Table of Contents State/Territory Name: Washington, D.C. State Plan Amendment (SPA) #: 09-08 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

D{PARTMENT OF HEALTH & HUMAN SERVICES .. C~ers for Medicare & Medicaid Services l.".r::>. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 aNTERS for MEDICARE & MEDICAID SEIMCES Region III/Division of Medicaid and Children's Health Operations APR c 9 201Cit I John McCarthy Deputy Director Department of Health Care Finance 825 North Capitol Street, N.E.- Suite 5200 Washington, DC 20002 Re: Approval - DC SPA 09-08, Eligibility Conditions and Requirements for Alien Pregnant Women and the Children of Alien Pregnant Women Dear Mr. McCarthy: We have reviewed the District of Columbia's State Plan Amendment (SPA) #09-08. This amendment elects the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 option in Section 214 to lift the five year bar ban on eligibility and provide full Medicaid coverage to all otherwise eligible alien children or pregnant women lawfully residing in the District of Columbia. Based on the information provided, we are pleased to inform you that the District of Columbia's SPA #09-08 has been approved. The effective date is January 1, 2010 as requested. The signed CMS form 179 and the approved State Plan pages are enclosed. If you have any questions regarding this amendment, please contact Barbara Williamson here in the Regional Office at (215) 861-4 721 , or via e-mail at barbara. williamson@cms.hhs.gov. Enclosures cc: Julie Hudman, DC DHCF Linda Elam, DC DHCF Diane Fields, DC DHCF Sincerely, Associate Regional Administrator /s/

, DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TR. NSM:TTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 09...08 FORM APPROVED OMB NO. 0938-01\13 2.STATE District of Columbia ll"~ TRANSMITfAL NUMBER: --------------~--------------- FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: ·--- -------r-Iitle Xl~c~!_!he Social Security Act TO: Regional Administrator 4. PROPOSED EFFECTIVE DATE Centers for Medicare & Medicaid Services Department of Health and Human Services January 1, 2010 5. TYPE OF PLAN MATERIAL (Check One): 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN ~AMENDMENT COMPLETE BLOO(S 6 THRU 10 IF THIS lS AN AMENDMENT (Separate Transmittal for each amendment) : 8. FEDERAL STATUTE/REGULATION CITATION ' 7. FEDERAL BUDGET IMPACT 42 CFR 435.406 :, ~ i.l. FFY 1£1 $530,748 -~b .. ~F~F~Y~/~ / ~$~ 70~7~ ,6~5~8~----------------------- 8. PAGE NUMBER OF THE 'PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 2.6-A pp 2,2a,2b, 3 \ 10. SUBJECT OF AMENDMENT: ' OR ATTACHMENT (If Applicable) ; Attachment 2.6-A pp 2-3 I Eligibility Conditions and Req\.1\rement-s for Documented Allen P1egnant Wt:.nv:lrl .and their Children 11 . GOVERNOR'S REVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED i'JO COMMENi 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WlTl-HN 45 DAYS OF SUBMITI AL ----~--~--------------------------------~ r~ c~· i·:E!i , AS SPECIFIED: DC ActN-":>.: 18-187 ~~J-C~-~riC IA L i 16. RETURN TO - ----·------~ John McCarthy · TYPED NAME : Deputy Diredor _Jo_h_n_M_c_C_a_rt_h.L...y - - --· - ·- ·-------------···---------· Depa imF?n ~ o"' He 8 1~h Care Finance 14. TITLE 828 N. Capitnl St, NE Deputy Director, Department of Health Care Finance ------: w ashingto.1, DC 20002 _;~;_;:::;;;b.:.:~:.=: T:....~.ryE;..;:2:.:~:.!..~~~0:_:~..=.~--E-D--------··------------·----.l-----·-·---·---------------------------- FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED ______ L18. DATE APPROVED ' FAPP 0 9 2010' FORM CMS-179 (o'-7--9-2-) --··~----··m--·~""ctio r;-;-;;;; 8:;;;;; ·,.· · ""-·~·-·------------- /s/ /s/

Revision: Citation 1905(p) of the Act 1905(s) ofthe Act TN No. Qj-o& Supersedes TN No. 91-9 HCFA-PM-91-4TC (BPD) ATTACHMENT 2.6-A Page 2 OMB No.: 0938- State: District of Columbia b. c. d. Condition or Requirement For the medically needy, meets the non-financial eligibility conditions of 42 CFR Patt 435. For financially eligible qualified Medicare beneficiaries covered under section 1902(a) (I 0) (E) (i) of the Act, meets the non-financial criteria of section 1905 (p) of the Act. For financially eligible qualified disabled and working individuals covered under section 1902(a) (I 0) (E) (ii) of the Act, meets the non- financial criteria of section 1905 (s). Approval D"PR 0 9 2010' Effective Date::J/) N\MIIl.l-\ f, J() f ()

Revision: CMS-PM- ATTACHMENT 2.6-A Page 2a OMBNo.: STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: District of Columbia ELIGffiiLITY CONDITIONS AND REQUIREMENTS Citation(s) Condition or Requirement 42 CFR 435.406 3. Is r~iding in the United States (U.S.), and-- a. Is a citizen or national of the United States; b. Is a qualified alien (QA) as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) as amended, and the QA's eligibility is required by section 402(b) of PRWORA as amended, and is not prohibited by section 403 ofPRWORA as amended; c. Is a qualified alien subject to the 5-year bar as described in section 403 of PRWORA, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 ofPRWORA; d. Is a non-qualified alien, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 ofPRWORA; e. Is a QA whose eligibility is authorized under section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended. X State covers all authorized QAs. State does not cover authorized QAs. f. State elects CHIPRA option to provide full Medicaid coverage to otherwise eligible pregnant women or children as specified below who are aliens lawfully residing in the United States; including the following: (1) A "Qualified alien" otherwise subject to the 5-year waiting period per section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996; (2) A citizen of a Compact of Free Association State (i.e., Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau) who has been admitted to the U.S. as a non-immigrant and is permitted by the Department of Homeland Security to reside permanently or indefmitely in the U.S.; (3) An individual described in 8 CFR section 1 03.12(a)( 4) who does not have a permanent residence in the country of their nationality and is in a status that permits the individual to remain in the U.S. for an indefinite period oftime, pending adjustment of status. These individuals include: TNNo: oq-o<£1 Supersedes TN No: 91-9 Approval Date f APR 0 9 2010 Effective Date:::¥\ N U. 0,.1(. ~ /1 cJ 6 I 0

.. . Revision: CMS-PM- ATTACHMENT 2.6-A Page 2b OMBNo.: STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: District of Columbia ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation(s) Condition or Requirement (a) An individuaF.currently in temporary resident status as an Amnesty beneficiary pursuant to section 210 or 245A of the Immigration and Nationality Act (INA); · (b) An individual currently under Temporary Protected Status pursuant to section 244 of the INA; (c) A family Unity beneficiary pursuant to section 301 ofPublic Law 101-649 as amended by, as well as pursuant to, section 1504 ofPublic Law 106-554; (d) An individual currently under Deferred Enforced Departure pursuant to a decision made by the President; and (e) An individual who is the spouse or child of a U.S. citizen whose visa petition has been approved and who has a pending application for adjustment of status; and (4) An individual in non-immigrant classifications under the INA who is permitted to remain in the U.S. for an indefinite period, including the following as specified in section 101(a)(15) ofthe INA: • A parent or child of an individual with special immigrant status under section 10l(a)(27) of the INA, as permitted under section 101(a)(l5)(N) ofthe INA; · • A Fiance of a citizen, as permitted under section 101(a)(15)(K) of the INA; • A religious worker under section 10l(a)(l5)(R); • An individual assisting the Department of Justice in a criminal investigation, as permitted under section 101(a)(l5)(S) ofthe INA; • A battered alien as permitted under section 101(a)(l5)(U)); and • An individual with a petition pending for 3 years or more, as permitted under section 101(a)(l5)(V) of the INA. X X Elected for pregnant women. Elected for children under age 21. g. X The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA section 214 option, it has verified, at the time of the individual's initial eligibility determination and at the time of the eligibility redetermination that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) ofthe Act. TNNo: OG-08 Supersedes Approval Date fAPR @ 9 2010 TN No: 91-9

. '· - ' Revision: HCFA-PM-91-4 August 1991 State: District of Columbia (BPD) Citation Condition or Requirement ATTACHMENT 2.6-A Page 3 OMB No.: 0938- 42 CFR 435.403 4. Is a resident of the State, regardless of whether or not the individual maintains the residence permanently or maintains it at a fixed address. TN No. 0'!-08' Supersedes TN No. 91-9 - -: State has interstate residence agreement with the following States: _ _ State has open agreement(s). __ Not applicable; no residency requirement. Approval DatAP R Q 9 20 10 Effective Date :1 A N U.~ IC~ 11 d. 0 I 0

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District of Columbia Attachment 4.19-D, Part II Page 1

DEPARTMENT OF HEALTH CARE FINANCE

STATE PLAN AMENDMENT ESTABLISHING REIMBURSEMENT PRINCIPLES AND METHODS FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES (ICFs/IID)

I. GENERAL PROVISIONS

A. The purpose of this Chapter is to establish principles of reimbursement that shall apply to each intermediate care facility for individuals with intellectual disabilities (ICF/IID) participating in the District of Columbia Medicaid program.

