maintain empathetic relationships; experience in conducting social and health

assessments; knowledge of human behavior, family/caregiver dynamics, human development

and disabilities; awareness of community resources and services; the ability to understand

and apply complex service reimbursement issues; and the ability to evaluate, negotiate and lan for the costs of care options.

3. Process for Performing Evaluation/Reevaluation. Describe the process for evaluating whether individuals meet the needs-based State plan HCBS eligibility criteria and any instrument(s) used to make this determination. If the reevaluation process differs from the evaluation process, describe the differences:

Applicants for the 1915(i) HCBS will apply to the Department’s HCBS Unit who will perform an initial phone screening to determine if the individual appears to have 1 or 2 critical needs. The screening instrument is a Department designed Health Screen form number W- 1506 that collects information on ADLs, IADLs, cognitive status, living arrangements, behavioral and health and safety issues. Once the referral and initial functional screen is done by HCBS Unit staff and the client appears to meet functional and financial eligibility criteria for the 1915i, the referral is sent to an Access Agency for the initial evaluation. The Care Manager meets with the client and his or her representative and explains the program prior to initiating the assessment. If the client consents, the care manager initiates the assessment. The uniform assessment instrument (W-1507A) evaluates 7 domains: health, function, psychosocial, environment, cognition, support system and finances. Risk indicators are discussed with the client and/or their representative.

Based on the assessment, unmet needs are identified and service options are discussed with the participant and their representative. Options regarding service providers are presented for the client to choose their services and providers.

The assessment is utilized to develop client centered goals and plans are developed that assist the client in achieving those goals. The Department as part of its audit process, reviews records to ensure that client goals are identified and reviewed at least annually.

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

TN: 17-0001 Page 7 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001

Once the plan is developed, the costs of the plan are calculated. The client and/or =o Icl hE representative are asked to sign off on the plan indicating their approval and/or agree EF 1 with it. The final plan of care is submitted to the department for utilization review and to ensure that needs and goals are addressed by the plan.

The Total Plan of Care is coordinated by the care manager and includes not only state plan services but also in-kind, Medicare covered, other insurance covered services and other federal funded such as Older American's Act programs.

The reevaluation utilizes the same level of care tool annually.

4. ¥v Reevaluation Schedule. (By checking this box the state assures that): Needs-based eligibility reevaluations are conducted at least every twelve months.

5. wv Needs-based HCBS Eligibility Criteria. (By checking this box the state assures that): Needs-based criteria are used to evaluate and reevaluate whether an individual is eligible for State plan HCBS.

The criteria take into account the individual’s support needs, and may include other risk factors: (Specify the needs-based criteria):

In order to qualify for Home and community based services under the 1915i, the applicant must require assistance with 1 or 2 critical needs. Critical needs are as follows: bathing, dressing, toileting, eating/feeding, transferring, and medication administration. Assistance includes supervision and cueing as well as direct, hands on assistance. Individuals receiving services under this 1915(i) benefit must have needs that are less stringent than nursing facility level of care. Those whose needs meet a nursing facility level of care will be served under a 1915(c) waiver.

6. ¥ Needs-based Institutional and Program Criteria. (By checking this box the state assures that): There are needs-based criteria for receipt of institutional services and participation in certain programs that are more stringent than the criteria above for receipt of State plan HCBS. If the state has revised institutional level of care to reflect more stringent needs-based criteria, individuals receiving institutional services and participating in certain programs on the date that more stringent criteria become effective are exempt from the new criteria until such time as they no longer require that level of care. (Complete chart below to summarize the needs-based criteria for State Plan HCBS and corresponding more-stringent criteria for each of the following institutions):

State plan HCBS NF (& NF LOC** programs) ICF/IID (& ICF/IID Applicable Hospital* (& needs-based eligibility LOC programs) Hospital LOC

criteria programs)

Requiring assistance | 1. Supervision or cueing > | Having a diagnosis of | Each chronic

See #5 above for 2. Hands-on > 3 ADLs evidenced by testing shall require description of critical and requiring services that

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 17-0001 Page 9 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001

7. ¥ Target Group(s). The state elects to target this 1915(i) State plan HCBS benefit to a spect FICIAL population based on age, disability, diagnosis, and/or eligibility group. With this election, the state will operate this program for a period of 5 years. At least 90 days prior to the end of this 5 year period, the state may request CMS renewal of this benefit for additional 5-year terms in accordance with 1915(i)(7)(C) and 42 CFR 441.710(e)(2). (Specify target group(s)):

Persons age 65 and older

O Option for Phase-in of Services and Eligibility. If the state elects to target this 1915(i) State plan HCBS benefit, it may limit the enrollment of individuals or the provision of services to enrolled individuals in accordance with 1915(i)(7)(B)(ii) and 42 CFR 441.745(a)(2)(ii) based upon criteria described in a phase-in plan, subject to CMS approval. At a minimum, the phase-in plan must describe: (1) the criteria used to limit enrollment or service delivery; (2) the rationale for phasing-in services and/or eligibility; and (3) timelines and benchmarks to ensure that the benefit is available statewide to all eligible individuals within the initial 5-year approval. (Specify the phase-in plan):

(By checking the following box the State assures that):

8. ¥ Adjustment Authority. The state will notify CMS and the public at least 60 days before exercising the option to modify needs-based eligibility criteria in accord with 1915(i)(1)(D)(ii).

9. Reasonable Indication of Need for Services. In order for an individual to be determined to need the 1915(i) State plan HCBS benefit, an individual must require: (a) the provision of at least one 1915(i) service, as documented in the person-centered service plan, and (b) the provision of 1915(i) services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the person-centered service plan. Specify the state’s policies concerning the reasonable indication of the need for 1915(i) State plan HCBS:

i. | Minimum number of services.

The minimum number of 1915(i) State plan services (one or more) that an individual must require in order to be determined to need the 1915(i) State plan HCBS benefit is:

ii. | Frequency of services. The state requires (select one):

v | The provision of 1915(i) services at least monthly

O | Monthly monitoring of the individual when services are furnished on a less than monthly basis

If the state also requires a minimum frequency for the provision of 1915(i) services other than monthly (e.g., quarterly), specify the frequency:

Home and Community-Based Settings

(By checking the following box the State assures that):

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i:

TN: 17-0001 OPAL

Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001

The state has submitted a revised statewide transition plan to CMS for review. Two services, Assisted Living and Adult Day Health have been reviewed and evaluated by the state for ongoing compliance with the CMS Final rules issued in 2014. The state has concluded based on a thorough systemic review and on site evaluations by HCBS staff and surveys completed by care managers and participants that these services fully comport with the settings requirements. Assisted Living services are provided in Managed Residential Communities. In these settings, assisted living services are available as a service option. Individuals may choose to receive assisted living services provided by a Licensed Assisted Living Service Agency or to receive other HCBS as an alternative. In a managed residential community the individual has a lease and has a private unit that has cooking facilities and a private living area. The participant is free to come and go as they chose and are able to participate fully in community activities. Their autonomy and privacy are protected.

A new service, Adult Family Living is being added with this renewal. For individual who choose to receive Adult Family Living Services, most will live in their own home of the home of a family member. Participants have the choice of a range of services but choose Adult Family Living so that a family member can provide their services. For those instances in which the home is owned by the provider, the contracted care management entity assesses each setting using the questions added to the universal assessment to evaluate compliance with the settings requirements. Although the updated assessment tool coming in July 2017 and the DSS regulatory language coming in June 2018 are beyond the SPA start date, the state assures monitoring compliance by training the care management providers on the settings requirements and upon initial assessment visit as the care plan is being developed, as well as during on-going monitoring and care plan updates, the care manager will assess the compliance of the service setting with CMS’ requirements. The care managers have been trained to bring any concerns or questions to the department for review and analysis.

The setting will be assessed on an ongoing basis by utilizing the assessment tool annually.

Some participants reside in Residential Care Homes. The state has surveyed residents and care managers in its assessment of the compliance of RCH’s with the settings requirements. HCBS staff also visited each community in which participants reside and completed a survey based on direct observation and interaction with the participants. Letters have gone out to each community outlining the department’s assessment of their compliance. We are currently waiting for plans of correction to be returned to the department. Additionally, there is a broad based group including multiple state agencies, the RCH association, coalitions representing the RCHs, Ct Legal Services meeting to revise the Department of Public Health Regulations that govern RCHs. As an initial step, DPH has introduced legislation in HB 5537. The language proposed is as follows:

"Residential care home" [, "nursing home'] or "rest home" means [an establishment] a community residence that furnishes, in single or multiple facilities, food and shelter to two or more persons unrelated to the proprietor and, in addition, provides services that meet a need beyond the basic provisions of food, shelter and laundry and may qualify as a setting that allows residents to receive home and community-based services funded by state and federal programs.

The state anticipates that not all Residential Care Homes will meet the settings requirements by 2019. Others will be submitted to CMS for review under the heightened scrutiny. If it is determined that the setting is not compliant with CMS requirements, participants will be offered a range of housing choices or may opt to discontinue HCBS.

The state assures that the settings transition plan included in this renewal will be subject to

any provisions or requirements included in the state’s approved Statewide Transition Plan. The state will imnlement anv reanired chances 11nan annraval of the statewide trans

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

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Person-Centered Planning & Service Delivery

(By checking the following boxes the state assures that):

¥ There is an independent assessment of individuals determined to be eligible for the State plan HCBS benefit. The assessment meets federal requirements at 42 CFR §441.720.

YO Based on the independent assessment, there is a person-centered service plan for each individual determined to be eligible for the State plan HCBS benefit. The person-centered service plan is developed using a person-centered service planning process in accordance with 42 CFR §441.725(a), and the written person-centered service plan meets federal requirements at 42 CFR §441.725(b).

¥ The person-centered service plan is reviewed, and revised upon reassessment of functional need as required under 42 CFR §441.720, at least every 12 months, when the individual’s circumstances or needs change significantly, and at the request of the individual.

Responsibility for Face-to-Face Assessment of an Individual’s Support Needs and Capabilities.

There are educational/professional qualifications (that are reasonably related to performing assessments) of the individuals who will be responsible for conducting the independent assessment, including specific training in assessment of individuals with need for HCBS. (Specify qualifications):

Care managers shall have the following additional qualifications:

demonstrated interviewing skills which include the professional judgment to probe as necessary to uncover underlying concerns of the applicants; demonstrated ability to establish and maintain empathic relationships; experience in conducting social and health assessments; knowledge of human behavior, family/caregiver dynamics, human development and disabilities; awareness of community resources and services; the ability to understand and apply complex service reimbursement issues; and the ability to evaluate, negotiate and plan for the costs of care options.

The registered nurse shall hold a license to practice nursing in the State of CT. Care Managers are encouraged but not required to be certified as a long term care manager.

Responsibility for Development of Person-Centered Service Plan. There are qualifications (that are reasonably related to developing service plans) for persons responsible for the development of the ndividualized, person-centered service plan. (Specify qualifications):

Same as #4 above

Supporting the Participant in Development of Person-Centered Service Plan. Supports and information are made available to the participant (and/or the additional parties specified, as appropriate) to direct and be actively engaged in the person-centered service plan development process. (Specify: (a) the supports and information made available, and (b) the participant's authority to determine who is included in the process):

Once the referral is processed by HCBS Unit staff and the client appears to meet functional

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

TN: 17-0001 Page 14 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001

OFFICIAL

and financial eligibility criteria for state plan Home and Community Based Services, the referral is sent to an Access Agency for the initial evaluation. The Care Manager makes an appointment to meets with the client and his or her representative if the client chooses to have someone else present. People are encouraged to have someone else present during the visit if they so choose. Most often, that is identified at the time of referral. The care manager explains the program prior to initiating the assessment. If the client consents, the care manager initiates the assessment. The uniform assessment instrument (W-1507A) evaluates 7 domains: health, function, psychosocial, environment, cognition, support system and finances. The person-centered assessment process focuses on unmet needs as well as individual preferences, goals, strengths and desired outcomes.

To the extent possible, individuals are encouraged to lead the discussion.

The assessment is utilized to develop client centered goals and plans are developed that assist the client in achieving those goals.

7. Informed Choice of Providers. (Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the 1915(i) services in the person-centered service plan):

During the development of the Total Plan of Care, participants will select providers from a list prepared by the fiscal intermediary. The fiscal intermediary maintains the list of service providers according to geographic areas within the state, and the availability may vary by geographic area. For example, in the western part of the state, a provider that serves the greater Danbury area may well not agree to provide services to a client living in Torrington. The client might choose a provider that will not extend their coverage outside of their service area. The care managers make a concerted effort to provide the clients with as many choices as possible and the expectation is that there is documentation in the clinical record of the choices given. The client may request a copy of the list at any time. If the client does not have a specific choice, providers are assigned on a rotating basis as long as the provider can meet all of the specifications requested by the client such as language spoken and the days and times that services are available. The Care Manager will describe the services available from providers on the list. Participants choose providers from the list and their signature on the total Plan of Care acknowledges freedom of choice.

Additionally, in every follow up monitoring contact the client is asked if they are satisfied with the services provided and if there are any problems with the delivery of the formal services. If the client indicates there are problems, then changing to another service provider is discussed as an option and the Care Manager again reviews with the participant, the service providers available to choose from. Again, that documentation is found in the clinical record.

Provider enrollment is open and continuous. New providers are added to the list as they meet the qualifications and are enrolled. Once added to the list, the care managers provide

the info to the participant as part of the monitoring contact if the client wishes to change providers and is also provided as a choice to all new clients.

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i:

TN: 17-0001

Page 15

Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001

9. Maintenance of Person-Centered Service Plan Forms. Written copies or electronic facsimiles of service

OFFICIAL

Process for Making Person-Centered Service Plan Subject to the Approval of the Medicaid Agency. (Describe the process by which the person-centered service is made subject to the approval of the Medicaid agency):

HCBS staff review 100% of all new service plans and must authorize the plan before it can be implemented. Utilization Review Nurses match needs with services to ensure all health and safety needs are being met.