B. An ICF/IID that is eligible to receive reimbursement under this chapter shall be certified as a Level 2 group home for mentally retarded persons (GHMRP), by the Department of Health (DOH), pursuant to 22 DCMR §§ 3100 et seq. for a period up to fifteen (15) months.

C. Medicaid reimbursement to ICFs/IID for services provided beginning on or after October 1, 2012, shall be on a prospective payment system consistent with the requirements set forth in this Chapter.

D. The Department of Health Care Finance (DHCF) shall pay for ICF/IID services through the use of rates that are reasonable and adequate to meet the costs that must be incurred by efficiently, economically operated facilities in order to provide services in conformity with applicable District and Federal laws, regulations, and quality and safety standards. DHCF applied consistent financial principles in developing the reimbursement methodology described in this chapter, including the following:

1. Basing payment rates on the acuity of each beneficiary, as determined by DHCF, or its designee; :

2. Establishing uniform reimbursement of services constituting the active treatment program for individuals who meet the requirements of 42 C.F.R. § 483.440(a);

3. Establishing consistent payment rates across the District of Columbia for the same classes of facilities serving individuals with comparable levels of need; and

4. One (1) day, inclusive of residential care and active treatment services, shall ; constitute the unit of service.

E. DHCF assures that the reimbursement methodology and policies set forth in this State Plan Amendment meet the requirements of 42 C.F.R. §§ 447.250 et seg. and 42 C.F.R. § 430.10.

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F. The reimbursement rates paid to ICFs/IID for Medicaid individuals residing in the facility shall be equal one hundred percent (100%) of the following components:

1. Residential component base rate, determined by acuity level, as defined in Section II, and inclusive of costs for the following:

Direct service;

All other health care and program related expenses;

Non-personnel operations;

Administration;

Non-Emergency Transportation;

Capital; and

Allowable share of the Stevie Sellows Intermediate Care Facility for the Intellectually and Developmentally Disabled Quality Improvement Fund Assessment.

Rme ne sp

2. Services constituting an active treatment program, described in Section IV., as set forth in the Individual Service Plan (ISP); and

3. Payments associated with participation in quality improvement initiatives, as set forth in Section V.

G. The reimbursement rates paid to ICFs/IID shall exclude the following:

Inpatient and outpatient hospital visits;

Clinic services;

Emergency department services;

Any other long-term care facility services;

Durable medical equipment that is solely for the use of one beneficiary (such as a specialized wheelchair); and

Prescription drug costs, excluding copays for individuals who are also subject to the Evans court order.

wPYN>

a»

H. ICF/IID reimbursement under this Attachment shall adhere to the “Policy on Reserved

Beds,” as set forth on page 2 of Attachment 4.19C of the State Plan for Medical Assistance. ;

I. An organization related to an enrolled ICF/IID (“related organization”) can furnish services and supplies under the prudent buyer concept, provided the costs of such services and supplies are consistent with costs of such items furnished by independent third party providers in the same geographic area. These requirements apply to the sale, transfer, leaseback or rental of the property, plant or equipment or purchase of services of any facility or organization.

J. In accordance with 42 C.F.R. § 456.360(a), the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code § 3-

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District of Columbia Attachment 4.19-D, Part II

I.

Page 3

1201.01 et seg.), as amended, and implementing rules, a qualified physician shall certify that an individual requires ICF/IID services. The certification shall be made at the time of admission for current Medicaid individuals, or for individuals who apply for Medicaid while residing in an ICF, before any payment is made to the ICF/IID.

. Recertification of a beneficiary’s need for continued ICF/IID services is required, at

minimum, twelve (12) months following the date of the previous certification, pursuant to 42 C.F.R. § 456.360(b).

. A Medicaid beneficiary shall be assessed by an interdisciplinary team within thirty (30)

days of admission to an ICF/IID. This determination shall provide the foundation for requests to elevate an acuity level assignment beyond Acuity Level 1.

ACUITY LEVEL ASSIGNMENTS

. Reimbursement rates shall be differentiated based on the beneficiary’s acuity level, as

recommended by the Department on Disability Services (DDS), through the Level of Need Assessment and Risk Screening Tool (LON), and interdisciplinary teams of health and habilitation professionals, pursuant to the Individual Service Plan (ISP).

. Acuity levels higher than Acuity Level 1 (Base) shall be approved by DHCF and shall be

specific to the medical and health care needs of each qualified beneficiary.

. Reimbursement under this chapter shall be governed according to the following acuity

levels:

1. Acuity Level 1 (Base) shall represent the health, habilitation, and support needs of a beneficiary whose level of care determination (LOC) reflects a need for ICF/IID services. Acuity Level 1 shall be the base acuity level;

2. Acuity Level 2 (Moderate) shall represent the health, habilitation, and support needs of a beneficiary who meets the requirements of Section II.C.1. and requires moderate levels of services in order to effectively support functional impairments, as described in Section II.G.;

3. Acuity Level 3 (Extensive — Behavioral) shall represent the health, habilitation, and support needs of a beneficiary who meets the requirements of Section II.C.1. and requires services and interventions than can address conditions associated with an extensive intellectual and developmental disability and significant behavioral challenges as described in Section II.H.;

4. Acuity Level 4 (Extensive — Medical) shall represent the health, habilitation, and support needs of a beneficiary who meets the requirements of Section II.C.1. and requires services and interventions that can address conditions associated with an

¥

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District of Columbia Attachment 4.19-D, Part II

Page 4

extensive intellectual and developmental disability and significant medical and support challenges as described in Section II.1.;

Acuity Level 5 (Pervasive) shall represent the health, habilitation, and support needs of a beneficiary who meets the requirements of Section II.C.1. and requires services and interventions that can address conditions associated with a pervasive intellectual and developmental disability and who exhibits dangerous behaviors and/or conditions that require one-to-one (1:1) supervision for twenty-four (24) hours per day or less, as described in Section II.J.; and

Acuity Level 6 (Pervasive Plus Skilled Nursing) shall represent the health, habilitation, and support needs of a beneficiary who meets the requirements of Section II.C.1. and requires services and interventions that can address conditions associated with a pervasive level of care to accommodate individuals with dangerous behaviors and/or conditions that require one-to-one (1:1) supervision twenty-four (24) hours per day and those individuals who are in need of extensive skilled nursing service as described in Section II.K.

D. For purposes of reimbursement, a beneficiary admitted on or after October 1, 2012, shall be assumed to be at Acuity Level 1 (Base). An ICF/IID may request that DHCF assign a

beneficiary to an enhanced level, above Acuity Level 1, if the facility provides the required documentation.

E. In order for a beneficiary to qualify at an acuity level beyond Acuity Level 1 (Base), the ICF/IID shall ensure that qualified health and habilitation practitioners assess each beneficiary using the LON.