HCBS staff conduct annual client record reviews for each of the four Access Agencies. Approximately one hundred (100) client records are randomly selected for review. In addition to the record reviews done by ACU staff, the Access Agencies are contractually required to perform record audits and produce quarterly reports to the Department summarizing those audits. The 100 records selected when combined with the reviews done by the Access Agency constitute a representative sample. A representative sample is achieved by combining the audits of both the Access Agency supervisors and Department staff. The reviews include an examination of the client’s most recent reassessment and confirm that the identified critical needs are consistent with the POC. The POC is reviewed to ensure that all identified needs are being met. HCBS staff conduct client satisfaction surveys in each of the five areas of the state that define the Access Agencies service areas.

Both the Department and the Access Agencies perform client satisfaction surveys.

HCBS client record reviews are conducted to monitor the Access Agencies compliance with its contract with the Department. The Access Agencies are contractually obligated to conduct client record reviews including assessing appropriateness of POC and report annually to the Department of Social Services.

Access Agencies must update the POC at the time of reassessment or when a significant change occurs in the client’s status, and utilize care plans consistent with the program’s Uniform Client Care Plan. The Uniform Client Care Plan identifies provider, type of service, number of hours provided, date service began, and date service was discontinued, noting the need for a back up plan. These services are monitored by the Department of Social Services through Quality Assurance and Client Satisfaction Annual Reports generated by the Access Agencies.

plans are maintained for a minimum period of 3 years as required by 45 CFR §74.53. Service plans are maintained by the following (check each that applies):

Y | Medicaid agency O_ | Operating agency ¥__| Case manager

O | Other (specify):

Services

State plan HCBS. (Complete the following table for each service. Copy table as needed):

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover):

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State: Connecticut §1915(i) State plan HCBS State plan Attach} (341A | TN: 17-0001 Page 16 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001

Service Title: | Adult Day Health Service Definition (Scope):

The service is provided 4 or more hours per day on a regularly scheduled basis for one or more days per week, or as specified in the service plan, in a center that is a non-institutional, community-based setting and shall encompass both health and social services needed to ensure the optimal functioning of the participant. Health services include personal care, health monitoring by a registered nurse, therapeutic diet meals and snacks and social services include recreation and other social activities. See additional detail below. Transportation to and from the center is included in the service definition and in the rate structure. Meals provided as part of these services shall not constitute a full nutritional regimen. Claims will denied by any Adult Day Health provider attempting to bill for transportation procedure codes. These procedure codes are not included on the Adult Day Health fee schedule and will deny as edits are built into the claim processing system to prevent duplicative transportation services for Adult Day Health from occurring.

Services Covered and Limitations

Payment for adult day services under the rate for a medical model is limited to providers that demonstrate to the department their ability to meet the following additional requirements:

a program nurse shall be available on site for not less than fifty percent of each operating day;

the program nurse shall be a registered nurse, except that a program nurse may be a licensed practical nurse if the program is located adjacent to a long term care facility licensed by the Department of Public Health, with ready access to a registered nurse from such long term care facility or the program nurse is supervised by a registered nurse who can be reached by telephone at any time during the operating day and who can be called to the center if needed within one half hour of the request. The program nurse is responsible for administering medications as needed and assuring that the participant's nursing services are coordinated with other services provided in the adult day health center, health and social services currently received at home or provided by existing community health agencies and personal physicians;

additional personal care services shall be provided as specified in the individual plan of care, including but not limited to, bathing and transferring;

ongoing training shall be available to the staff on a regular basis including, but not be limited to, orientation to key specialty areas such as physical therapy, occupational therapy, speech therapy and training in techniques for recognizing when to arrange or refer clients for such services; and

Individual therapeutic and rehabilitation services shall be coordinated by the center as specified in the individual plan of care including but not limited to, physical therapy, occupational therapy and speech therapy. The center shall have the capacity to provide such

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State: Connecticut TN: 17-0001

Effective: 02/01/2017

§1915(i) State plan HCBS

Approved: 1/27/17

State plan Attachment 3.1-1: Page 17 Supersedes: TN 12-001

services on site; this requirement shall not preclude the provider of adult day health services from also arranging to provide therapeutic and rehabilitation services at other locations in order to meet needs of individual clients.

Payment for adult day services shall include the costs of transportation, meals and all other required services except for individual therapeutic and rehabilitation services.

For participants receiving assisted living services, adult day services are included as part of the monthly rate. A separate reimbursement for this service is not authorized. The assisted living service agency may arrange for adult day health services and reimburse the adult day service provider from their all-inclusive rate.

Additional needs-based criteria for receiving the service, if applicable (specify):

None

(Choose each that applies):

Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services.

¥ | Categorically needy (specify limits):

May be provided up to 7 times per week

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard

(Specify): (Specify): (Specify): (Specify):

Adult Day None Certified by Providers of Adult Day Health Center Adult Day services shall meet all applicable Provider Care federal, state and local requirements Agency Association including zoning, licensing,

sanitation, fire and safety requirements

provide, at a minimum, nursing consultation services, social work services, nutritionally balanced meals to meet specialized dietary needs as prescribed by health care personnel,

personal care services, recreational

OFFICIAL

(ct-17-0001)(approval-document)(page-23)Page 23#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i: TN: 17-0001 Page 19 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 =

ective pp OF L

any applicable requirements shall be grounds for the termination of its certification and participation as a department service provider

Verification of Provider Qualifications (For each provider type listed above. Copy rows as

needed):

Provider Type Entity Responsible for Verification Frequency of Verification (Specify): (Specify): (Specify):

ADC Provider | Department’s Fiscal Intermediary Initially to enroll and Every 2 years thereafter

Service Delivery Method. (Check each that applies):

O | Participant-directed ¥ | Provider managed

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover):

Care Management Service Definition (Scope).

Services that assist participants in gaining access to needed program and other State plan services, as well as medical, social, educational and other services, regardless of the funding source for the services to which access is gained. Care managers additionally are responsible for monitoring the ongoing provision of services in the participant's plan of care and continually monitor that the client's health and safety needs are being addressed. They complete the initial and annual assessment and reassessment of an individual's needs in order to develop a comprehensive plan of care. They confirm the initial needs criteria determination done by Department staff and reassess the needs criteria annually and maintain documentation for department review.

DSS has implemented a tiered case management system. Tiered case management is based on client's level of need and the number and type of case management interventions required. TIER A clients, with the fewest needs, receive a quarterly contact and an annual reassessment. Leveling Criteria for TIER A is 3 or less care management interventions in a 6 month period. If2 of those interventions are crisis interventions, client is automatically elevated to level 2. TIER B clients receive monthly monitoring, a six month field visit and an annual reassessment. Leveling criteria is 4-6 care management interventions in a 6 month period. TIER C clients, the highest level, receive monthly monitoring, quarterly field visits, six month visit, and an annual reassessment. Leveling criteria is 7 or more care management interventions in a 6 month period. There are four categories of case management intervention: Crisis Intervention, Service Brokerage and Advocacy, Risk Management and Client Engagement/Re-engagement. Crisis Intervention Efforts have two principle aims 1)

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

TN: 17-0001 Page 20 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 AECrIr wit HGIAL

Cushion the stressful event by immediate or emergency emotional or environmental first aid and 2) Strengthen the person in his or her coping through immediate therapeutic clarification and guidance during the crisis period. Examples of incidents that precipitate crisis interventions: suicide assessment, incidents of abuse, victimization, neglect, exploitation, imminent threat of homelessness. Service Brokerage and Advocacy requires that the Care Manager facilitate continual interaction between various segments of the service delivery system. When service breakdowns or requests for service changes occur, the Care Manager assists clients to ensure their rights to receive services based upon the person-centered model of care are upheld. Service brokerage and advocacy interventions include activities around finding and keeping providers for clients with difficult service needs, pre and post transitioning from an inpatient setting to the community, hospice and end of life care. Risk Management includes the identification of potential and perceived risks to the individual falling into four general categories; health, behavior, personal safety risks, and in-community risks. Managing these risks includes identification and documenting risks, developing written plans for addressing them, negotiating with clients the risks presented keeping client choice central to the process, and monitoring outcomes related to the risk. Client engagement refers to the process through which clients become active or involved in their care plans and participation in the program. The engagement process has several conceptualizations where interventions are designed to enhance client 1) receptivity, 2) expectancy 3) investment, 4) working relationship. Care management interventions are weighted according to complexity, severity and number of tasks required. Crisis intervention is weighted highest followed by Service Brokerage and Advocacy, Risk Management and Client Engagement/Re- engagement. Clients may move to a different tier based on their current needs with prior authorization from DSS. Care management per diem rates will be adjusted according to which tier the client is in.

Additional needs-based criteria for receiving the service, if applicable (specify):

None

(Choose each that applies):

v | Categorically needy (specify limits):

Service may be billed on a per diem basis as long as the client remains in a community- based setting. Care management per diem may not be billed when a client is in an institutional setting.

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard (Specify): (Specify): (Specify): (Specify): Care The registered | Care Managers | Providers are the Access Agencies

(ct-17-0001)(approval-document)(page-26)Page 26#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

TN: 17-0001 Page 22 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL Agency Access Agency is

responsible to verify the qualifications and licenses of their care management staff upon employment and annually thereafter

Service Delivery Method. (Check each that applies):

O | Participant-directed ¥_ | Provider managed

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover):

Respite Service Definition (Scope):

Services provided to individuals unable to care for themselves; furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care. In home respite providers shall include but are not limited to homemakers, companions or Home Health aides. Services may be provided in the home or outside of the home including but not limited to a licensed or certified facility such as a Rest Home with Nursing Supervision or Chronic and Convalescent Nursing Home. Federal financial participation is not claimed for the cost of room and board except when provided as part of respite care furnished in a facility approved by the State that is not a private residence. Respite services do not duplicate or overlap existing services. The state ensures no overlap as the services have unique procedure codes.

Additional needs-based criteria for receiving the service, if applicable (specify):

none

(Choose each that applies):

Y | Categorically needy (specify limits):

Respite services provided in a licensed facility are limited to 30 days per calendar year per recipient. In home respite services are limited to 720 hours per year per recipient.

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

(ct-17-0001)(approval-document)(page-29)Page 29#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

TN: 17-0001 Page 25 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFEFICIAI

Service Specifications (Specify a service title for the HCBS listed in Atachment 4.19-B that the state plans to cover):

Personal Care Assistant Service Definition (Scope):

One or more persons assisting an elder with tasks that the individual would typically do for him/herself in the absence of a disability. Such tasks may be performed at home or in the community. Such services may include physical or verbal assistance to the consumer in accomplishing any Activity of Daily Living (ADL), or Instrumental Activities of Daily Living (ADL). ADLs include bathing, dressing, toileting, transferring, and feeding. IADLs include meal preparation, shopping, housekeeping, laundry and cueing/reminders for self medication administration. Transportation costs associated with the provision of personal care outside of the participant's home is billed separately and is not included in the scope of personal care. PCA service in the state plan is agency based which compliments the 1915k PCA service that offers self directed PCA and not agency based.

Additional needs-based criteria for receiving the service, if applicable (specify):

none

(Choose each that applies):

Y | Categorically needy (specify limits):

Up to 14 hours per week may be provided. Recipients of PCA services will not be eligible to receive Homemaker or Companion services. Edits have been created in the MMIS to deny any Homemaker or Companion claims for PCA service recipients. Personal Care may not be provided to participants receiving Assisted Living Services as all of the functions of personal care are provided by the Assisted Living Service provider. The benefit plan for Assisted Living service recipients excludes personal care so that there could be no duplicative billing. 1915k and 1915i personal care may not be billed for the same hours. The services are authorized in the participants’ service plan and scheduled so there is no overlap. 1915i personal care will be subject to electronic visit verification effective 1/1/17 which will ensure that services that overlap would not be reimbursed. Edits in the MMIS prevent the procedure codes for self directed and agency based PCA from being provided at the same time.

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard (Specify): (Specify): (Specify): (Specify): PCA Agency The PCA hired by the agency shall

(ct-17-0001)(approval-document)(page-32)Page 32#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i: TN: 17-0001 Page 28 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

Non-medical care, supervision and socialization provided to a functionally impaired adult. Companions may assist or supervise the individual with such tasks as meal preparation, laundry and shopping, but do not perform these activities as discrete services. The provision of companion services does not entail hands-on nursing care. Providers may also perform light housekeeping tasks which are incidental to the care and supervision of the individual. This service is provided in accordance with a therapeutic goal in the plan of care, and is not purely diversional in nature.

Companion services may include, but are not limited to, the following activities:

(A) _ escorting an individual to recreational activities or to necessary medical, dental or business appointments;

(B) _ reading to or for an individual;

(C) supervising or monitoring an individual during the self-performance of activities of daily living such as meal preparation and consumption, dressing, personal hygiene, laundry and simple household chores;

(D) reminding an individual to take self-administered medications; (E) providing monitoring to ensure the safety of an individual; (F) assisting with telephone calls and written communications; and

(G) _ reporting changes in an individual's needs or condition to the supervisor or care manager.

Additional needs-based criteria for receiving the service, if applicable (specify):

none

(Choose each that applies):

v Categorically needy (specify limits):

Companion Services may not be provided to a participant receiving PCA services. An edit was built into the MMIS to reject any billing for the Companion procedure code if the PCA procedure code is billed. The total plan of care specifies if both homemaker and companion services are authorized for the participant. The duties of each are defined as part of the overall plan and are not duplicative. This service may not be provided by a relative of the participant.

Oo Medically needy (specify limits):

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i: TN: 17-0001 Page 30 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFEICIAI

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover):

Chore

Service Definition (Scope): Services needed to maintain the home in a clean, sanitary and safe environment. This service includes heavy household chores such as washing floors, windows and walls, tacking down loose rugs and tiles, moving heavy items of furniture in order to provide safe access and egress. These services will be provided only in cases where neither the individual, nor anyone else in the household, is capable of performing or financially providing for them, and where no other relative, caregiver, landlord, community/volunteer agency, or third party payer is capable of or responsible for their provision. In the case of rental property, the responsibility of landlord, pursuant to the lease agreement, will be examined prior to any authorization of service.