F. Acuity level assignments shall be recertified annually.

G. A beneficiary shall qualify for Acuity Level 2 (Moderate) when exhibiting at least one (1) of the following characteristics:

1. Is unable to perform two (2) or more activities of daily living (ADL); 2. Is non-ambulatory; 3. Is unable to evacuate self without assistance in the event of a fire and other emergency situation; 4. Is assessed to lack life safety skills to ensure self-preservation; or TN No. Supersedes Approval Date JAN 95 2013 Effective Date OCT . 1 2012

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District of Columbia Attachment 4.19-D, Part II

5.

Page 5

A diagnosis of one of the following:

Blindness;

Deafness;

Autism Spectrum Disorder; or Epilepsy.

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H. A beneficiary shall qualify for Acuity Level 3 (Extensive — Behavioral) when he or she is dually diagnosed with an intellectual and developmental disability and with one or more behavioral disorders that:

1.

2.

Are assaultive, self-abusive, including pica, or aggressive;

Require a written behavior plan which is based on current data and targets the identified behaviors; and

Require intensive staff intervention and additional staff resources to manage the behaviors as set forth in Section II-H.1.

I. A beneficiary shall qualify for Acuity Level 4 (Extensive — Medical) when he or she requires skilled nursing and extensive health and habilitation supports on a daily basis. Skilled nursing and extensive health and habilitation supports shall be prescribed by the individual’s primary care physician or advanced practice registered nurse.

J. A beneficiary shall qualify for Acuity Level 5 (Pervasive) when he or she requires one- to-one (1:1) staffing and exhibits one (1) or more of the following characteristics:

1.

A history of, or is at high risk for, elopement resulting in risk to beneficiary or others;

Exhibits behavior that is life-threatening to the beneficiary or others;

Exhibits destructive behavior that poses serious property damage, including fire- setting;

Is a sexual predator; and

A history of, or is at high risk for, falls with injury, and a primary care physician or advanced practice registered nurse order for one-to-one (1:1) supervision.

K. A beneficiary shall qualify for Level 6 (Pervasive Plus Skilled Nursing) if the beneficiary requires at least one (1) type of skilled nursing that shall be ordered by a primary care physician or advanced practice registered nurse and provided, at minimum, on an hourly

basis.

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District of Columbia _ Attachment 4.19-D, Part II Page 6

L. The number of one-to-one (1:1) staffing hours shall be approved by DHCF using results from assessments conducted by ICFs/IID. Under Levels 5 and 6 (Pervasive and Pervasive Plus Skilled Nursing), DHCF’s approval shall be based on having the staff member(s) assigned to the beneficiary having no other duties while assigned to the beneficiary.

M. Each ICF/IID shall have responsible direct care staff on duty and awake on a twenty-four (24) hour basis when individuals are present to ensure prompt, appropriate action in the event of injury, illness, fire, or other emergency.

N. Prior to the expiration of the current ISP, each ICF/IID shall be responsible for requesting renewal of the beneficiary’s acuity level assignment by compiling the beneficiary’s information in the required format(s) and ensuring the submission of supporting documentation to DDS.

O. DHCF may refuse requests for retroactive adjustments to reimbursement rates based on late renewal submissions. Ii. REIMBURSEMENT METHODOLOGY A. The rates for ICF/IID services were developed based on Fiscal Year (FY) 2010 cost data reported by providers of different sizes serving individuals at varying acuity levels. The

rates shall vary based on staffing ratios, facility size, and beneficiary acuity level.

B. For the purposes of rate-setting, and independent of the rubric used by the Department of Health for licensing, DHCF shall classify ICFs/IID as follows:

1, Class I-A facility with five (5) or fewer licensed beds; and 2. Class II - A facility with six (6) or more licensed beds.

C. The residential component of the rate shall be based on a model that includes the following seven (7) cost centers:

1. The “Direct Service” cost center shall include expenditures as follows: a. Direct Care Staff Compensation, to include the following:

i. Nurses, including registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs); ii. Qualified Mental Retardation Professionals (QMRPs); iii. | House managers; iv. Direct support personnel; and

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b.

Attachment 4.19-D, Part II Page 7

v. Allocated time of staff who have administrative duties and are also utilized in direct service support, subject to the results of a time study or time sheet process that has been approved by DHCF; and

Fringe benefits, including but not limited to required taxes, health insurance, retirement benefits, vacation days, paid holidays, and sick leave.

2. The “All Other Health Care and Program Related” cost center shall include expenditures for:

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OBB rr Tr rae me ep

Pharmacy co-pays and over-the-counter medications;

Medical supplies;

Therapy costs, including physical therapy, occupational therapy, and speech therapy;

Physician services;

Behavioral health services provided by peychologists or psychiatrists; Nutrition and food;

Medical record maintenance and review;

Insurance for non-direct care health staff;

Program materials related to providing active treatment;

Program materials excluding active treatment;

Quality assurance;

Training for direct care staff;

. Program development and management, including recreation;

Incident management; and Clothing for individuals.

3. The “Non Personnel Operations” cost center shall include expenditures for:

a b c. d

Food service and supplies related to food service;

. Laundry;

Housekeeping and linens; and

. Non-capital repair and maintenance.

4. The “Administration” cost center shall include expenditures for:

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Boe mo

Payroll taxes;

Salaries and consulting fees to non-direct care staff;

Insurance for administrators and executives;

Travel and entertainment (related to training seminars and staff appreciation events);

Training costs;

Office expenses;

Licenses

Office space rent or depreciation;

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Attachment 4.19-D, Part II Page 8

Clerical staff; Interest on working capital; and Staff transportation.

5. The “Non-Emergency Transportation” cost center shall include expenditures

for:

ao ep

mo

Vehicle license, lease, and fees;

Vehicle maintenance;

Depreciation of vehicle;

Staffing costs for drivers and aides, not otherwise covered by, or in excess of costs for direct support personnel;

Fuel; and

Vehicle insurance.

6. The “Capital” cost center shall include expenditures for leased or owned properties:

PRmo ae gp

Depreciation and amortization;

Interest on capital debt;

Rent;

Minor equipment;

Real estate taxes;

Property insurance;

Other capital; and

Utilities, including electricity, gas, telephone, cable, and water.

7. Capital costs shall be offset by all amounts received for days reimbursed pursuant to the “Policy on Payment for Reserved Beds in Intermediate Care Facilities for the Intellectually Disabled,” page 2 of Attachment 4.19C of the State Plan.

8. The “Stevie Sellows Intermediate Care Facility for the Intellectually and Developmentally Disabled Quality Improvement Fund Assessment” cost center shall include only the allowable share of the Assessment expenditure consistent with 42 U.S.C. § 1396(b)(w) and 42 C.F.R. §§ 433.68, 433.70, and

433.72.

D. Fiscal Year (FY) 2013 rates shall be based on FY2010 provider reported expenses and shall be paid for services delivered beginning on October 1, 2012, through September 30, 2013. FY 2013 rates, and all rates thereafter, shall be published in the D. C. Register. FY 2013 rates incorporate the following principles:

1. FY 2013 Non-Personnel Operations per diem rates were based on FY 2010 costs, inflated twelve percent (12%);

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2. FY 2013 Capital per diem rates were based on FY 2010 costs, inflated fifteen percent (15%);

3. FY 2013 rates were calculated as the quotient of total industry expenditures divided by the total number of industry licensed beds per reported as FY 2010 costs;

4. The FY 2013 rate for Non-Emergency Transportation shall be eighteen dollars ($18); and ;

5. Calculations were performed separately for Class I and Class II facilities for capital expenditures.

E. FY 2014 rates shall be based on the reported FY 2013 cost reports. In establishing the rates for FY 2014, DHCF shall use FY 2013 rates as a baseline to compare to the FY 2013 cost reports and address the following:

1. DHCF shall make adjustments to each cost center rate based on the actual costs reported in order to ensure appropriate payment. These adjustments may increase or decrease the per diem rates for each cost center;

2. DHCF shall adjust cost centers by reviewing submitted cost reports, analyzing industry-wide changes (for example, changes affecting personnel costs or medical supplies), and any relevant changes in District statutes and/or regulations; and

3. The resulting rates shall be inflated annually, beginning in FY 2014, in accordance with the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Market Basket Index or other appropriate index if the CMS Skilled Nursing Facility Market Basket Index is discontinued.