When an individual requires one-time only unique or specialized services in order to maintain a healthy and safe environment, they may receive highly skilled chore services which include moving, extensive cleaning or extermination services. Highly skilled chore services are subject to prior authorization by the department. The department may authorize services on a case by case basis such as extermination to be repeated if the initial treatment did not resolve the pest problem.

Additional needs-based criteria for receiving the service, if applicable (specify):

(Choose each that applies):

vs Categorically needy (specify limits):

Oo Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard (Speci): (Specify): | Speci): | is necapy:

(ct-17-0001)(approval-document)(page-36)Page 36#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i:

TN: 17-0001 Page 32

Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL state plans to cover): | Assisted Living

Service Definition (Scope):

Personal care and services, homemaker, chore, attendant care, companion services, medication oversight, therapeutic social and recreational programming, provided in a home- like environment in a Managed Residential Community, in conjunction with residing in the community. A managed residential community is a living arrangement consisting of private residential units that provides a managed group living environment including housing and services. A private residential unit means a living arrangement rented by the participant that includes a private full bath within the unit and facilities and equipment for the preparation and storage of food. Each unit has lockable access, is free to receive visitors and leave the setting at times and durations of the individual’s choosing, access to the grater community is easily facilitated and individuals can choose whether to share a living space. This service includes 24 hour on-site response staff to meet scheduled or unpredictable needs in a way that promotes maximum dignity and independence, and to provide supervision, safety and security. Other individuals or agencies may also furnish care directly, or under arrangement with the Managed Residential Community, but the care provided by these other entities supplements that provided by the community care facility and does not supplant it. Mental health counseling and the Personal Emergency Response System are services available to assisted living clients above and beyond the assisted living service. Nursing and skilled therapy services are incidental rather than integral to the provision of assisted living services. Payment is not made for 24 hour skilled care. Federal financial participation is not available for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement.

Personalized care is furnished to individuals who reside in their own living units (which may include dually occupied units when both occupants consent to the arrangement) which includes kitchenette and living rooms and which contain bedrooms and toilet facilities. The consumer has a right to privacy. Living units may be locked at the discretion of the consumer, except when a physician or mental health professional has certified in writing that the consumer is sufficiently cognitively impaired as to be a danger to self or others if given the opportunity to lock the door. Each living unit is separate and distinct from each other.

The communities have a central dining room, living room or parlor, and common activity center(s)(which may also serve as living rooms or dining rooms). The consumer retains the right to assume risk, tempered only by the individual's ability to assume responsibility for that risk. Care must be furnished in a way which fosters the independence of each consumer. Routines of care provision and service delivery must be consumer-driven to the maximum extent possible, and treat each person with dignity and respect.

Care plans will be developed based on the individual's service needs. There are four levels of service provided in assisted living facilities based on the consumer's combined needs for personal care and nursing services. The four levels are occasional which is 1-3.75 hours per week of service, limited which is 4-8.75 hours per week of service, moderate which is 9- 14.75 hours per week of service and extensive which is 15-25 hours per week of service.

(ct-17-0001)(approval-document)(page-39)Page 39#

State: Connecticut

§1915(i) State plan HCBS

State plan Attachment 3.1—i:

TN: 17-0001 Page 35 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL (C. Training or technical assistance for the participant or for the direct benefit of the

participant receiving the service, and where appropriate, the family members, guardians, advocates or authorized representatives of the participants.

Additional needs-based criteria for receiving the service, if applicable (specify):

Care plans will be developed based on the needs identified in the comprehensive assessment The cost of the Assistive Technology cannot exceed the yearly cost of the service it replaces. When an assistive technology device is identified that will support the participant’s independent functioning, the services will be reduced commensurate with the cost of the service it replaces. This reduction will be made with consideration of the participant’s health and safety needs.

(Choose each that applies): |

Y | Categorically needy (specify limits):

The service shall be capped at an annual cost of $1000

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard

(Specify): (Specify): (Specify): (Specify):

Agency n/a n/a Medicaid provider status for assistive technology and supplies or agency that obtains Medicaid performing provider status

Agency- State of CT

Pharmacy Department of

Consumer Protection Pharmacy Practice Act: Regulations concerning

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i: TN: 17-0001 Page 36 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

practice of pharmacy Sec. 20-175-4-6-7

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed):

Provider Type Entity Responsible for Verification Frequency of (Specify): (Specify): Verification (Specify): Agency Fiscal Intermediary At the start of service

Service Delivery Method. (Check each that applies):

O | Participant-directed v | Provider managed

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the State plans to cover):

Service Title: | Environmental Accessibility Modifications Service Definition (Scope):

Minor Home Modifications required by the individual's plan of care which are necessary to ensure health, welfare and safety of the individuals to function with greater independence in their home and without which the individual would require institutionalization. Such adaptations may include the installation of hand rails and grab bars in the tub area, widening of doors and installation of ramps. Excluded are those adaptations or improvements to the home which are of general utility and are not of direct medical or remedial benefit to the individuals such as carpeting, roof repair or air conditioning. Adaptations which add to the total square footage of the home are excluded from this benefit. All services shall be provided in accordance with applicable state or local building codes. Adaptations are excluded if the residence is owned by someone other than the participant and the adaptations would be the responsibility of the owner/landlord.

Additional needs-based criteria for receiving the service, if applicable (specify):

Specify limits (if any) on the amount, duration, or scope of this service for (chose each that applies):

M | Categorically needy (specify limits): This service is subject to prior authorization by Department staff O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification (Specify): Other Standard (Specify): (Specify): (Specify): Individual (non 1. The vendor or relative) contractor shall provide

all services, materials,

(ct-17-0001)(approval-document)(page-43)Page 43#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—1: TN: 17-0001 Page 39 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard (Specify): (Specify): (Specify): (Specify): Individual A social worker who holds a masters

degree from an accredited school of social work, or an individual who has a master’s degree in counseling, psychology or psychiatric nursing and has experience in providing mental health services to the elderly may also provide mental health counseling.

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed):

Provider Type Entity Responsible for Verification Frequency of Verification (Specify): (Specify): (Specify): Individual Fiscal Intermediary At the time of enrollment

as a provider and bi- annually thereafter

Service Delivery Method. (Check each that applies):

O | Participant-directed | M4 | Provider managed

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the State plans to cover):

Service Title: | Home Delivered Meals

Service Definition (Scope): Home delivered meals, or "meals on wheels," include the preparation and delivery of one or two meals for persons who are unable to prepare or obtain nourishing meals on their own. Meals must meet a minimum of one-third for single meals and two-thirds for double meals of the daily recommended allowance and requirements as established by the Food and Nutrition Academy of Sciences National Research Council. Home delivered meals do not constitute a full nutritional regime. Special diet meals are available such as diabetic, cardiac, low sodium and renal as are ethnic meals such as Hispanic and Kosher meals.

Liquid supplements, such as Ensure may be provided to 1915i participants where available.

Additional needs-based criteria for receiving the service, if applicable (specify):

Specify limits (if any) on the amount, duration, or scope of this service for (chose each that applies):

wi | Categorically needy (specify limits):

(ct-17-0001)(approval-document)(page-45)Page 45#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i: TN: 17-0001 Page 41

Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the State plans to cover):

Service Title: | Personal Emergency Response System

Service Definition (Scope): PERS is an electronic device which enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable "help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once a "help" button is activated. The response center is staffed by trained professionals 24/7. PERS services are limited to those individuals who live alone, or who are alone for significant parts of the day, and have no regular caregiver for extended periods of time, and who would otherwise require extensive routine supervision. Installation, upkeep and maintenance of the device are provided.

Additional needs-based criteria for receiving the service, if applicable (specify):

Specify limits (if any) on the amount, duration, or scope of this service for (chose each that applies):

Categorically needy (specify limits):

Provider may bill for one time only installation and monthly rate thereafter

0 | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard

(Specify): (Specify): (Specify): (Specify):

Agency- Vendor that has an approved contract vendors who through DSS as a performing provider sell and install

PERS

equipment

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed):

Provider Type Entity Responsible for Verification Frequency of Verification (Specify): (Specify): (Specify): Agency Fiscal Intermediary At the time of

enrollment and biannually thereafter

Service Delivery Method. (Check each that applies):

O | Participant-directed ir} | Provider managed

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the State plans to cover):

(ct-17-0001)(approval-document)(page-46)Page 46#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i: TN: 17-0001 Page 42

Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

Service Title: | Transportation

Service Definition (Scope).

Transportation services provide access to social services, community services and appropriate social or recreational facilities that are essential to help some individuals avoid institutionalization by enabling these individuals to retain their role as community members. This service is offered in addition to medical transportation offered under the state plan and shall not replace it.

(A) These services are provided when transportation is required to promote and enhance independent living and self-support; and

(B) _ Transportation services may be provided by taxi, livery, bus, invalid coach, volunteer organization or individuals. They shall be reimbursed when they are necessary to provide access to needed community based services or community activities as specified in the approved plan of care. Relatives may not reimbursed for transportation.

Additional needs-based criteria for receiving the service, if applicable (specify):

Specify limits (if any) on the amount, duration, or scope of this service for (chose each that applies):

M | Categorically needy (specify limits):

Adult Day Health providers cannot bill the transportation procedure code. Transportation is a separate and distinct procedure code and that service is not contracted to be provided by Adult Day Care providers thus preventing duplicate billing. Relatives may not provide this service.

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard (Specify): (Specify): (Specify): (Specify):

Agency- In order to Commercial receive Transportation | payment, all Providers commercial transportation providers shall be regulated carriers and meet all applicable state and federal permit and licensure requirements, and vehicle registration requirements. Commercial

(ct-17-0001)(approval-document)(page-48)Page 48#

State plan Attachment 3.1—i: Page 44

OFFICIAL

State: Connecticut §1915(i) State plan HCBS

TN: 17-0001

Effective: 02/01/2017 Supersedes: TN 12-001

Approved: 1/27/17

enrollment and bi annually thereafter

At the time of enrollment and biannually thereafter

Individual Fiscal Intermediary

Provider

Service Delivery Method. (Check each that applies): 0 | Participant-directed M

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the State plans to cover):

Bill Payer

| Provider managed

Service Title:

Service Definition (Scope):

A bill payer is a trained agency staff member who is paired with a client that is having difficulty managing their routine monthly finances. Staff member assists with writing checks that client signs, budgeting, paying bills on time, balancing checkbook, Social Security and Medicare questions and problems. The person can assist with applications for financial assistance programs, medical insurance claims and other financial matters including applications for senior housing and medical insurance. Electronic bill payment is permitted as part of this service.

Specify limits (if any) on the amount, duration, or scope of this service for (chose each that applies): © | Categorically needy (specify limits):

Service is limited to 3 hours per month.

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type License Certification Other Standard

(Specify): (Specify): (Specify): (Specify):

Agency If the agency Agency providing bill payer service is provider is a bonded and insured against fraudulent Homemaker/C | behavior. Bill payer's activities are ompanion overseen by the agency administrator Agency, they | or their designee. Cases are regularly must be reviewed and coaching is provided to registered with | the bill payer as needed. Online the Department | banking and bill paying is an option as of Consumer part of this service Protection.

Verification of Provider Qualifications (For each provider type listed above. Copy rows as

needed):

Provider Type Entity Responsible for Verification Frequency of Verification (Specifiv): (Specify): (Specify):

(ct-17-0001)(approval-document)(page-49)Page 49#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i:

TN: 17-0001 Page 45 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL Agency Fiscal intermediary At the time of

enrollment and every two years thereafter

Service Delivery Method. (Check each that applies): O | Participant-directed |a | Provider managed

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the State plans to cover):Transitional Care Management/Care Transitions

Service Definition (Scope):

An evidence-based set of actions designed to ensure health care coordination, continuity and avoidance of preventable poor outcomes in vulnerable participants as they move between institutional and home and community based settings. Core activities include: facilitating coaching and teaching, helping participants identify "red flags" to prevent readmissions, understand contributing factors for current admission whether hospital or NF, scheduling timely follow up with primary care provider, facilitating transportation, partnering with hospital care coordinators and community providers to enhance continuity of care and prevent readmissions. Service includes either a home visit or telephone follow up no more than 72 hours after discharge. Service may be provided for up to 120 days prior to discharge and will be considered complete when the person is discharged back to the community. This service also includes a status review visit by the care manager when a program participant is in a hospital or nursing facility setting when the purpose of that visit is to reevaluate the total plan of care needs upon discharge back to the community based setting. This transitional care management service is provided one time in the first 45 days of a nursing home stay and/or one time only during a hospital stay. This can occur only within 180 consecutive days prior to discharge. Care transitions and status reviews are two separate and distinct procedure codes on the department’s published fee schedule.

Specify limits (if any) on the amount, duration, or scope of this service for (chose each that applies):

Available only to those who have been enrolled in the program as an active participant. Not available to program applicants. Limited to no more than one unit in 60 days. Cannot be billed concurrently with a status review which is a face to face visit while the participant is institutionalized.

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

(ct-17-0001)(approval-document)(page-51)Page 51#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i:

TN: 17-0001 Page 47 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

licensed social worker is preferred for this service but not required.

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed):

Provider Type (Specify): Entity Responsible for Verification Frequency of Verification (Specify): (Specify): Access Agency Department of Social Services Annually

Service Delivery Method. (Check each that applies):

Participant-directed | M4 | Provider managed

Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the State plans to cover):

Chronic Disease Self- Management Programs

Service Definition (Scope): The Chronic Disease Self-Management Program (Live-Well) is a workshop given two and a half hours, once a week, for six weeks, in community settings such as senior centers, churches, libraries and hospitals. People with different chronic health problems attend together. Workshops are facilitated by two trained leaders, one or both of whom are non-health professionals with chronic diseases themselves. Subjects covered include:

1) techniques to deal with problems such as frustration, fatigue, pain and isolation, 2) appropriate exercise for maintaining and improving strength, flexibility, and endurance, 3) appropriate use of medications, 4) communicating effectively with family, friends, and health professionals, 5) nutrition, 6) decision making, and 7) how to evaluate new treatments.