F, Reimbursement rates shall be rebased in FY 2017, and every three (3) years thereafter. G. Direct Service cost center reimbursement rates shall be calculated based on staffing

ratios, facility size, and individuals’ acuity levels. All rates shall accommodate the following staffing patterns:

1. Two (2) Direct Support Personnel (DSP) at three (3) shifts per day for three hundred sixty-five (365) days per year, at the following staffing ratios:

a. Class I Facilities: One (1) staff member to every two (2) individuals (1:2) and

b. Class II Facilities: One (1) staff member for every three (3) individuals (1:3).

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2. One (1) Licensed Practical Nurse (LPN) for each facility at one (1) shift per day for three hundred sixty-five (365) days per year, for all ICFs/IID;

3. One (1) additional LPN for each ICF/IID at one (1) shift per weekend day (Saturday and Sunday) for fifty-two (52) weeks per year. This staffing pattern shall apply only to Class II Facilities.

4. One (1) Registered Nurse (RN), one (1) Qualified Mental Retardation Professional (QMRP), and one (1) house manager, each at one (1) shift per day for two hundred forty-nine (249) days per year, at a ratio of one (1) staff person to every twelve (12) individuals (1:12) for all ICFs/IID.

5. For services provided to individuals assigned to acuity levels higher than Acuity Level I, an ICF/IID shall be paid rates that can accommodate additional staffing needs as follows:

a.

Acuity Level 2 (Moderate) rates shall also include one (1) additional DSP at three (3) shifts per day for three hundred sixty-five (365) days per year, at a staffing ratio of one (1) DSP for every two (2) individuals (1:2) for all ICFs/IID.

Acuity Level 3 (Extensive — Behavioral) rates shall also include costs associated with two (2) additional DSPs. The rates for Acuity Level 3 shall include one (1) DSP at three (3) shifts per day for three hundred sixty-five (365) days per year, at a staffing ratio of one (1) DSP staff member for every two (2) individuals for all ICFs/IID. The rate shall also include one (1) DSP at two (2) shifts per day for three hundred sixty-five (365) days per year, at a staffing ratio of one (1) DSP staff member for every two (2) individuals for all ICFs/IID.

Acuity Level 4 (Extensive — Medical) rates shall also include costs associated with one (1) additional LPN at two (2) shifts per day for three hundred sixty-five (365) days per year, for all ICFs/IID. Class II facilities shall also receive a rate that includes one (1) certified nurse aide (CNA) at two (2) shifts per day for three hundred sixty-five (365) days per year.

Acuity Level 5 (Pervasive) rates shall vary based on the number of one-to- one services prescribed for a beneficiary. Acuity Level 5 rates shall also include one (1) DSP at two (2) or three (3) shifts per day, for five (5) or seven (7) days per week for fifty-two (52) weeks per year, at a staffing ratio of one (1) DSP to one (1) beneficiary (1:1).

Acuity Level 6 (Pervasive Plus Skilled Nursing) rates shall vary based on the number of one-to-one services prescribed for a beneficiary. Acuity Level 6 rates shall also include one (1) LPN at one (1), two (2), or three

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(3) shifts per day for seven (7) days per week for fifty-two (52) weeks per year, at a staffing ratio of one (1) LPN to one (1) beneficiary (1:1).

6. The base salaries used in the development of FY 2013 rates for direct care staff wages and salaries shall be as follows:

Direct Support Personnel: $12.50 per hour

Licensed Practical Nurse: $21.00 per hour

Certified Nurse Aide: $16.83 per hour

House Manager: $45,000 per year

Registered Nurse: $70,000 per year

Qualified Mental Retardation Professional: $60,000 per year

mo Boss

7. Salaries set forth in Section III.G.6. shall be treated as follows:

a. “Paid time off” shall include the addition of eighty (80) hours of paid leave. Holiday pay shall include the addition of forty-four (44) hours to ensure the rate includes the rate of pay plus one-half (1/2) the rate of pay (time and one-half) for holidays worked;

b. In order to accommodate fringe benefits the following principles shall apply:

i. Salaries shall be inflated by twenty percent (20%); and

ii. Paid leave and holiday pay shall be inflated by twelve percent (12%); and

c. All rates include paid time off and holiday pay for all hourly full-time equivalents (FTE).

8. For FY 2014 and after, Direct Care Staff Compensation shall be inflated by the greater of any adjustment to the living wage or the associated costs of benefits and inflation based on the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Market Basket Index or other appropriate index if the CMS Skilled Nursing Facility Market Basket Index is discontinued.

H. All Other Health Care and Program Related Expenses cost center reimbursement rates shall be calculated based on the facility size and the direct care cost center rate, which varies by staffing ratios and individuals’ acuity levels. The rate for this cost center is calculated as a fixed percentage of the rate for direct services, at twelve percent (12%) for Class I facilities and at seventeen percent (17%) for Class II facilities.

I. Non-personnel Operations cost center reimbursement rates shall be calculated based on industry average reported costs. The Non-personnel Operations rate shall be equal to the

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industry average reported expenses per licensed bed day for the line items included in the cost center, and shall be uniformly set for all providers.

. Administration cost center reimbursement rates shall be calculated based on the staffing ratios, facility size, and individuals’ acuity levels. The Administration rate shall vary based on the nature of ownership of the physical premises where the ICF/IID is

housed. The Administration rate shall be a uniform percentage of the sum of the rates for all other cost centers and acuity levels, as set forth in the D.C. Municipal Regulations.

. Non-Emergency Transportation cost center reimbursement rates shall be based on the industry average expenses divided by the total number of licensed bed days. The industry average expense is determined based on the rate charged by the District’s Non- Emergency Transportation broker for services provided to beneficiaries with comparable medical need (i.e., enrolled in the 1915(c) ID/DD HCBS Waiver). This rate is then adjusted to account for group-based transportation of ICF/IID residents, using an average of two beneficiaries being present for each round-trip.

. Capital cost center reimbursement rates shall be calculated in accordance with 42 C.F.R. § 413.130 and based on the industry average reported expenses per licensed bed day for the line items included in this cost center as described above and the rate shall vary based on the nature of ownership of the physical premises where the ICF/IID is housed. The Capital rate for leased premises shall be equal to the industry average reported expenses per licensed bed day for the line items included. The Capital rate for provider-owned premises shall be equal to fifty percent (50%) of the rate for leased premises. The Capital rate shall also be subject to the following principles:

1, When a sale/leaseback of an existing ICF/IID facility occurs, the ICF/IID’s allowable capital related cost may not exceed the amount that the facility would have included had the facility retained legal title;

2. When a depreciable asset is acquired, the cost basis of the depreciable asset is the . lesser of the net book value of the previous owner or the fair market value;

3. Facilities must employ the straight-line method for calculating depreciation; accelerated methods for calculating depreciation are not acceptable. The amount of an annual depreciation is determined by first reducing the cost of the assets by any salvage value and then dividing by the number of years of useful life of the asset. The useful life may be shorter than the physical life depending upon the usefulness of the particular asset to the provider;

4. ICFs/IID shall follow the guidelines on useful life published by the Internal Revenue Service or the booklet entitled "Estimated Useful Lives of the Depreciable Hospital Assets" published by the American Hospital Association. Depreciation expense for the year of disposal can be computed by using either the half-year method or the actual time method;

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5. Assets shall be recorded using historical cost, except for donated assets which shall be recorded at fair market value at the time they were received, based on the lesser of at least two (2) bona fide appraisals. Costs during the construction of an asset, consulting and legal fees, interest, fund raising, etc., should be capitalized as a part of the cost of the asset;

6. When an asset is acquired by a trade-in, the cost of the new asset is the sum of the book value of the old asset and any cash or issuance of debt as consideration paid;

7. Facilities that previously did not maintain fixed asset records and did not record depreciation in prior years will be entitled to any straight-line depreciation of the remaining useful life of the asset. The depreciation shall be based on the cost of the asset or fair market value of a donated asset at the time of purchase, construction or donation over its normal useful life. No depreciation may be taken on an asset that would have been fully depreciated if it had been properly recorded at the time of acquisition;

8. Leasehold improvements may be depreciated over the lesser of the asset's useful life or the remaining life of the lease;

9. Ona case by case basis, DHCF may reimburse an ICF/IID by providing an offset to capital costs that is equal to the daily amount computed under Section IIL.L in situations when the Department on Disability Services is unable to fill vacant bed space(s). The ICF/IID shall receive the product of the capital cost multiplied by the administrative rate anytime this payment is made;

10. The add-on capital cost shall be the capital component of the daily per-diem rate, multiplied by the number of vacant bed space(s); and

11. In order to be eligible for capital add-on payments, ICFs/IID shall incur costs and provide DHCF with proof of the vacant bed space. |

M. Effective October 1, 2013, and annually thereafter, the per diem rates for Non-Personnel Operations, Non-Emergency Transportation, Capital, and Active Treatment shall be adjusted for inflation in accordance with the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Market Basket Index or other appropriate index if the CMS Skilled Nursing Facility Market Basket Index is discontinued.