The program is helpful for people with chronic conditions, as it gives them the skills to coordinate all the things needed to manage their health, as well as to help them keep active in their lives. The therapeutic goals of the service are adjustment to serious impairments, maintenance or restoration of physical functioning, self management of chronic disease, acquisition of skills to address minor depression, management of personal care and development of skills to work with care providers including behavior management. The program is also available in Spanish and is called Tomando Control de su Salud.

Specify limits (if any) on the amount, duration, or scope of this service for (chose each that applies):

M | Categorically needy (specify limits):

The program provides up to six sessions of two hours each. The participant is strongly encouraged to attend all six sessions. The service is limited to one six session service per calendar year.

O | Medically needy (specify limits):

(ct-17-0001)(approval-document)(page-54)Page 54#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

TN: 17-0001 Page 50 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAI cover):

Adult Family Living/Foster Care

Service Definition (Scope): Personal care and supportive services (homemaker, chore, attendant services, meal preparation) that are furnished to program participants who reside in a private home by a principal caregiver who lives in the home. Adult Family Living/Foster Care is furnished to adults who receive these services in conjunction with residing in the home. Service includes 24 hour response capability to meet scheduled or unpredictable resident needs to provide supervision, safety and security based on ADL, IADL, cognitive or behavioral needs. Service allocation is based on ADL, IADL, cognitive or behavioral needs. Services also include social and recreational activities and cueing or reminders to take medications. Separate payment will not be made for homemaker or chore services furnished to an individual receiving adult family living/foster care services, since these are integral to and inherent in the provision of Adult Family Living/Foster Care services. Edits in the MMIS system do not allow these services to be billed when Adult Family Living/Foster Care is in place as a service. Although this service has four levels, only the first two are applicable to the 1915i population. The last two are applicable only to those who meet NF level of care and are served under our 1915c waiver.

Level 1: service provided to individuals who because of their impairments, require supervision on a daily basis and require cueing or supervision to perform ADLs and may also have cognitive or behavioral challenges

Level 2: services provided to individuals who require hands on assistance to perform 2 ADLs ona daily basis.

The agency that provides the Adult Family Living/Foster Care service will supervise the supports delivered by the direct care provider. This service may be provided in the home of either the care provider or the participant, whichever is preferable to the participant. The direct provider may be a relative of the client as long as they are not a legally liable relative. Adult Family Living/Foster Care is limited to no more than 3 participants in a home. The Adult Family Living/Foster Care provider may not administer medication but may supervise the participant’s self-administration of medication. Payments made for Adult Family Living/Foster Care are not made for room and board, items of comfort or convenience, or the costs of home maintenance, upkeep and improvement. Room and board payments are excluded from the rate

Specify limits (if any) on the amount, duration, or scope of this service for (chose each that applies):

Categorically needy (specify limits):

O | Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed):

Provider Type (Specify): License Certification Other Standard (Specify): (Specify): (Specify): Agency Tn order to be an Adult Family Living/Foster Care provider setting,

(ct-17-0001)(approval-document)(page-56)Page 56#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-1: TN: 17-0001 Page 52 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

provider agency in order to be credentialed to provide Adult Family Living/Foster Care must provide evidence of an ability to certify that the individual homes meet all of the requirements included in this description and can demonstrate an ability to monitor the delivery and quality of service provided to the program participant. The agency may also provide relief to the direct service provider or the care manager can provide relief through the provision of other program services. The provider agency bills the MMIS directly. The provider is then responsible to pay the direct caregiver.

Each home will be assessed for compliance with the CMS settings requirements utilizing the questions in the universal assessment that were added to address the required components that would constitute an integrated setting.

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed):

Provider Type (Specify): Entity Responsible for Verification Frequency of Verification (Specify): (Specify): Agency Fiscal Intermediary Upon enrollment and Every two years thereafter

Service Delivery Method. (Check each that applies):

Participant-directed [e| | Provider managed

Y Policies Concerning Payment for State plan HCBS Furnished by Relatives, Legally Responsible Individuals, and Legal Guardians. (By checking this box the state assures that): There are policies pertaining to payment the state makes to qualified persons furnishing State plan HCBS, who are relatives of the individual. There are additional policies and controls if the state makes payment to qualified legally responsible individuals or legal guardians who provide State Plan HCBS. (Specify (a) who may be paid to provide State plan HCBS; (b) the specific State plan HCBS that can be provided; (c) how the state ensures that the provision of services by such persons is in the best interest of the individual; (d) the state’s strategies for ongoing monitoring of services provided by such persons; (e) the controls to ensure that payments are made only for services rendered; and (f) if legally responsible individuals may provide

(ct-17-0001)(approval-document)(page-58)Page 58#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i:

TN: 17-0001 Page 54 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

Participant-Direction of Services

Definition: Participant-direction means self-direction of services per §191IS(A)(G)(iii).

Election of Participant-Direction. (Select one):

O | The state does not offer opportunity for participant-direction of State plan HCBS.

© | Every participant in State plan HCBS (or the participant’s representative) is afforded the opportunity to elect to direct services. Alternate service delivery methods are available for participants who decide not to direct their services.

© | Participants in State plan HCBS (or the participant’s representative) are afforded the opportunity to direct some or all of their services, subject to criteria specified by the state. (Specify criteria):

Description of Participant-Direction. (Provide an overview of the opportunities for participant- direction under the State plan HCBS, including: (a) the nature of the opportunities afforded; (b) how participants may take advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that they provide; and, (d) other relevant information about the approach to participant-direction):

Self directed Personal Care Assistant Services are available in CT under the 1915k state plan option so are no longer included in the 1915i

Limited Implementation of Participant-Direction. (Participant direction is a mode of service delivery, not a Medicaid service, and so is not subject to statewideness requirements. Select one):

O | Participant direction is available in all geographic areas in which State plan HCBS are available.

O | Participant-direction is available only to individuals who reside in the following geographic areas or political subdivisions of the state. Individuals who reside in these areas may elect self- directed service delivery options offered by the state, or may choose instead to receive comparable services through the benefit’s standard service delivery methods that are in effect in all geographic areas in which State plan HCBS are available. (Specify the areas of the state affected by this option):

Participant-Directed Services. (Indicate the State plan HCBS that may be participant-directed and the authority offered for each. Add lines as required):

= * . Employer Budget Part -Dire articipant-Directed Service ‘Authority Authority Oo |

Oo Oo

(ct-17-0001)(approval-document)(page-60)Page 60#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1—i:

TN: 17-0001 Page 56 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: NEW OFFICIAL

7. Voluntary and Involuntary Termination of Participant-Direction. (Describe how the state facilitates an individual's transition from participant-direction, and specify any circumstances when transition is involuntary):

8. Opportunities for Participant-Direction

Participant-Employer Authority (individual can select, manage, and dismiss State plan HCBS providers). (Select one):

The state does not offer opportunity for participant-employer authority.

Participants may elect participant-employer Authority (Check each that applies):

| Participant/Co-Employer. The participant (or the participant’s representative) functions as the co-employer (managing employer) of workers who provide program services. An agency is the common law employer of participant-selected/recruited staff and performs necessary payroll and human resources functions. Supports are available to assist the participant in conducting employer-related functions.

| Participant/Common Law Employer. The participant (or the participant’s representative) is the common law employer of workers who provide program services. An IRS-approved Fiscal/Employer Agent functions as the participant’s agent in performing payroll and other employer responsibilities that are required by federal and state law. Supports are available to assist the participant in conducting employer-related functions.

Participant-Budget Authority (individual directs a budget that does not result in payment for medical assistance to the individual). (Select one):

fo}

The state does not offer opportunity for participants to direct a budget.

[e)

Participants may elect Participant—Budget Authority.

Participant-Directed Budget. (Describe in detail the method(s) that are used to establish the amount of the budget over which the participant has authority, including the method for calculating the dollar values in the budget based on reliable costs and service utilization, is applied consistently to each participant, and is adjusted to reflect changes in individual assessments and service plans. Information about these method(s) must be made publicly available and included in the person-centered service plan.):

Expenditure Safeguards. (Describe the safeguards that have been established for the timely prevention of the premature depletion of the participant-directed budget or to address potential service delivery problems that may be associated with budget underutilization and the entity (or entities) responsible for implementing these safeguards.

(ct-17-0001)(approval-document)(page-61)Page 61#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i:

TN: 17-0001 Page 57 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: NEW OFFICIAL Quality Improvement Strategy

Quality Measures

(Describe the state's quality improvement strategy. For each requirement, and lettered sub-requirement, complete the table below):

1. Service plans a) address assessed needs of 1915(i) participants; b) are updated annually; and (c document choice of services and providers.

2. Providers meet required qualifications.

3. Settings meet the home and community-based setting requirements as specified in this SPA and in accordance with 42 CFR 441.710(a)(1) and (2).

4. The SMA retains authority and responsibility for program operations and oversight.

5. The SMA maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers.

6. The state identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation, including the use of restraints.

(Table repeats for each measure for each requirement and lettered sub-requirement above.)

Service plans a) address assessed needs of 1915(i) participants; b) are updated

. annually; and (c document choice of services and providers. Requirement

Discovery

Discovery 1 Evidence :

Number and percent of service plans that are updated and revised annually

(Performance 2. Number and percent of clients educated about the full range of services Measure) and choices of providers available as evidenced by their signature on the W-990 form, "Your Rights and Responsibilities

Discovery Activity

(Source of Data & sample size)

Representative sample of record audits conducted by both the contracted Access Agency and the SMA. Sample size to be determined by using on-line tool to determine representative sample size with a confidence level of 95%

Monitoring Contracted Access Agency and SMA Responsibilities (Agency or entity that conducts discovery activities)

Frequency

Annually

(ct-17-0001)(approval-document)(page-70)Page 70#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 17-0001 Page 66 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: NEW OFFICIAL

The State of Connecticut has been utilizing a comprehensive system of checks and balances in order to establish consistent quality assurance within services provided to clients through its Medicaid Waiver and state funded Home Care Program for Elders. The state has been utilizing the same QIS for the 1915(i) participants. The state has been guided by state and federal regulations to assist in establishing procedures and the many varied data collection, aggregation and analysis processes that are currently utilized. Through the productive process of analysis, discovery, remediation and improvement, the state recognizes the benefit to client services that can be obtained through some system design changes.

Statewide chart audits of access agency clients are conducted quarterly. Sampling size of client chart reviews requires a representative sample. Therefore, we have developed a system in which the Access Agencies provide data on supervisory record audits utilizing a tool developed by a Quality Improvement Committee consisting of both Access Agency and Alternate Care Unit (SMA) staff. A system was designed to accomplish a representative sample review by utilizing the data from that supervisory review supplemented by annual reviews done by SMA staff. We have added a quarterly reporting requirement for the Access Agencies to provide a summary report of supervisory record reviews done on a regular basis.

Service Plan

The SMA contracts with Access Agencies who provide independent care managers. The care managers complete a comprehensive, multi-dimensional assessment that is consumer centered and is the basis for the development of the service plan. The assessment instrument is designed to identify unmet needs and health and safety risk factors as well as personal goals. Service plans are updated and revised as client’s needs change but no less frequently than annually. Department Utilization Review Nurses review and approve every initial plan of care before the services are implemented. The Care Manager monitors the clients’ needs and the delivery of the authorized service plan on a monthly basis. HCBS unit staff also review a representative sample of reassessment plans of care. In addition SMA staff conducts annual record audits of the care managers’ records. This combined with the Access Agency supervisory record review, constitutes a representative sample. Access agency care managers have been trained in person centered planning and further training is planned.

A tool was developed for access agency supervisors to complete when conducting supervisory record reviews. The data is summarized and reported to the SMA quarterly.

Consumer satisfaction surveys are conducted by both the Access Agency and SMA staff. The surveys are useful in identifying trends that may require system remediation.

The department is currently a CMS TEFT grant recipient and we are testing the Participant Experience Survey. It is our intention to utilize the PES as our QA survey tool once the testing is complete and CMS determines the final tool.

Qualified Providers:

The state’s contracted fiscal intermediary currently credentials all HCBS state plan HCBS providers initially and every two years thereafter. Once credentialed, the provider must enroll directly with the department’s MMIS contractor and sign the Medicaid provider agreement. The certifications and qualifications are incorporated into the regulations that govern the CT Home Care Program for Elders (17b-342). The Department has incorporated an expanded administrative review of audits to

include ver required through contracts, policies and procedures. The State Plan HCBS will operate

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 17-0001 Page 67 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: NEW OFFICIAL

to include verification that licensure, certification and qualifications are monitored and documented as required through contracts, policies and procedures. The State Plan HCBS will operate under the same rules as the HCBS Waiver.

The Department cross matches providers with the HHS-OIG Fraud Protection and Detection Exclusion list to block participation of providers found on this list.

Access Agencies perform checks of staff licensure (RN and SW if applicable) routinely at time hire and annual performance review.

The fiscal intermediary is required to have procedures in place to verify that subcontractors meet all of the criteria to be an HCBS provider. They must provide documentation that the subcontractor meets Department standards and requirements to assure provider eligibility, adherence to program requirements and standards, quality of service delivery and that services are delivered in accordance with participants! plans of care.

The fiscal intermediary is contractually obligated to assist providers in meeting the provider qualifications needed to be a participating provider. They offer training programs both for existing providers as well as for providers who wish to enroll. Documentation of the grievances and all of the accompanying correspondence is maintained in a central file in HCBS Unit.

The fiscal intermediary also contractually required to audit a sample of the HCBS providers to ensure that they have appropriate documentation to substantiate the claims that are billed.

Health and Welfare

The Department holds Access Agency meetings bi-monthly for the purpose of disseminating information and discussing issues of concern. Elder Protective Services (PSE), Alternate Care Unit and Access Agencies collaborate to identify and resolve health and safety concerns. The Alternate Care Unit Manager and/or Health and Safety Nurse Consultant have ongoing consultation and dialogue with the Protective Services for Elders manager as needed on case by case basis.

A workgroup was developed to facilitate discussions between access agencies, PSE and ACU staff with respect to informed risk versus self determination, i.e. what is an acceptable level of risk to both the client and the program.

All findings related to participant safeguards are entered into a data base within the Community Options Unit. Communications occur with the care manager and other Access Agency staff as appropriate for any corrective action or interventions. Access Agency staff monitors the HCBS participants on a monthly basis and will continue to follow up on the identified problem as needed.

Self neglect was identified as a trend in Health and Safety Reporting. Improved collaboration between ACU, PSE and AA's was established for the purpose of updating "best practices" guidelines for care managers when addressing self-neglect issues.

Health standard monitoring is already in place at the Access Agency level, but data aggregation and reporting, including analysis for trending of this information, has been initiated by the Community Options Unit. Health promotion and prevention questions have been added to the Uniform Assessment Instrument

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State: Connecticut §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 17-0001 Page 68 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: NEW OFFICIAL

and reported annually allowing for further analysis. We expect to utilize this tool universally sometime in 2017.

The department has initiated a fully web based critical incident reporting system that allows for tracking and trending. It allows us to track client specific data as well as provider trends.

A performance measure has been added to our critical incident reporting system to identify any use of restrictive interventions such as restraints and seclusion. The care managers as part of their face to face assessments and reassessments will review for the use of restrictive interventions and intervene as indicated by the presenting situation.

There are no HCBS that are provided in a 24 hour supervised environment in which medication administration is done by waiver providers. In Managed Residential Communities, persons lease an independent apartment and waiver services are not provided on a 24 hour basis.

The State of Connecticut has been utilizing a comprehensive system of checks and balances in order to establish consistent quality assurance within services provided to clients through its Medicaid Waiver and state funded Home Care Program for Elders. The state will be utilizing the same QIS for the 1915(i) participants. The state has been guided by state and federal regulations to assist in establishing procedures and the many varied data collection, aggregation and analysis processes that are currently utilized. Through the productive process of analysis, discovery, remediation and improvement, the state recognizes the benefit to client services that can be obtained through some system design changes.

Financial Accountability

The State of Connecticut contracts with HP (formerly EDS) to employ a data system to ensure reimbursement is consistent with HCBS requirements. The Department introduced the MMIS system Interchange for the purpose of upgrading the old claims processing system. It is now a Windows environment. The provider relations unit oversees the contract with HP, as part of the medical operations process. They can make changes to procedure codes, edits and audits. Clients are identified by Medical Eligibility or Benefit Plan code. Providers are based on type and specialty. The system is designed to make sure it can be billed only for what is allowed through the edits and audits system. We have requested this report from MAR on a semi-annual basis. Problematic providers will be identified for potential additional training. MAR reports 382 and 383 are already in place and can be separated by Medicaid eligibility code to identify the number, percent of denied claims, the error code reason, provider number, top 5 most frequently occurring error reasons, error status code. The reports will be the basis for determining is systems changes are needed. It will allow for the tracking of trends and identify problematic service providers. The SMA will use the reporting to identify remediation needs or system changes.

(ct-17-0001)(approval-document)(page-74)Page 74#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 4.19-B: TN: 12-0001 Page 22

Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL

Methods and Standards for Establishing Payment Rates

Services Provided Under Section 1915(i) of the Social Security Act. For each optional service, describe the methods and standards used to set the associated payment rate. (Check each that applies, and describe methods and standards to set rates):

HCBS Case Management

Rates are determined by the Department's Rate Setting Unit. Pursuant to the Connecticut Department of Social Services Provider Manual, all schedules of payment for covered Medical Assistance Program goods and services shall be established by the Commissioner of Social Services and paid by the Department of Social Services in accordance with applicable federal and State states and regulations. Except as noted in the plan, state developed fee schedule rates are published at www.ctdssmap.com. The fee scheduled utilized for this 1915i is the Connecticut Home Care Program.

The majority of the regularly scheduled services provided to clients utilize a fixed fee

schedule. Fee-for-service billing from an established fee schedule pays uniform rates

across providers and are called “max fee” within the Medicaid Management Information

System. This program does not pay a percent of usual and customary charges. Payments

are uniform for all providers and limited to the lower of the amount claimed or the amount

published on the fee schedule for that service.

HCBS Homemaker

Same as HCBS Case Management above and priced at max fee

HCBS Home Health Aide

HCBS Personal Care

HCBS Adult Day Health

Same as HCBS case management above and priced at max fee

HCBS Habilitation

HCBS Respite Care

Same as HCBS case management above and priced at max fee

For Individuals with Chronic Mental Illness, the following services:

O | HCBS Day Treatment or Other Partial Hospitalization Services

O | HCBS Psychosocial Rehabilitation

O | HCBS Clinic Services (whether or not furnished in a facility for CM1)

(ct-17-0001)(approval-document)(page-75)Page 75#

State: Connecticut §1915(i) State plan HCBS State plan Attachment 4.19-B:

TN: 12-0001 Page 23 Effective: 02/01/2017 Approved: 1/27/17 Supersedes: TN 12-001 OFFICIAL v Other Services (specify below)

HCBS Companion- Same as HCBS case management above and priced at max fee

HCBS Chore-Same as HCBS case management above and priced at max fee

HCBS Assisted Living- Same as HCBS Case Management above and priced at max fee

HCBS Assistive Technology- Manual pricing is used for assistive technology equipment or other services such as home modifications that require manual pricing. These services are, however, capped to a maximum level as identified in the SPA document. Rates for assistive technologies are case-specific and not published in the fee schedule. Reimbursement for assistive technology is based on actual service contracts for the services rendered. The fiscal intermediary reimburses the contractor. The fiscal intermediary is reimbursed through the Medicaid Management Information System based upon submitted claims.

HCBS Environmental Accessibility Adaptations- Manual pricing is used for home modifications that require manual pricing. These services are, however, capped to a maximum level as identified in the SPA document. Minor Home Modifications required by the individual's plan of care which are necessary to ensure health, welfare and safety of the individuals to function with greater independence in their home and without which the individual would require institutionalization. Such adaptations may include the installation of hand rails and grab bars in the tub area, widening of doors and installation of ramps. Excluded are those adaptations or improvements to the home which are of general utility and are not of direct medical or remedial benefit to the individuals such as carpeting, roof repair or air conditioning. Adaptations which add to the total square footage of the home are excluded from this benefit. All services shall be provided in accordance with applicable state or local building codes. Adaptations are excluded if the residence is owned by someone other than the participant and the adaptations would be the responsibility of the owner/landlord. Rates for environmental modifications are case- specific and not published in the fee schedule. Reimbursement for environmental modifications is based on the lower of at least two bids from licensed contractors. The fiscal intermediary reimburses the contractor. The fiscal intermediary is reimbursed through the Medicaid Management Information System based upon submitted claims. This service is subject to department prior authorization

HCBS Home Delivered Meals- This service is the same as HCBS case management and is priced at max fee ;

HCBS Adult Family Living- This service has a tiered rate and is the same as HCBS case management and is priced at max fee

HCBS Mental Health Counseling- Mental Health Counseling service is priced at max fee. Fee schedule rates are published at www.ctdssmap.com

HCBS Personal Emergency Response Systems- Personal Emergency Response System service is priced at max fee

HCBS Transportation- Transportation Service is priced at max fee. Fee schedule rates are published at www.ctdssmap.com HCBS Bill Payer- this service is priced at max fee and published in the fee schedule

(ct-18-0016)(approval-document)(page-4)Page 4#

OFFICIAL

Attachment 4.19-B Page 1(d) STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Connecticut

(g) Chemical Maintenance Clinics.

1. Chemical maintenance services shall be reimbursed based on a provider-specific weekly rate listed below. Providers shall be certified and licensed by SAMHSA (Substance Abuse and Mental Health Services Administration) and the Connecticut Department of Public Health and shall comply with all applicable federal and state requirements, including, but not limited to, requirements specific to the provision of chemical maintenance services.

2. New chemical maintenance providers licensed by the Department of Public Health shall receive the weighted statewide rate as listed below. Any existing provider that opens an additional licensed location shall receive the provider’s current rate as listed below.

3. When two or more current chemical maintenance providers merge to form a different legal entity, the data used to calculate the provider specific weekly rate of the original entities are totaled and used as the basis for determining a rate for the new entity. The same methodology will be used when one chemical maintenance provider purchases another chemical maintenance provider.

4. In order to qualify for chemical maintenance reimbursement, providers shall ensure all participants receive appropriate intake and/or annual physical exams. This requirement is a prerequisite to being able to bill for chemical maintenance services. Reimbursement for physical exams is a component of the weekly rate and shall not be reimbursed separately.

5. To receive payment of chemical maintenance services (including methadone dispensing) at the weekly rate, at least one unit of the following categories of service per day for seven days must have been provided: in-person medication administration, take-home medication doses or any in-person clinical service provided at the clinic that meets the billing code clinical and minimum time definitions for individual, group or family psychotherapy or any combination thereof. A provider may bill multiple weekly rates during an in-person dispensing visit in order to account for the dispensed take-home doses up to the limitations in federal requirements for take-home doses, provided that the total number of doses billed is no greater than the total number of days allocated to each weekly rate. For any week for which such a service is provided on fewer than seven days, the Department shall prorate the rate to pay only for the number of days in the week during which such a service was provided.

TN # 18-0016 Approval Date 06/21/18_____________ Effective Date 02-01-2018 Supersedes TN # 12-011

(ct-18-0016)(approval-document)(page-5)Page 5#

OFFICIAL Attachment 4.19-B Page 1(d)i

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Connecticut

6. The rate for chemical maintenance treatment includes all of the following: intake evaluation; initial physical examination; medication administration, including face-to- face medication administration or take-home medication; on-site drug use screening and monitoring; and all routine individual, group and family substance use disorder counseling services. Other services may be provided and paid for separately in accordance with the applicable reimbursement methodology for the service.

7. The provider shall perform or make arrangements for the provision of all routine drug use screening and monitoring, which is included in the weekly rate. The minimum frequency for in-house drug use testing is eight per year or as otherwise required under federal rules. Any laboratory work other than routine drug use screening may be provided by a laboratory other than the behavioral health clinic and such services are not included in the rate for chemical maintenance treatment. Such drug use testing services that are outside the weekly rate for chemical maintenance services that are conducted by a certified and Medicaid enrolled independent laboratory may be billed separately in accordance with section (3) of Attachment 4.19-B of the Medicaid State Plan. The chemical maintenance clinic provider shall include clinical documentation demonstrating the need for any external laboratory testing ordered or referred by the provider. The provider shall also include documentation in each member’s medical records that appropriate medical personnel at the provider have reviewed and interpreted external laboratory tests and explain in the medical records how such interpretation of the tests has affected the member’s plan of care.

8. The sources used by the Department to develop the provider-specific chemical maintenance weekly rate include, but are not limited to:

• Annual Chemical Maintenance Provider cost reports • Medicaid claims data from the Medicaid management information system • Subject matter expertise with developing mental health payment models • Provider’s budget forecasts and financial statements • Feedback from providers and other stakeholders.

TN # 18-0016 Approval Date_06/21/18____________ Effective Date 02-01-2018 Supersedes TN # NEW

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES FORM APPROVED 0MB NO. 0938-0193 I. TRANSMITTAL NUMBER: 19-0025 2. STATE: CT TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES 5. TYPE OF STATE PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DA TE: July I, 2019 NEW STATE PLAN _AMENDMENT TO BE CONSIDERED AS NEW PLAN 1AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Section 191 S(k) of the Social Security Act and 42 CFR 441, Subpart K 7. FEDERAL BUDGET IMPACT: a. FFY 2019 $1,000 b. FFY 2020 $8,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If applicable) Attachment4.19-B, Page 27 Attachment 4.19-B, Page 27 I 0. SUBJECT OF AMENDMENT: Effective July I, 2019, this SPA amends Attachment 4.19-B of the Medicaid State Plan to update the effective date of the fee schedule for Community First Choice Services (under section 191 S(k) of the Social Security Act) in order to implement a ten percent (10%) rate increase for home-delivered meals. 11. GOVERNOR'S REVIEW (Check One): __K_GOVERNOR'S OFFICE REPORTED NO COMMENT _COMMENTS OF GOVERNOR'S OFFICE ENCLOSED _NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 13. 14. TITLE: Deputy Commissioner 15. DA TE SUBMITTED: September 26, 2019 _OTHER, AS SPECIFIED: 16. RETURN TO: State of Connecticut Department of Social Services 55 Farmington A venue - 9th floor Hartford, CT 06105 Attention: Ginny Mahoney FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED-ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM CMS-179 (07-92) September 30 2019 November 13 2019 July 1 2019 Francis T. McCullough Director Division of Medicaid Field Operations-East /S/ /S/

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OFFICIAL Attachment 4.19-B Page 27 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Connecticut Community First Choice State Plan Option Pursuant to Section 1915(k) of the Social Security Act The payment methodology described below applies to all services and supports provided under Connecticut’s Community First Choice (CFC) State Plan Option pursuant to section 1915(k) of the Social Security Act, as described in and provided in accordance with Attachment 3.1-K of the Medicaid State Plan. Except as otherwise provided below, CFC services are paid pursuant to the current fee schedule for CFC, which was set as of July 1, 2019, 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,” then to “Provider Fee Schedule Download.” All governmental and private providers are reimbursed according to the same fee schedule. Medicaid payment under CFC does not include payment for room and board. Payments are made by the Medicaid agency directly to the providers of State plan services or to the Fiscal Intermediary to disperse payments. Payments for all State plan services are made through the State’s Medicaid Management Information System (MMIS). As set forth on the fee schedule referenced above, the following CFC services are reimbursed as described below: Attendant Care: Attendant care rates are billed under five distinct payment methodologies, each of which is based on the plan of care and the specific circumstances of the services provided, as follows: 1. Hourly Rate: When care is provided over a period of time which is neither live-in care for a continuous twenty-four hour period, nor a 12-hour overnight shift, a quarter-hour rate is used. 2. Per Diem Rate: When care is provided for a continuous twenty four hour period by a live-in attendant, a per diem rate is billed, which assumes that the attendant receives at least eight hours of sleep, at least five of which is uninterrupted. 3. Pro-Rated Per Diem Rate: When the 24 hour shift is not completed; services are billed at a pro-rated per-diem rate. 4. Overnight Rate: When care is provided overnight for a twelve-hour period, services are billed under an overnight rate, which assumes that the attendant sleeps for half of the hours. TN # 19-0025 Approval Date 11/13/19_________ Effective Date 07/01/2019 Supersedes TN # 15-012