N. The Stevie Sellows Intermediate Care Facility for the Intellectually and Developmentally Disabled Quality Improvement Fund Assessment is a broad based assessment on all ICF/ID providers in the District of Columbia at a uniform rate of five and one-half percent (5.5%) of each ICF/IID’s gross revenue. The allowable cost of the Assessment is calculated consistent with 42 U.S.C. § 1396(b)(w) and 42 C.F.R. §§ 433.68, 433.70, and 433.72.

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ACTIVE TREATMENT SERVICES

A beneficiary residing in an ICF/IID shall receive continuous active treatment services, consistent with the requirements set forth in 42 CFR § 483.440. Active treatment services shall vary depending on the needs of the beneficiary, as determined by the interdisciplinary team.

An ICF/IID shall ensure that a beneficiary receives active treatment services on a daily basis. The ICF/IID may affiliate with outside resources to assist with program planning and service delivery or the facility may provide active treatment services directly.

A program of active treatment services shall include aggressive, consistent implementation of a program of specialized training, treatment, health services and other related services that is directed towards:

1. The acquisition of the behaviors necessary for the beneficiary to function with as much self-determination and independence as possible; and

2. The prevention or deceleration of regression or loss of current optimal functional status.

In accordance with 42 C.F.R. §§ 483.440(c) - (d), an interdisciplinary team shall determine the type of active treatment services that a beneficiary needs based on preliminary evaluations, assessments, and re-assessments. Each beneficiary’s active . treatment requirements shall be described in his Individual Program Plan (IPP), pursuant to 42 C.F.R. § 483.440(c). The ICF/IID shall ensure that each beneficiary receives all of the services described in the IPP.

The per diem for active treatment shall equal the average of FY12 active treatment rates multiplied by two hundred forty-nine (249) days of service, to account for the maximum days of service provided, and divided by three hundred sixty-five (365).

Stevie Sellows’ Quality Improvement (QI) Initiative — Supplemental Payment

The purpose of the Stevie Sellows’ Quality Improvement (QI) Initiative is to provide supplemental payments, under the Stevie Sellows’ Quality Improvement Fund to qualified District of Columbia, Medicaid-Certified, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) for participation in a training programs designed to improve the quality of care for beneficiaries with intellectual disabilities, by efforts to reduce employee turnover and increase the qualifications of employees. .

For Fiscal Year (FY) 2015, and annually thereafter, DHCF, in collaboration with the Department on Disability Services (DDS) will approve a slate of training topics , for selection by ICFs/IID interested in participating in the QI Initiative. Topics may vary

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each fiscal year, and DHCF will solicit suggestions from stakeholders, including but not limited to the provider community, beneficiaries, or District licensing agencies.

C. For each fiscal year, in order for an ICF/IID to be considered for payments under the Stevie Sellows’ Quality Improvement Fund, an ICF/IID must submit an application packet no later than June 30" of the preceding fiscal year and meet the standards set forth in this section. The application packet must include the following:

1. A Letter of Intent 2. Copy of Training Plan which identifies:

a. Projected training cost;

b. Training curriculum which includes the selected training topic(s) chosen from the approved slate of topics, objectives, length of training (a minimum of 16 hours per employee), and methods/medium;

c. Handouts that may be used to teach employees;

d. Competency test(s) to be administered;

e. Quality improvement tool(s) that will be used to assess employee performance, after training is administered;

f. Tool(s) that will used to evaluate the effectiveness of the training; and

g. Process for assessing and measuring the Plan annually.

D. For FY 2015 and thereafter, each employee must complete a minimum of sixteen (16) hours of classroom training annually by their anniversary date of hire.

E. Training must be competency based, with employees receiving a passing score of 80% or better.

F, Training must be provided by an industry - recognized organization.

G. Training must have a person-centered perspective that is focused on improving the quality of life or care for individuals residing in ICFs.

H. Training must be provided to employees excluding managers, administrators and contract employees.

I. ICF/ID facilities that do not submit completed application materials within the required timeframe to the address below will not be considered for payment:.

The D.C. Department of Health Care Finance

Project Manager, Long Term Care Division, Special Needs Branch 899 North Capitol Street, NE, Suite 6037

Washington, DC, 20002

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J. ICFs shall be responsible for the following:

1.

Completed training records shall be maintained in the ICFs/IID administrative offices and shall contain the following for former and current employees:

a. Names, hire dates, and position titles for all employees;

b. Training curriculum and handouts used to teach employees;

c. Training completion date, and verification score or graded tests; and d. Training sign - in sheets.

ICF/IID shall submit information to DHCF regarding personnel changes (e.g., when an employee leaves the agency, changes his/her name or receives a promotion).

In order to receive payment, an ICF/IID must meet the requirements identified above in Section II and submit the items below:

a. Quarter One - A copy of the written notification by DHCF for approval of items listed in section I. above, and a complete list of employee names, hire dates, and position titles for all employees, submitted within fourteen (14) days of the end of the fiscal quarter;

b. Quarter Two - The ICF/IID will submit to DHCF completed records indicating that 50% of employees have completed required training and have passed a written competency test (Score of 80% or better), submitted within fourteen (14) days of the end of the fiscal quarter;

c. Quarter Three - The ICF/IID will submit to DHCF completed records indicating that 100% of employees have completed required training and have passed a written competency test (Score of 80% or better), submitted within fourteen (14) days of the end of the fiscal quarter; and

d. Quarter Four - Annually the ICF/IID will produce and submit a Comprehensive Training Report no later than August 1that includes the following:

i. Documentation of incurred training expenses;

ii. Documentation of training completion date, graded tests, and training sign in sheets;

iii.Performance measures which indicate the total number of employees who received training vs. the total number of employees who received a passing score, and the total number of individuals served vs. the total number of individuals with documented evidence that quality of care was improved, as a result of the employee’s implementation of training received; and

iv.A brief summary of how training impacted employee turnover and improved the qualifications/skills of the employee, and how the performance measures demonstrate the agency’s progress towards quality improvement and/or challenges. If challenges have been identified, the summary should also include interventions the ICF/HD will implement to improve quality of care for individuals.

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4. Payment shall not be made to an ICF/IID to cover costs that the ICF/IID incurred for employees attending agency required/standard training or for training sponsored by a D.C. governmental agency.

5. Missed timelines and discrepancies in documents/records provided may result in the need for a Corrective Action Plan (CAP).

J. The responsibilities of DHCF shall include:

1. The responsibility for this initiative shall be is vested in the Deputy Director, Medicaid, Department of Health Care Finance (DHCF). Implementation of this initiative is the responsibility of the Health Care Delivery Management Administration, Long Term Care Division, Special Needs Branch.

2. Within 90 days of receipt of application materials, DHCF will notify ICFs/IID in writing whether the training plan submitted by the ICF/IID was approved. Approval of the training topic does not guarantee that the ICF/IID will meet all necessary requirements for payment under the Stevie Sellows’ quality improvement fund.

3. For FY 15, and annually thereafter, to identify performance improvement opportunities DHCF, Division of Quality and Health Outcomes will perform trend and data analysis of information provided. Findings will be shared with individual provider agencies.

4. An ICF/IID will be subject to random audits conducted by DHCF, Special Needs Branch. Audits may include; but not be limited to the following:

a. Training record reviews; b. Interviews with agency personnel; and/or c. In-class monitoring.