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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | CT2020MS0001O | CT-20-0003 Package Header Package ID CT2020MS0001O Submission Type Official Approval Date 6/29/2020 Superseded SPA ID N/A SPA ID CT-20-0003 Initial Submission Date 3/31/2020 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives CT SPA-20-0003--Cost of Living Adjustment (COLA) Increase SPA-20-0003 proposes to amend Supplement 6 to Attachment 2.6-A and Addendum pages 1-3 to Supplement 6 to Attachment 2.6-A. Effective January 1, 2020, the Department proposes to pass along the increase in Federal SSI benefits and, therefore, will increase the Aged, Blind and Disabled (AABD) unearned income disregard for recipients. AABD recipients who receive a Social Security COLA increase for FY 2020 will be offset by an increase in the AABD unearned disregard. As a result, the AABD recipient's total income (the combined federal Social Security and State Supplement payment) will increase. State Supplement payments will not increase for single individuals. For married couples living together, the increase will be $3.00 per person per month. Please note: The only changes Connecticut is making through this SPA is to amend Supplement 6 to Attachment 2.6-A and Addendum pages 1-3 to Supplement 6 to Attachment 2.6A. The only language that is being superseded through this SPA are to the pages listed above. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2020 $0 Second 2021 $0 Federal Statute / Regulation Citation 42 CFR 435.234 20 CFR 416.2095-416.2099 Supporting documentation of budget impact is uploaded (optional). Name Date Created CT SPA 20-0003 Fiscal Note COLA Increase 3/11/2020 9:59 AM EDT CT SPA 20-0003 Special Needs 6/26/2020 9:07 AM EDT CT SPA 20-0003 Special Needs 2 6/26/2020 9:07 AM EDT Page 5 of 53 Medicaid State Plan Print View 08/05/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | CT2020MS0001O | CT-20-0003 Package Header Package ID CT2020MS0001O Submission Type Official Approval Date 6/29/2020 Superseded SPA ID N/A SPA ID CT-20-0003 Initial Submission Date 3/31/2020 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Yes No  The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner:  All Indian Health Programs Date of solicitation/consultation: Method of solicitation/consultation: 3/3/2020 Email  All Urban Indian Organizations Date of solicitation/consultation: Method of solicitation/consultation: 3/3/2020 Email States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below:  All Indian Tribes Date of consultation: Method of consultation: 3/3/2020 Email The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Page 8 of 53 Medicaid State Plan Print View 08/05/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | CT2020MS0001O | CT-20-0003 Package Header Package ID CT2020MS0001O Submission Type Official Approval Date 6/29/2020 Superseded SPA ID New User-Entered SPA ID CT-20-0003 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831. A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the financial methodologies of either the SSI program or the AFDC program in effect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive and More Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). Yes No 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group. 3. The state applies more restrictive financial eligibility requirements to individuals who are age 65 or older or who have blindness or disability. The more restrictive requirements are no more restrictive than those requirements contained in the state's Medicaid plan in effect on January 1, 1972. 4. The more restrictive requirements are described in More Restrictive Methodologies Under 1902(f). Page 10 of 53 Medicaid State Plan Print View 08/05/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | CT2020MS0001O | CT-20-0003 Package Header Package ID CT2020MS0001O Submission Type Official Approval Date 6/29/2020 Superseded SPA ID New User-Entered SPA ID CT-20-0003 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 C. Financial Responsibility of Relatives 1. In determining financial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources. ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in effect as of July 16, 1996. 2. In determining financial eligibility for individuals who are age 65 or older or who have blindness or a disability, the state may apply more restrictive requirements for relative responsibility than specified in B.1., but no more restrictive than the requirements under the Medicaid plan in effect on January 1, 1972. These methodologies are described in More Restrictive Methodologies under 1902(f). Page 11 of 53 Medicaid State Plan Print View 08/05/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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Medicaid State Plan Eligibility Income/Resource Methodologies More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | CT2020MS0001O | CT-20-0003 Package Header Package ID CT2020MS0001O Submission Type Official Approval Date 6/29/2020 Superseded SPA ID New User-Entered SPA ID CT-20-0003 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 The state applies more restrictive requirements than SSI under the authority of section 1902(f) of the Act, and consistent with 42 CFR 435.121. A. Use of More Restrictive Requirements The state applies more restrictive eligibility requirements to individuals who are age 65 or older or who have blindness or disability. The more restrictive requirements are no more restrictive than those requirements contained in the state's Medicaid plan in effect on January 1, 1972. The state does not apply more restrictive requirements if: 1. The requirement conflicts with the requirements of section 1924 of the Act, which governs the eligibility and post-eligibility treatment of income and resources of institutionalized individuals with community spouses; 2. The requirement conflicts with a more liberal requirement which the agency has elected to use under 42 CFR 435.601; or 3. The more restrictive requirement conflicts with a more liberal requirement the state has elected to use under §435.234(c) in determining eligibility for State supplementary payments. B. Populations with More Restrictive Requirements The state applies more restrictive requirements for the following populations:  1. Individuals age 65 or older  2. Individuals who have blindness  3. Individuals who have a disability C. Types of More Restrictive Requirements Used The state applies more restrictive requirements for the following populations:  1. The state uses more restrictive requirements with respect to income.  2. The state uses more restrictive requirements with respect to resources. 3. The state uses more restrictive requirements with respect to the definition of disability. 4. The state uses more restrictive requirements with respect to the definition of blindness. 5. The state uses more restrictive requirements with respect to financial responsibility of relatives. 6. The state uses other more restrictive requirements. Page 16 of 53 Medicaid State Plan Print View 08/05/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | CT2020MS0001O | CT-20-0003 Package Header Package ID CT2020MS0001O Submission Type Official Approval Date 6/29/2020 Superseded SPA ID New User-Entered SPA ID CT-20-0003 Initial Submission Date 3/31/2020 Effective Date 1/1/2020 J. Income Deductions When applying more restrictive requirements, the state deducts SSI payments received by the individual and state supplement payments that meet the conditions specified in 42 CFR 435.232 and 435.234. The state also allows the following individuals to deduct incurred medical and remedial expenses (spend down) to become categorically eligible under the group for individuals in 209(b) states who are age 65 or over or who have blindness or a disability: 1. SSI beneficiaries and eligible spouses of SSI beneficiaries 2. State supplement recipients or individuals who are eligible for but not receiving a state supplementary payment. 3. Individuals who would be eligible for SSI/SSP but for OASDI COLA increases since April, 1977 (42 CFR 435.135) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI benefits, as follows: a. All of the OASDI benefits is deducted from income. b. Part of the OASDI benefits is deducted from income. c. None of the OASDI benefits is deducted from income. 4. Disabled widows and widowers ineligible for SSI due to increase in OASDI (42 CFR 435.137) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI benefits, as follows: a. All of the OASDI benefits is deducted from income. b. Part of the OASDI benefits is deducted from income. c. None of the OASDI benefits is deducted from income. 5. Disabled widows and widowers ineligible for SSI due to early receipt of social security (42 CFR 435.138) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI benefits, as follows: a. All of the OASDI benefits is deducted from income. b. Part of the OASDI benefits is deducted from income. c. None of the OASDI benefits is deducted from income. 6. Adult children with disabilities (1939(a)(2)(D) and 1634(c) of the Act) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OASDI benefits, as follows: a. All of the OASDI benefits is deducted from income. b. Part of the OASDI benefits is deducted from income. c. None of the OASDI benefits is deducted from income. Page 19 of 53 Medicaid State Plan Print View 08/05/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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DEPARTMENT OF HEALTH AND HUMAN SERVICES HEAL TH CARE FINANCING ADMINISTRATION FORM APPROVED 0MB NO. 0938-0I93 I. TRANSMITTAL NUMBER: 20-0010 2. STATE: CT TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OE HEAT TH AND HUMAN SERVICES 5. TYPE OF STATE PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFICATION: TI1LE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4 .. PROPOSED EFFECTIVE DATE 2-3-20 NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN __lLAMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Section 1940, subsection 1903(i)(24) of the Social Security Act 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $193,804 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN 10. SUBJECT OF AMENDMENT: Asset Verification System I I. GOVERNOR'S REVIEW (Check One): __ GOVERNOR'S OFFICE REPORTED NO COMMENT __ COMMENTS OF GOVERNOR'S OFFICE ENCLOSED SECTION OR ATTACHMENT (If applicable) Supplement 16 to Attachment 2.6-A; Addendum pages2-3 to Supplement 16 to Attachment 2.6-A __lL OTHER, AS SPECIFIED: __ NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Comments, if any, to follow. 12. SIGNATURE OF STATE AGENCY OFFICIAL: LIM-· n 13. TYPED NAME: Kathleen Brennan 14. TITLE: Deputy Commissioner 15. DATE SUBMITTED: February 19, 2020 16. RETURN TO: State of Cotu1ecticut Department of Social Services 55 Farmington Ave Hartford, CT 06106-3725 Attention: Laura Catarino FOR REGIONAL OFFICE USE ONLY 17. DATERECEIVED: I 18. DATE APPROVED: PLAN APPROVED-ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 21. TYPEDNAME: 23. REMARKS: FORMHCFA-179 (07-92) 20. SIGNATURE OF REGIONAL OFFICIAL: 22. TITLE: Supplement 16 to Attachment 2.6A Page 1-3 March 5, 2020 February 3, 2020 James G. Scott Director Division of Program Operations March 29, 2020 /S/ Supplement 16 to Attachment 2.6A, Page 1-3 /S/

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

TRANSMITTAL AND NOTICE OF APPROVAL

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

FORM APPROVED OMB NO. 0938-0193 . TRANSMITTAL NUMBER: 2. STATE: CT 20-0016

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

TO: REGIONAL ADMINISTRATOR

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

. PROPOSED EFFECTIVE DATE: July 1, 2019

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: Section 1905(a)(1) of the Social Security Act and 42 CFR 440.10 and 447.253(a), (b), and (c)

7. FEDERAL BUDGET IMPACT: FFY 2019 $0 FFY 2020 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-A, Page 1(x) Attachment 4.19-A, Page 1(x)a Attachment 4.19-A, Pages 1(xi)

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ff applicable) Attachment 4.19-A, Page 1(x) Attachment 4.19-A, Page 1(x)a Attachment 4.19-A, Pages 1(xi)

10. SUBJECT OF AMENDMENT: Effective July 1, 2019, this SPA makes the following technical corrections to approved SPA 19-0017 (inpatient hospital supplemental payments): (1) On Attachment 4.19-A, Page 1(x) at the bottom, the language “Attachment 4.19-A Page 1 (x)(a)” will move to the top of Attachment 4.19-A, Page 1(x)(a) and (2) On Attachment 4.19-A, Page 1(xi), in Section (2b), the State Fiscal Year (SFY) date at the end of

the first sentence “20212026” is replaced with “2026”.

11. .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:

13. TYPED NAME: Deidre S. Gifford

14. TITLE: Commissioner

15. DATE SUBMITTED: June 4, 2020

16. RETURN TO:

State of Connecticut

Department of Social Services

55 Farmington Avenue — 9th floor Hartford, CT 06105

Attention: Ginny Mahoney

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED: 6/29/20

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: TANS

20. SIGNATURE OF REGIONAL OFFICIAL:

21. TYPEDNAME: Karen Shields

22. TITLE: Acting Director, FMG

23. REMARKS:

FORM CMS-179 (07-92)

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Attachment 4.19-A Page 1(x) STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Connecticut

(2) Supplemental Reimbursement for Inpatient Hospital Services. General criteria applicable to all inpatient hospital supplemental payments made under this section 2 of Attachment 4.19-A (Attachment 4.19-A, Pages 1(x) through 1(xii)(b)). (a) If a hospital is merged with or acquired by another hospital, the supplemental payments that would have been paid to the merging hospital shall instead be paid to the acquiring hospital starting with the first calendar quarter that begins on or after the effective date of the merger or acquisition. (b) If a hospital dissolves or ceases to exist, the supplemental payments that would have been paid to the dissolved hospital shall not be made to any other hospital for the remainder of the state fiscal year (SFY) in which the effective date of the dissolution occurred. Effective starting with the beginning of the SFY after the dissolution, the supplemental payments that would have been made to the dissolved hospital will be distributed in accordance with each supplemental payment pool’s distribution methodology. (c) All figures in supplemental payment eligibility and/or distribution methodologies based on each hospital’s filings with the State of Connecticut, Office of Health Strategy (OHS), formerly Department of Public Health, Office of Health Care Access (OHCA), are subject to adjustment if the applicable OHS report is adjusted upon audit by OHS. There shall be no further redistribution of inpatient hospital supplemental payments after adjustments are made based on such audit. (d) For all of the pools described below, effective for dates of service from SFY 2027 and forward (July 1, 2026 forward), the amounts shall continue at the levels in effect during SFY 2026 unless this section is modified by a future SPA. (2a) Supplemental Payments for General Inpatient Hospital Services Supplemental payments to eligible hospitals shall be made from a pool of funds in the amount of $305 million for each of the state fiscal years ending June 30, 2020 (SFY 2020) and June 30, 2021 (SFY 2021), $285 million for SFY 2022, and $261 million per SFY for SFY 2023 through SFY 2026. The payments shall be made quarterly throughout each fiscal year except that the payment for the first quarter of SFY 2020 shall be made as an interim payment that is reconciled to the actual amount before the end of the SFY. (a) Hospitals eligible for supplemental payments under this paragraph are non- governmental licensed short-term general hospitals located in the state other than short- term children’s general hospitals, but including a short-term general hospital operated by the State as a receiver. TN# 20-0016 Approval Date ___________ Effective Date: 07-01-2019 Supersedes TN# 19-0017 6/29/20

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: CT TRANSMITTAL AND NOTICE OF APPROVAL 20-0017 OF STATE PLAN MATERIAL 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE: CENTERS FOR MEDICARE AND MEDICAID SERVICES April 1, 2020 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 IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Sections 1905(a)(4)(A) and 1919 of the Social Security Act FFY 2020 $6,000 and 42 CFR 440.40(a), 440.155, and 483.120 FFY 2021 $14,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If applicable) Addendum Page 1(g) to Attachments 3.1-A and 3.1-B Addendum Page 1(g) to Attachments 3.1-A and 3.1-B 10. SUBJECT OF AMENDMENT: Effective April 1, 2020, this SPA amends Attachments 3.1-A and 3.1-B of the Medicaid State Plan to increase the allowable units for individual day program services provided to individuals residing in a Medicaid-certified nursing facility who are 21 years of age or older and have been found through the Preadmission Screening and Resident Review (PASRR) process to need such services. Specifically, the daily limit for individual day program services is increased to eight hours per day. As provided in the approved state plan, additional hours may be approved by prior authorization based on individual need. 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: 13. TYPED NAME: Deidre S. Gifford State of Connecticut Department of Social Services 14. TITLE: Commissioner 55 Farmington Avenue – 9th floor Hartford, CT 06105 15. DATE SUBMITTED: Attention: Ginny Mahoney June 30, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM CMS-179 (07-92) /s/ /s/ June 30 2020 July 16, 2020 April 1 2020 James G. Scott Director, Medicaid & CHIP Operations Group

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: CT TRANSMITTAL AND NOTICE OF APPROVAL 21-0005 OF STATE PLAN MATERIAL 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE: CENTERS FOR MEDICARE AND MEDICAID SERVICES January 1, 2021

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 IS ANAMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1905(a)(5) of the Social Security Act and 42 CFR a.FFY 2021 $277,000 440.50 b. FFY 2022 $427,000

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:| 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (lf applicable) Attachment 4.19-B, Page 1(a)i(E) Attachment 4.19-B, Page 1(a)i(E)

10. SUBJECT OF AMENDMENT: Effective January 1, 2021, this SPA amends Attachment 4.19-B of the Medicaid State Plan by incorporating various 2021 Healthcare Common Procedure Coding System (HCPCS) updates (additions, deletions and description changes) to the Physician Office and Outpatient, Physician-Radiology, Physician-Radiology, and Physician-Surgery fee schedules. Second, this SPA updates the reimbursement methodology to 100% of the January 2021 Medicare Average Sales Price (ASP) Drug Pricing file. Finally, this SPA makes the following technical update to the Person-Centered Medical Home (PCMH) program. As part of the federal HCPCS update, the definitions of two codes previously eligible for the PCMH fee-for-service add-on payment were revised so that they can no longer be able to be billed in the context of evaluation and management (E&M) services (Current Procedural Terminology [CPT] codes 99354 and 99355). This SPA removes those codes from the list of codes eligible for the PCMH fee-for-service add-on and replaces them with CPT code 99417, which is priced in a manner that is designed to be cost-neutral to the prior level for CPT codes 99354 and 99355.

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:

13. TYPED NAME: Deidre S. Gifford. MD. MPH State of Connecticut Department of Social Services

14. TITLE: Commissioner 55 Farmington Avenue — 9th floor Hartford, CT 06105

15. DATE SUBMITTED: Attention: Ginny Mahoney

March 30, 2021

FOR REGIONAL OFFICE USE ONLY

17. DATERECEIVED: March 30, 2021 18. DATE APPROVED: (May 24, 2021

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: January 1, 2021 21. TYPED NAME: sage 22. TITLE: _. wae . : Todd McMillion Director, Division of Reimbursement Review

23. REMARKS:

FORM CMS-179 (07-92)

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Attachment 4.19-B Page 1(a)i(E) STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: CONNECTICUT (5) Physician’s services – Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of physician’s services. The agency’s fee schedule rates were set as of January 1, 2021 and are effective for services provided on or after that date. All rates are published on the Connecticut Medical Assistance Program website: www.ctdssmap.com. From this web page, go to “Provider,” then to “Provider Fee Schedule Download,” then select the applicable fee schedule. Person-Centered Medical Home (PCMH) practices are individual sites of independent physician groups, solo physician practices, nurse practitioner groups, and individual nurse practitioners that have met National Committee for Quality Assurance (NCQA) Level 2 or Level 3 medical home recognition or NCQA medical home recognition under the 2017 or later NCQA standards (which do not recognize specific levels of recognition). PCMH practices must comply with all NCQA PCMH requirements and all additional written department requirements, including participation in various primary care initiatives operated by the State. The department offers a PCMH Glide Path program, which pays enhanced rates to practices that are providing some of the additional Medicaid services required for NCQA PCMH recognition. In order to qualify for Glide Path, a practice must demonstrate that it has begun providing a more advanced standard of primary care and has committed to achieving NCQA PCMH recognition in a set period of time. Glide Path practices must also comply with all additional written department requirements, including participation in various primary care initiatives operated by the State. Beginning January 1, 2012, PCMH and Glide Path practices may be eligible for a rate add-on to the procedure codes on the physician fee schedule identified below. PCMH practices may also be eligible for retrospective annualized supplemental payments for performance incentives and performance improvement. Independent physician-led Glide Path practices with five or fewer full-time equivalent practitioners across all practice locations may also be eligible for a supplemental payment at each Glide Path phase. (a) Glide Path and PCMH Rate Add-On: The department will pay a rate add-on for the following procedures in addition to the amounts listed for each procedure code on the physician fee schedule: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99406, 99407, 99408, 99409, 99411, 99412, 99417, 99374, 99377, 99379, 99380, 96110, 99050, 99051, 99053, D0145, TN # 21-0005 Approval Date __________ Effective Date 01/01/2021 Supersedes TN # 20-0025 05/24/21

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5/17/22, 11:52 AM Medicaid State Plan Print View Optional State Supplement Beneficiaries MEDICAID I Medicaid State Plan I Eligibility I CT2021 MS00020 I CT-21-0033 Package Header Package ID CT2021 MS0002O Submission Type Official Approval Date 1212212021 Superseded SPA ID CT-21--0003 System-Derived SPA ID CT-21-0033 Initial Submission Date 9/30/2021 Effective Date 7/1/2021 D. Income Standard of Optional State Supplement Program 1. The income standard for the optional state supplement: a. Varies by political subdivision. Q Yes 0 No b. Varies by payment classification. 0 Yes Q No The payment classifications used are: D i. All individuals age 65 or older. regardless of living arrangement. D ii. All individuals who have blindness. regardless of living arrangement. D iii. All individuals who have a disability, regardless of living arrangement. D iv. Independent living. D v. Living in household of another. D vi. Independent living and receiving non-medical care outside the home. D vii. Living in household of another and receiving non-medical care outside the home. D viii. Living in a domiciliary facility or other group living arrangement. C ix. Other payment classification. Name of Classification Independent Living (level 1) Individual $572.44 Name of Classification New Horizon shared w/related person/one eligible Description: For independent living arrangements (Level 1 ), the Standard of Assistance includes a fixed amount for personal needs of $172.44 for a single person and an allowance for shelter. The shelter component of the standard is the actual cost as paid, up the specific maximum of $400.00 for a single individual living alone There is a no income standard for a couple as Level 1 indicates living alone. System would not allow entry of 0.00 Couple $0.01 Description: For the New Horizons living arrangement. the Standard of Assistance includes a fixed amount for personal needs of $137.03 and an allowance for the charge to the individual https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAM0-BtAWpTg06QfW7sfytGJjTskhdvPqCEg80q... 17/21

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5/17/22, 11:52 AM Medicaid State Plan Print View Individual S2020.00 Name of Classification Independent Living (level 2) Individual S372.44 Name of Classification Domiciliary with one eligible member Individual S2112.30 Name of Classification Domiciliary with two eligible members Individual S2112.30 Name of Classification New Horizon (shared with unrelated person) for shelter set by the Department in accordance with State law. The maximum standard of assistance for New Horizon living arrangement is $2,020 for an individual living alone or with a related person and $4,402 for a couple with one eligible member. Couple S4402.00 Description: For independent living arrangements (Level 2), the Standard of Assistance includes a fixed amount for personal needs of $172.44 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 the specific maximum of $200.00 Couple S744.88 Description: For domiciliary living arrangements, the standard includes a fixed amount for personal needs of $30.36 and an allowance for the charge to the individual for room and board set by the Department in accordance with State law. The maximum standard of assistance for domiciliary living arrangements is S2112.30 for an individual and S4494.30 for a couple with one eligible member. Couple S4494.30 Description: For domiciliary living arrangements, the standard includes a fixed amount for personal needs of $30.36 and an allowance for the charge to the individual for room and board set by the Department in accordance with State law. The maximum standard of assistance for domiciliary living arrangements is S2112.30 for an individual and S4224.60 for a couple with one eligible member. Couple S4224.60 Description: For the New Horizons living arrangement. the Standard of Assistance includes a fixed amount for personal needs of S137.03 and an allowance for the charge to the individual https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1 iljGeHwXRmZtl2Llcjf-vAMa-BtAWp T g06QfW7 sfytGJjTskhdvPqCEg80q... 18/21

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5/17/22, 11:52 AM Medicaid State Plan Print View PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatOf)' information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes. improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements. and individualized content that reflects the characteristics of the partirular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts. improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), induding 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 acruracy 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. This view was generated on 5/17/2022 11:52 AM EDT https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1il jGeHwXRmZtl2Llcjf-vAM0-BtAWpTg06QfW7sfytGJjTskhdvPqCEg80q... 21/21

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DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 1 - 0 0 3 7 CT -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT ® XIX n XXI 4. PROPOSED EFFECTIVE DATE October 1, 2021 FORM APPROVED 0MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) Social Sec. Act Sec. 1902(a)(18), (25), 1906, 1912, 1917(a) and (b) a FFY 2022 $ 10,000,000 b. FFY 2023 $ 10,000,000 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Pages 53, 53a, 53c, 70 OR ATTACHMENT (If Applicable) Attachment 4.17-A, Page 1 Pages 53, 53a, 53c, 70 Attachment 4.22-A, Page 1 Attachment 4.17-A, Page 1 Attachment 4.22-A, Pages 2 through 6 (NEW) Attachment 4.22-A, Page 1 Attachment 4.22-B, Pages 1: Attachment 4.22 B Pages 2-3 (NEW Attachment 4.22-B, Page 1 Attachment 4.22-C, Pages 1 and 2 - (intentionally deleted) Attachment 4.22-C, Pages 1 and 2 (intentionally deleted) 9. SUBJECT OF AMENDMENT 1. Removes federally optional liens and recoveries. 2. Updates third-party liability section to reflect current law and practice. 3. Removes the language regarding the cost effectiveness premium purchase program for group health insurance that is authorized under section 1906 of the SSA. 10. GOVERNOR'S REVIEW (Check One) (!) GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL CIAL 0 OTHER, AS SPECIFIED: 15. RETURN TO State of Connecticut -------- Department of Social Services 12 · Deidre s. Gifford, MD, MPH 55 Farmington Avenue - 9th floor --------------------- Hartford, CT 06105 13. TITLE Attention: Ginny Mahoney Commissioner 14. DATE SUBMITTED December 29, 2021 FOR CMS USE ONLY 16. DATE RECEIVED December 29, 2021 17. DATE APPROVED June 28, 2022 PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 19. SIG October 1, 2021 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS FORM CMS-1 79 (09124) Instructions on Back Division of Program Operations

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Attachment 4.17-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CONNECTICUT

Liens and Adjustments or Recoveries

1. The State uses the following procedures for determining that an institutionalized individual cannot reasonably be expected to be discharged from the medical institution and return home: a. The process for determining whether an institutionalized individual cannot be reasonably expected to be discharged from the long-term care facility to return home is based on the following: (1) diagnosis of the individual’s medical condition as documented by the long-term care facility’s authorizing physician; and (2) the physician’s prognosis for the individual’s recovery; and (3) availability of private care which the individual could receive at home as an alternative to institutionalization; and (4) statement from the individual if he or she is competent. regarding the intent to return home; and (5) financial ability of the individual to maintain the home.

b. If there is no reasonable expectation that the institutionalized individual can return home the Department sends a written notice to the individual or conservator which includes: (1) a statement of the Department's intent to recover from the individual’s estate the cost of medical assistance paid on behalf of the individual; and (2) the reason for the intended action; and (3) the specific regulation and/or statute supporting such action; and (4) an explanation of the assistance unit’s right to request a Fair Hearing and the Fair Hearing procedures.

2. The following criteria are used for establishing that a permanently institutionalized individual's son or daughter provided care as specified under regulations at 42 CFR § 433.36(f): a. the individual’s medical condition warrants institutionalization, as verified by a physician; and b. the son or daughter claims and verifies rendering or paying for homemaker or home health aide services for a specific number of hours per day in order to avoid the individual’s institutionalization.

3. The State defines the terms below as follows: x Estate – a decedent estate is the asset and liabilities which a deceased person has at the time of his or her death. x Individual's home -- real property which someone owns and is using as a principal residence. x Equity interest in the home – the amount of equity which the legal owner has in an asset. x Residing in the home for at least one or two years -- the sibling or son or daughter of the individual resided in the home for one or two years respectively immediately before the date of the individual's admission to the medical institution and they provided care to the individual which permitted the individual to reside at home rather than in an institution. x Discharged from a Medical Institution – the individual no longer requires institutional care and leaves the facility for an indefinite period of time with the intention of remaining home. x Lawfully residing – actually residing at a certain address and publicly affirming this address as one's residence to local Post Offices, Voters Registration Office, or other governmental agencies.

TN #: 21-0037

Approval Date: 06/28/22

Effective Date: 10/01/2021 Supersedes TN #: 04-002

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Attachment 4.22-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CONNECTICUT

Requirements for Third Party Liability - Identifying Liable Resources

42 C.F.R. § 433.138 Identifying liable third parties (b) Obtaining health insurance information: Initial application and redetermination processes for Medicaid eligibility: (b) (1) The Connecticut Department of Social Services (CTDSS) determines Medicaid eligibility. CTDSS obtains commercial health insurance information from the applicant or client during the respective initial application and redetermination of Medicaid benefits. CTDSS utilizes a Third-Party Liability (TPL) Contractor to verify and validate the health insurance information and transmit it to CTDSS. Also, CTDSS utilizes a TPL Contractor to identify client commercial health insurance coverage not identified through the initial application or redetermination of Medicaid benefits. (b) (2) Not applicable (b) (3) Not applicable

(c) Obtaining Other Information: The CTDSS ImpaCT System captures non-custodial parent name, social security number, and employer information.