K. The supplemental payment shall conform to the Medicaid Upper Payment Limits (UPL) which ensures that rates do not exceed usual and customary charges billed to the general public in 42 CFR § 447.271.

L. For each fiscal year, the aggregate annual supplemental payment to all ICFs/IID shall not exceed 2% of the total reimbursements paid under Section III of this State Plan Amendment.

M. The supplemental payment rate shall be the lesser of the amount specified in Section V divided by the number of licensed Medicaid beds as certified at the beginning of the fiscal year, or the sum of total industry training costs divided by the total number of licensed Medicaid beds as certified at the beginning of the fiscal year. The total industry training costs are determined from the training application packages submitted pursuant to Section II (A).

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Supplemental payments to individual ICF/IID will be the lesser of the following: the supplemental rate multiplied by the number of licensed Medicaid beds operated by the provider as certified at the beginning of the fiscal year, or the actual training costs incurred by the provider. Supplemental payments shall not exceed providers’ actual costs or the calculable payment per licensed Medicaid bed.

. Supplemental payments made in accordance with this section shall be included in the cost

report submitted annually and shall be recorded as an offset to the costs incurred.

In order to receive supplemental payment reimbursements an ICF/IID shall incur costs and provide DHCF with evidence of training requirements as outlined in sections II (A) and IV (A-G).

. Acceptable forms of evidence shall include a copy of any invoice(s) for training costs and

cancelled check(s) reflecting the facility’s payment of the invoice(s). Within 90 days of receipt of required documents, DHCF shall notify the ICF/IID and process payments.

. Payments made in accordance with this section are not subject to assessment under the

Stevie Sellows Quality Improvement Fund. REBASING

Effective October 1, 2016 (FY 2017), and every three (3) years thereafter, reimbursement rates for the residential component shall be updated based on cost reports from the most recently audited year.

COST REPORTING AND RECORD MAINTENANCE

. Each ICF/IID shall report costs annually to DHCF no later than ninety (90) days after the

end of the provider’s cost reporting period, which shall correspond to the fiscal year used by the provider for all other financial reporting purposes, unless DHCF has approved an exception. All cost reports shall cover a twelve (12) month cost reporting period.

. cost report that is not completed in accordance with the requirements of this Section

shall be considered an incomplete filing, and DHCF shall notify the ICF/IID within thirty (30) days of the date on which DHCF received the incomplete cost report.

. DHCF shall issue a delinquency notice if the ICF/IID does not submit the cost report as

specified in Section VII.A. and has not previously received an extension of the deadline for good cause.

. Late submission of cost reports shall result in a refundable withholding of an amount

equal to seventy-five percent (75%) of the facility’s total payment for the month that the cost report was due, and the same amount shall be withheld each month until the cost report is received.

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The costs described in Section III. shall be reported on a cost report template developed by DHCF. The cost report shall be completed in accordance with accompanying instructions. The cost report instructions shall include, at minimum, guidelines and standards for determining and reporting allowable costs.

If the ICF/IID utilizes outside resources pursuant to Section IV.B., the ICF/IID shall submit the cost reports or invoices provided by the outside resources as an attachment to the submitted cost report under Section VII.E. Where the active treatment program is provided in house, the provider shall provide its own cost report in the active treatment section of the cost report.

In the absence of specific instructions or definitions contained in the accompanying regulations, cost report forms and instructions, the treatment and allowability of costs shall be determined in accordance with the Medicare Principles of Reimbursement, 42 C.F.R. Part 413, and the interpretation found in the relevant Provider Reimbursement Manual.

Any allocated time claimed under Section III.C.1.a.v. must be supported by contemporaneous time sheets attested to by the persons concerned, or a random moment time study designed and reviewed by an independent firm. Such documentation shall be submitted with the cost report in support of all amounts claimed.

All of the facility’s accounting and related records, including the general ledger and records of original entry, and all transaction documents and statistical data, shall be permanent records and be retained for a period of not less than five (5) years after the filing of a cost report. ;

If the records relate to a cost reporting period under audit or appeal, records shall be retained until the audit or appeal is complete.

In accordance with Section I.I., the ICF/IID shall disclose a list of related organizations, associated amounts, and the reason(s) for payment to each related organization in the cost report.

Costs incurred during a period when an ICF/IID is subject to denial of payment for new admissions, described in Section XIII, shall be included on the cost report for the period during which payment was denied, in order to accurately determine rates in subsequent

periods.

FISCAL ACCOUNTABILITY AND AUDITING

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Beginning in FY 2014, except for the Administration cost center, each facility shall spend at least ninety-five percent (95%) of the rate under each cost center on service delivery to Medicaid individuals. Facilities expending less than ninety-five percent (95%) of each cost center shall be subject to repayment requirements.

Beginning in FY 2014, each ICD/IID shall spend one hundred percent (100%) of the rate for Active Treatment on service delivery to Medicaid individuals. Facilities expending less than one hundred percent (100%) of the rate for Active Treatment shall be subject to repayment requirements.

DHCF shall evaluate expenditures subject to the requirements in this Section through annual review of cost reports.

The repayment amount shall be the difference between ninety-five percent (95%) of the rate component and reported expenses plus the administrative percentage, as set forth in the D.C. Municipal Regulations.

DHCF, or its designee, shall review each cost report for completeness, accuracy, compliance, and reasonableness through a desk audit.

On-site audits shall be conducted not less than once every three (3) years. Each ICF/IID shall allow access, during on-site audits or review by DHCF or U.S. Department of Health and Human Services auditors, to relevant financial records and statistical data to verify costs previously reported to DHCF.

NOTICE OF RATES AND RIGHT TO APPEAL DHCF shall publish in the D.C. Register all rates and all procedures and timeframes for

requesting an informal review and appeals in the D.C. Register consistent with the requirements set forth in this Section.

. For Fiscal Years 2013 and after, DHCF will send a transmittal to all providers notifying

them of the rates.

Provider appeals under this State Plan Amendment shall be limited to challenges based on acuity level assignments and audit adjustments.

Filing an appeal with OAH shall not stay any action to recover any overpayment to the ICF/IID, and the provider shall be immediately liable to the program for overpayments set forth in the Department’s decision.

UTILIZATION REVIEW REQUIREMENTS

In accordance with 42 C.F.R. § 456.401, DHCF shall maintain a written Utilization Review Plan (URP) for each ICF/IID enrolled in the District of Columbia’s Medicaid

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program. This plan shall describe the review process that shall be used for each beneficiary receiving services furnished by the ICF/IID.

B. Utilization review for ICFs/IID enrolled in D.C. Medicaid may be conducted by any of the following:

1. The ICF/IID; 2. DHCF or its designee; or 3. Any other approved method.

C. At least annually, DHCF shall ensure that each ICF/IID has a completed and approved URP on file. The URP shall, at minimum, include the following:

1. A description of how utilization review is performed;

2. The frequency of utilization review;

3. Assurances and documentation establishing that the personnel who shall perform utilization review meet the requirements of 42 C.F.R. § 456.406(b);

4. Administrative staff responsibilities related to utilization review;

5. The types of records maintained by the utilization review team;

6

The types and frequency of any reports developed by the utilization review team, and related plan for dissemination; and

7. The procedures that shall be used when corrective action is necessary.

D. In accordance with 42 C.F.R. §§ 456.431 - 456.438, each URP shall establish a process - whereby each beneficiary residing in the ICF/IID receives continued stay reviews, at minimum, every six (6) months.

E. The URP shall establish written methods and criteria used to conduct continued stay reviews. The URP shall also set forth enhanced criteria used to assess a case if the beneficiary’s circumstances reflect any of the following associations:

1. High costs; 2. Frequent and excessive services; or 3. Questionable patterns of care by treating clinicians.

XI. COMMENCING TERMINATION OR IMPOSING SANCTIONS AGAINST ICFs/IID

A. In order to qualify for Medicaid reimbursement, intermediate care facilities for persons with intellectual and developmental disabilities (ICFs/IID) shall comply with federal conditions of participation (CoPs), pursuant to 42 C.F.R. §§ 483.400-483.480. The CoPs include adherence to acceptable standards in the following areas:

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Governing body and management; Client protections;

Facility staffing;

Active treatment services;

Client behavior and facility practices; Health care services;

Physical environment; and

Dietetic services.