(d) Exchange of Data: (d) (1) CTDSS utilizes alternative sources of information than the SWICA and SSA wage and earnings files in determining the legal liability of third parties. (d) (2) CTDSS utilizes a TPL Contractor who conducts data exchanges with commercial health insurance companies on a daily and bi-weekly basis to identify new client health insurance coverage or changes to be made to existing client TPL. The TPL Contractor utilizes its proprietary national eligibility platform that contains subscriber enrollment information for over one thousand (1,000) health insurance companies in which the TPL Contractor has agreements to perform electronic data matches to identify CTDSS Medicaid clients with health insurance coverage. The TPL Contractor transmits to CTDSS new client health insurance, or changes to be made to existing client health insurance. Also, CTDSS provides the TPL Contractor with a monthly child support enforcement file that contains the names of Medicaid and non-Medicaid children, and their absent parents’ names and social security numbers that have medical support enforcement orders to provide health insurance to the child. The TPL contractor conducts data exchanges with commercial health insurance companies to identify if the children have health insurance coverage and reports this information to CTDSS.

TN #: 21-0037

Approval Date: 06/28/22

Effective Date: 10/01/2021 Supersedes TN #: 87-61

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Attachment 4.22-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CONNECTICUT

Requirements for Third Party Liability - Identifying Liable Resources, Cont’d

(d) (3) CTDSS is the State IV-A agency and receives financial information from federal and state agencies to determine Supplemental Nutrition Assistance Program eligibility and enrollment. This information includes client employment information, which is maintained on the CTDSS ImpaCT eligibility system. (d) (4) CTDSS will attempt to secure agreements from the State of Connecticut Workers’ Compensation Commission, to obtain information that identifies Medicaid clients and absent or custodial parents of Medicaid clients with employment-related injuries or illnesses. CTDSS will attempt to secure agreements from the State of Connecticut Department of Motor Vehicle accident report files, to obtain information that identifies those Medicaid clients injured in motor vehicle accidents, whether injured as pedestrians, drivers, passengers, or bicyclists. (d) (5) If CTDSS is unable to secure the agreements specified in (d) (4) of this section, CTDSS will submit documentation to the CMS regional office that demonstrates the agency made a reasonable attempt to do so.

(e) Diagnosis and trauma code edits. The CTDSS TPL Contractor and MMIS Contractor perform trauma diagnosis claim reviews. The TPL Contractor selects claims that have diagnosis codes within the range defined for accident/trauma (800.00-999.9), or where the diagnosis codes are within the range defined as the supplementary classification of external causes of injury and poisoning found in diagnosis code range E800-E999, inclusive. A trauma case is established when selected claim(s) meet a $250 threshold. For trauma case reviews that result in the identification of a client lawsuit, the case is referred to the State of Connecticut Department of Administrative Services (DAS). DAS recovers Medicaid claim costs from the client’s lawsuit. For trauma case reviews that result in the identification of a client workers’ compensation case, the TPL Contractor recovers the Medicaid claim costs from the workers’ compensation carrier. The MMIS Contractor establishes a trauma case by selecting hospital claims that have an accident indicator, or a primary or secondary diagnosis code within the range defined for accident/trauma or supplementary classification of external causes of injury, and the client’s claim(s) payments have accumulated to meet a $500 threshold. When a trauma case is established, the MMIS Contractor sends the hospital an accident questionnaire to obtain information to determine if the case is the result of an accident and third-party liability may exist. If a hospital response is received indicating third party liability may be available, the hospital accident questionnaire and any other hospital- provided information are scanned into the interChange OnBase reporting system.

TN #: 21-0037

Approval Date: 06/28/22

Effective Date: 10/01/2021 Supersedes TN #: NEW

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Attachment 4.22-A Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CONNECTICUT

Requirements for Third Party Liability - Identifying Liable Resources, Cont’d

(f) Data exchanges and trauma code edits: Frequency. The CTDSS TPL Contractor performs health insurance data exchanges daily for new enrolled Medicaid clients, and on a bi-weekly basis for existing Medicaid clients. The CTDSS TPL and MMIS Contractor perform trauma diagnosis claim reviews monthly.

(g) Follow up procedures for identifying legally liable third party resources: (g) (1) SWICA, SSA wage and earnings files, and title IV-A data exchanges. (i) CTDSS utilizes alternative sources of information than the SWICA and SSA wage and earnings files in determining the legal liability of third parties. CTDSS utilizes a TPL Contractor who conducts data exchanges with commercial health insurance companies on a daily and bi-weekly basis to identify new client health insurance coverage or changes to be made to existing client health insurance coverage. From commercial health insurance data exchanges performed daily, the TPL Contractor will identify active client health insurance and transmit the health insurance policy information to CTDSS within one (1) day of performing the data exchange. From commercial health insurance data exchanges performed bi-weekly, the TPL Contractor will identify active client health insurance, or changes that need to be made to existing client health insurance and transmit this information to CTDSS within fourteen (14) days of performing the data exchange.

Also, the CTDSS TPL Contractor utilizes proprietary data exchange technology to identify previously unknown health insurance coverage for existing CTDSS clients, or changes that need to be made to existing clients’ currently known health insurance coverage. CTDSS sends the TPL Contractor a weekly file of active Medicaid clients. The TPL Contractor uses this file to perform bi-weekly commercial health insurance data exchanges for these clients. The TPL Contractor will identify within fourteen (14) days of receiving a weekly enrollment file those clients that have active health insurance coverage, or changes that need to be made to a client’s existing health insurance. This health insurance information is immediately integrated with the CTDSS interChange system, resulting in CTDSS meeting the requirements specified under § 433.139 Payment of claims, (b).

TN #: 21-0037

Approval Date: 06/28/22

Effective Date: 10/01/2021 Supersedes TN #: NEW

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Attachment 4.22-A Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CONNECTICUT

Requirements for Third Party Liability - Identifying Liable Resources, Cont’d

(ii) The CTDSS TPL Contractor utilizes proprietary data exchange technology to provide CTDSS with daily health insurance information at the point of client enrollment into the Connecticut Medicaid Program. CTDSS sends the TPL Contractor a daily file of new Medicaid clients enrolled in the HUSKY A, C, and D, Q01 ((dual eligible clients with full and partial Medicaid benefits) and N03 (CT Home Care Program for Elders) coverage groups. The TPL Contractor uses this file to perform daily commercial health insurance data exchanges for these newly enrolled clients. The TPL Contractor will identify within one (1) day of receiving a daily enrollment file those clients that have active health insurance coverage and transmit this information to the CTDSS ImpaCT eligibility system. The new ImpaCT health insurance information is immediately integrated with the CTDSS interChange System resulting in CTDSS meeting the requirements specified under § 433.139 Payment of claims, (b).

Also, the TPL Contractor utilizes proprietary data exchange technology to identify previously unknown health insurance coverage for existing CTDSS clients, or changes that need to be made to existing clients’ currently known health insurance coverage. CTDSS sends the TPL Contractor a weekly file of active Medicaid clients. The TPL Contractor uses this file to perform bi-weekly commercial health insurance data exchanges for these clients. The TPL Contractor will identify within fourteen (14) days of receiving a weekly enrollment file those clients that have active health insurance coverage, or changes that need to be made to a client’s existing health insurance. This health insurance information is immediately integrated with the CTDSS interChange system, resulting in CTDSS meeting the requirements specified under § 433.139 Payment of claims, (b).

(g) (2) Health insurance information and workers' compensation data exchanges. (i) CTDSS uses the procedures described above in 433.138 (g) (1), (i), (ii) to identify legally liable third party resources so the state agency may process claims under the third party liability payment procedures specified in § 433.139 (b) through (f).

(g) (3) State motor vehicle accident report file data exchanges. CTDSS does not perform State motor vehicle accident report file data exchanges currently.

TN #: 21-0037

Approval Date: 06/28/22

Effective Date: 10/01/2021 Supersedes TN #: NEW

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Attachment 4.22-A Page 5 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CONNECTICUT Requirements for Third Party Liability - Identifying Liable Resources, Cont’d

(g) (4) Diagnosis and trauma code edits. (i) The CTDSS TPL Contractor performs trauma diagnosis claim reviews. The TPL Contractor selects Medicaid claims using the following criteria: claims with diagnosis codes within the range defined for accident/trauma (800.00-999.9), or within the range defined as the supplementary classification of external causes of injury and poisoning found in diagnosis code range E800-E999, inclusive; claim service periods are within one (1) year from selection date; a claim(s) meets a $250 threshold. Claims that meet this criterion establishes a trauma case. The TPL Contractor sends the client associated with the trauma case an accident questionnaire to obtain information about the person’s injury or illness. For trauma case reviews that result in the identification of a client lawsuit, the case is referred to the State of Connecticut Department of Administrative Services (DAS). DAS recovers Medicaid claim costs from the client lawsuits. For trauma case reviews that result in the identification of a client workers’ compensation case, the TPL Contractor recovers the Medicaid claim costs from the workers’ compensation carrier. (ii) CTDSS incorporates client lawsuit or workers’ compensation information into the client eligibility case file.

(h) Obtaining other information and data exchanges: Safeguarding information. (h) (1) The CTDSS ImpaCT and interchange (MMIS) systems which process, store, and store electronic protected health information (ePHI) have been certified to a “Moderate” data classification using the NIST 800-53 version 4 Data Security Control set. This classification has been accredited by federal regulatory bodies such as IRS, SSA, and CMS through multiple risk assessments and onsite audits. (h) (2) The CTDSS TPL Contractor maintains Data Use Agreements (DUAs) with the health insurance companies in which it performs data exchanges to identify CTDSS clients who have health insurance coverage. The DUAs specify the information to be exchanged, the names and titles of the TPL Contractor officials with the authority to request third party information, the methods, including the formats to be used, and the timing for requesting and providing the information, the safeguards limiting the use and disclosure of the information as required by Federal or State law or regulations, and the method the TPL Contractor will use to reimburse reasonable costs of furnishing the information if payment is requested.

TN #: 21-0037

Approval Date: 06/28/22

Effective Date: 10/01/2021 Supersedes TN #: NEW

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Attachment 4.22-B Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CONNECTICUT Requirements for Third Party Liability – Payment of Claims, Cont’d

(B) Section 1902(a)(25)(F) provides that in the case of any services covered under such plan which are provided to an individual on whose behalf child support enforcement is being carried out by the State IV-D agency, the state shall make payment for such service in accordance with the usual payment schedule under such plan for such services without regard to any third-party liability for payment for such services, if such third-party liability is derived (through insurance or otherwise) from the parent whose obligation to pay support is being enforced by such agency, if payment has not been made by such third party within 100 days after the date the provider of such services has initially submitted a claim to such third party for payment for such services, except that the State may make such payment within 30 days after such date if the State determines doing so is cost-effective and necessary to ensure access to care. The state has determined that paying within 30 days after such date is cost-effective and necessary ensure access to care and the state, as required, seeks reimbursement from such third party.

(C) CTDSS Utilizes a mechanized claims processing and information retrieval system - “interChange or “iC” to process Medicaid claims. The iC will cost avoid and reject the claim if the provider has not demonstrated that client third party liability has first been utilized. The CTDSS Medicaid provider participation manual advises providers how to submit claims to the iC system that demonstrates the provider first utilized client third party liability. Providers’ claims that fail to show proof that the third party either denied or partially paid a claim are rejected on the provider’s Medicaid remittance. When the provider correctly submits a claim showing proof client third party liability was first utilized, the iC system will adjudicate and pay the claim to the extent that payment allowed under the agency's payment schedule exceeds the amount of the third party's payment.

(c) Probable liability is not established, or benefits are not available at the time claim is filed. CTDSS will adjudicate and pay the full amount under the agency’s payment schedule at the time the claim is filed if the existence of client third party liability is not known.

(d) Recovery of Reimbursement

(1) CTDSS does not currently have any waivers to not cost avoid claims and instead seek recovery of reimbursement from client third party.

TN #: 21-0037

Approval Date: 06/28/22

Effective Date: 10/01/2021 Supersedes TN #: NEW

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Attachment 4.22-B Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CONNECTICUT Requirements for Third Party Liability – Payment of Claims, Cont’d

(2) The CTDSS TPL Contractor will seek to recover Medicaid costs from commercial health insurance or Medicare within 60 days after the end of the month in which the client third party liability is identified.

(e) Waiver of requirements. CTDSS does not currently have any waivers to not cost avoid claims and instead seek recovery of reimbursement from client third party, or to not seek Medicaid recovery from legally liable third parties.

(f) Suspension or termination of recovery of reimbursement.

Non-Hospital Claims for Commercial Insurance: The CTDSS TPL Contractor uses a minimum threshold of $0 for Medicaid claim amount to select and bill Medicaid claims that are directly billed to commercial health insurance.

Hospital Claims for Commercial Insurance: The CTDSS TPL Contractor uses a minimum Medicaid claim dollar threshold amount of $50 for selecting Medicaid hospital claims to be recovered through the commercial health insurance disallowance process; CTDSS recoups the Medicaid claim from the provider and the provider pursues health insurance reimbursement.

Claims for Medicare Part A: The CTDSS TPL Contractor uses a minimum Medicaid claim dollar threshold amount of $200 for selecting Medicaid claims to be recovered through the Medicare Part A disallowance process; CTDSS recoups the Medicaid claim from the provider and the provider pursues Medicare Part A reimbursement.

Claims for Medicare Part B: The CTDSS TPL Contractor uses a minimum Medicaid claim dollar threshold amount of $50 for selecting Medicaid claims to be recovered through the Medicare Part B disallowance process; CTDSS recoups the Medicaid claim from the provider and the provider pursues Medicare Part B reimbursement.

TN #: 21-0037

Approval Date: 06/28/22

Effective Date: 10/01/2021 Supersedes TN #: NEW

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