SPNAMPWNS

B. An ICF/ID that fails to maintain compliance with the CoPs may be subject to alternative sanctions and/or termination of its participation in the Medicaid program.

XI. ALTERNATIVE SANCTIONS IN CASES OF NON-IMMEDIATE JEOPARDY

A. In accordance with Section 1902(i)(1)(B) of the Social Security Act, the District of Columbia may impose alternative sanctions against an ICF/IID when that facility fails to

meet the CoPs, but the violation does not place beneficiary health or safety in immediate jeopardy.

B. In lieu of terminating the provider agreement, DHCF may impose one or more alternative sanctions against an ICF/IID that meets the criteria in 29 DCMR § 4150.1, as follows:

Denial of payment, as described in Section XIII;

Directed Plan of Correction (DPoC), as described in Section XIV; Directed In-Service Training (DIST), as described in Section XV; or State Monitoring, as described in Section XVI.

PYeN>

C. DHCF shall, in conjunction with DOH, determine the appropriateness of alternative

sanctions against an ICF/IID that is in violation of the CoPs according to the following factors:

Seriousness of the violation(s);

Number and nature of the violation(s);

Potential for immediate and serious threat(s) to ICF/IID residents;

Potential for serious harm to ICF/IID residents;

Any history of prior violation(s) and/or sanction(s);

Actions or recommendations of DDS, developmental disability advocacy groups, or health care entities;

Mitigating circumstances; and

Other relevant factors.

AwWPYNE

en

XIII. DENIAL OF PAYMENT

A. Pursuant to Section 1902(i) of the Act and 42 C.F.R. § 442.118, and in lieu of termination in situations where residents are not in immediate jeopardy, DHCF may initiate a one-

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time, denial of payment for claims associated with new admissions at ICFs/IID that fail to comply with one or more of the CoPs for Medicaid enrollment.

The denial of payment term shall be eleven (11) months, beginning on the first day of the month after DHCF imposes the denial of payments.

DHCF shall also deny payment to ICFs/IID if DOH previously initiated enforcement actions due to immediate jeopardy, and the facility has failed to mitigate the circumstances that caused immediate jeopardy.

DHCF, in coordination with DOH, shall notify the ICF/IID that it is subject to denial of payment. The written notification shall indicate the following:

1. That the ICF/IID has up to sixty (60) days to correct the cited deficiencies; and 2. The procedures that will commence once the sixty (60) days have lapsed, pursuant to Section XIILE.

If the ICF/IID does not correct the violations within the sixty (60) day timeframe, then

DHCF shall notify the facility of its intention to deny payment. This written notification shall include:

1. Reasons for denial of payment;

2. Information on the right to request a hearing though the Office of Administrative Hearings (OAH), pursuant to 29 DCMR §§ 1300 et seq.;

3. Details of public notice; and

4. The effective date for denial of payments.

If an ICF/IID appeals DHCF’s decision to deny payment, DHCF shall notify the provider that the effective date of the sanction, established in Section XIILB., is suspended until the appeal is resolved.

If denial of payment is upheld at the appeal, the DHCF shall notify the facility and the public at least thirty (30) days before the newly established effective date of the sanction.

DHCF, in coordination with DOH, shall monitor the facility’s progress in improving cited violation(s) throughout the eleven (11) month period.

The Director of DHCF shall consider modifying or rescinding denial of payment upon the occurrence of one of the following:

1. Circumstances have changed and resulted in alterations of the CoPs violation(s) in such a manner as to immediately jeopardize beneficiary health and safety; or

2. The ICF/IID achieves full compliance with the CoPs in fewer than eleven (11) months; or

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3. The ICF/IID makes significant progress in achieving compliance with the CoPs through good faith efforts.

DHCF shall terminate the provider agreement of an ICF/IID that has been unable to achieve compliance with the CoPs during the full eleven (11) month period of denial of payment. Termination shall be effective on the first day following the last day of the denial payment period.

An ICF/IID provider agreement that is subject to denial of payment is automatically extended for the eleven (11) month period if the provider agreement does not lapse on or before the effective date of denial of payments.

ICF/IID provider agreements that are subject to denial of payment can only be renewed when the denial period expires or is rescinded.

DIRECTED PLAN OF CORRECTION (DPoC)

The DPoC shall be a plan developed by the District of Columbia that requires ICFs/IID to take prompt, timely action to achieve correction and continued compliance with CoPs

and other District of Columbia Medicaid requirements.

The DPoC shall be developed in coordination with and approved by DOH, DHCF and DDS, incorporating findings from DDS’ Continuous Quality Improvement Plan.

The DPoC shall specify:

1. How corrective action will be accomplished for individuals found to have been affected by the deficient practice;

2. How the facility will identify other individuals who have the potential to be affected by the same deficient practice, and how the facility will act to protect

individuals in similar situations;

3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;

4. How the facility will monitor its corrective actions and performance to ensure that the deficient practice(s) is/are being corrected and will not recur;

5. When the corrective action must be complete; 6. How substantial compliance will be measured; and

7. How the DPoC related to other alternative sanctions.

TN No.

Supersedes _ Approval Date JAN 25 2013 Effective Date ocT ae | 2012

TN No. 97-02

District of Columbia Attachment 4.19-D, Part II

Page 25

D. A state monitor shall oversee implementation of the DPoC, and shall ensure compliance with the plan.

XV. DIRECTED IN-SERVICE TRAINING (DIST)

A. A DIST shall be used to address deficiencies determined by the District to be correctable through education. The sanction shall require the staff and relevant contractors of the ICF/IID to attend in-service trainings and demonstrate competency in the information presented during the trainings.

B. DHCF, in consultation with DOH and DDS, shall develop the areas for ICF/IID staff and contractor training by incorporating the findings from the Continuous Quality Improvement Plan.

C. Facilities shall use training programs developed by well-established developmental disabilities organizations, such as universities and developmental advocacy organizations, to meet training requirements described in this Section.

D. The ICF/IID shall bear the expense of the DIST.

E. A state monitor shall oversee implementation of DIST, and shall ensure compliance with the requirements.

XVI. STATE MONITORING

A. State monitoring shall be the District’s oversight of efforts made by the ICF/IID to correct cited deficiencies. State monitoring shall be a safeguard against the facility’s further noncompliance.

B. The following entities may serve as the State Monitor:

1. DOH; 2. DHCF; 3. DDS; or 4. A District of Columbia contractor that meets the following requirements: i. Is not a designee or current contractor of the monitored facility; ii. Does not have an immediate family member who is a resident of the facility; iii. Is not a person who has been terminated for cause by the facility; and iv. Is nota former contractor who has had a contract canceled, for cause, by the facility. Supersedes Approval Date JAN 9.5 2013 Effective Date T “L208

TN No. 97-02

District of Columbia Attachment 4.19-D, Part II Page 26

C. State monitoring shall be discontinued under the following circumstances:

1. The facility’s provider agreement is terminated; or 2. The facility has demonstrated to the satisfaction of the District of Columbia that it is in substantial compliance with the CoPs.

XVII. ACCESS TO RECORDS

Each ICF/IID shall allow appropriate DHCF personnel, representatives of the Department of Health and Human Services and other authorized agents or officials of the District of Columbia government and federal government full access to all records during announced and unannounced audits and reviews.

XVII. DEFINITIONS

For purposes of this Part of Attachment 4.19-D, the following terms shall have the meanings ascribed:

A. Active Treatment - A program of specialized and generic training, treatment, health services and related services designed toward the acquisition of the behaviors necessary for the beneficiary to function with as much self-determination and independence as possible, and the prevention or deceleration of regression or loss of current optimal functional status. These services shall be provided consistent with Federal standards.

B. Activities of Daily Living - The ability to bathe, transfer, dress, eat and feed self, engage in toileting, and maintain bowel and bladder control (continence).

C. Acuity Level - The intensity of services required for a Medicaid beneficiary residing in an ICF/IID. Individuals with a high acuity level require more care; those with lower acuity levels require less care.

D. Administrator - An individual responsible for the administration or implementation of ICF/IID policies or procedures, and other roles other than delivering services directly related to resident treatment and care, food service, or maintenance of the facility.

E. Allowable costs - Actual costs, after appropriate adjustments, incurred by an ICF/TID, which are reimbursable under the Medicaid program.

F. Base year - The standardized year on which rates for all facilities are calculated to derive a prospective reimbursement rate.

G. Depreciation - The systematic distribution of the cost or other basis of depreciable assets, less salvage value, over the estimated useful life of the assets.

TN No. __ JAN 25 2013 OCT ¥ 2012

Supersedes Approval Date Effective Date TN No. 97-02

District of Columbia Attachment 4.19-D, Part II Page 27

H. Direct service costs - Costs incurred by a provider that are attributable to the operation of providing services to individuals.

I. Elopement - To run away; abscond.

J. Employee - A worker in an ICF/IID that does not serve as a manager or administrator, and is not under contract to provide professional services.

K. Facility - An intermediate care facility for individuals with intellectual disabilities.

L. Habilitation — The process by which a person is assisted to acquire and maintain those life skills which enable him or her to cope more effectively with the demands of his or her own person and of his or her own environment, including, in the case of a person committed under § 7-1304.06a, to refrain from committing crimes of violence or sex offenses, and to raise the level of his or her physical, intellectual, social, emotional and economic efficiency.

M. Holiday pay - Shall have the meaning ascribed within a labor agreement, provider policy, or in the absence of either, by the U.S. Department of Labor.

N. Individual Support Plan (ISP) - The document produced through coordinated efforts of ICFs/IID and DDS. The ISP is the successor to the Individual Habilitation Plan as defined in the court-approved Joy Evans Exit Plan. For purposes of Medicaid reimbursement, the individual program plan, as described in 42 C.F.R. § 483.440(c), shall be included within the ISP.

O. Industry Average - The sum of total industry expenditures divided by total industry licensed bed days per reported fiscal year costs.

P. Interdisciplinary team - A group of persons, with special training and experience in the diagnosis and habilitation of individuals with intellectual and developmental disabilities, with the responsibility to perform a comprehensive evaluation of each beneficiary and participating in the development, implementation, and monitoring of the beneficiary’s individual habilitation plan. The “core team” shall include the individual, the individual’s representative, the service coordinator, and relevant clinical staff.

Q. Level of Care Determination (LOC) - The assessment used by the Department on Disability Services to determine a beneficiary’s eligibility for ICF/IID services.

R. Level of Need Assessment and Risk Screening Tool (LON) - The comprehensive and uniform assessment tool developed by the Department on Disability Services that determines the beneficiary’s individual support needs and identifies potential risks to be addressed by the interdisciplinary team.

TN No. ZF Supersedes Approval Date JAN 25 2013 Effective Date ocr 1 20i TN No. 97-02

District of Columbia Attachment 4.19-D, Part II

Ss.

BB.

Page 28

Licensed bed days — Bed day policy for beneficiaries residing in Intermediate Care Facilities for the Intellectually and Developmentally Disabled pursuant to Attachment 4.19C of the District of Columbia State Plan for Medical Assistance.

. Life safety skills - An individual’s ability to protect oneself from perceived and

apparent risks and life-threatening situations such as fires, evacuation emergencies, traffic, and ingestion of toxic substances.

. Manager - An individual who is responsible for the administration of an ICF/IID

facility inclusive of human resources, maintenance, and policy management.

. Non-ambulatory - A beneficiary who spends all time out of bed in a wheelchair or a

chair.

. One-to-One - An altered staffing pattern that allows one staff to provide services to

an individual with intellectual disabilities exclusively for an authorized period of time.

. Owner - A person who is a sole proprietor, partner, or corporate stockholder-

employee owning any of the outstanding stock of the contracted provider.

. Per diem rate - The rate per day established by DHCF.

. Professional services — Services provided pursuant to any legal arrangement.

Professional services shall include occupational and speech therapies and nursing care services provided by an individual or a corporation.

. Quality of care improvements - The same definition as set forth in D.C. Official Code §

47-1270, and any subsequent amendments thereto.

Related organization - In accordance with 42 C.F.R. § 413.17(b)(1), an organization is related to an ICF/IID when the ICF/IID, to a significant extent, is associated or affiliated with, or has control over, or is controlled by the organization furnishing the services, facilities, or supplies.

TN No.

Supersedes Approval Date JAN 25 2013 Effective Date OCT = 1. 2012 TN No. 97-02

Table of Contents State/Territory Name: District of Columbia State Plan Amendment (SPA)#: 13-07MM This file contains the following documents in the order listed: 1.) Approval letter 2.) Summary Form 3.) Approved SPA Pages

~ DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEDICAID SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFT #102520134019 NOV 2 0 2013) Dr. Linda Elam, Ph.D., MPH Deputy Director/Medicaid and CHIP Department of Health Care Finance 899 North Capitol Street, N.E. - Suite 6037 Washington, D.C. 20002 Dear Dr. Elam: The Centers for Medicare & Medicaid Services (CMS) has completed its review of the District of Columbia's State Plan Amendment (SPA) 13-07MM. SPA13-07MM identifies MAGI-based eligibility groups and incorporates general eligibility requirements into the District of Columbia's State Plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014. Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of the District of Columbia's approved State Plan. • S14, pages 1 through 6 • S25, pages 1 through 3 • S28, pages 1 through 4 • S30, pages 1 through 5 • S32, pages 1 through 2 • S50, page 1 • S51, page 1 • S52, pages 1 through 4 • S53, pages 1 through 2 • S54, page 1 • S55, page 1 • S57, pages 1 through 2 • S59, page 1 Notwithstanding any other provisions of the District of Columbia State Plan, the financial eligibility methodologies described in SPA 13-07MM apply to all MAGI-based eligibility groups covered under the District of Columbia's State Plan. The MAGI financial methodologies set forth in 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Page 2- Dr. Linda Elam This letter authorizes the approval of the enclosed Medicaid State Plan Eligibility Summary Page (CMS 179), and the approved SPA pages. If you have any questions regarding this SPA, please contact Sabrina Tillman-Boyd at 215-861- 4721 or by email at Sabrina . Tillman-Bo yd(~cm s.hhs .gov. Enclosures cc: Claudia Schlosberg, DHCF M. Diane Fields, DHCF Sincerely, (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /s/

DC.0222.ROO.OO- Jan 01,2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Statefferritory name: Dist. of Columbia Transmittal Number: Page 1 of2 Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits of the submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. 13-07 Proposed Effective Date 01/01/2014 (mm / dd! yyyy) Federal Statut~/Re.gulation Citation Patient Protection and Affordable Care Act of2010, approved March 23, 2010 (Pub. L. No. 111-148, 124 Stat I Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 20 15 Subject of Amendment Includes the following SPAs: Mandatory: SIO: MAGI Income Methodology S 14 AFDC Income Standard S25 Parents and Other Caretakers S28 Pregnant Women S30 Infants and Children Under Age 19 S32 Individuals Below 133% of the FPL Optional: S50 Individuals Above 133% ofthe FPL $ 34873961 .00 $ 52497391.00 S52 Reasonable Classifications of Individuals S53 Non IV-E Adoption Assistance S55 Tuberculosis S57 Foster Care Adolescents S59 Family Planning Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal v Other, as specified Describe: B20-199, Budget Support Act of20 13 Amount (b) (1) (A) (b) (b) (1) (A), (b)

DC.0222.ROO.OO- Jan 01, 2014 Signature of State Agency Official Submitted By: Diane Fields Last Revision Date: Oct 30,2013 Submit Date: Aug 23,2013 Page 2 of2 (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /s/

Medicaid Eligibility A.FJ}Cnlnconie Stand~rds ,, .. , ,·r, Enter the AFDC Standards below. A II states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May I, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other.standards is optional. !\1AGI-equi).'alf9(A.F:R~:Paymept Standar.cl·.'Jn Effect.-As of May 1, 198.8 · I~9."!.e ~t~~dar(J-o_E'ntty.;-. J1()iJar -'}mount -.Automatic Increa~ 1e Option The standard is as follows: \e Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way jEnter the statew:ide standard TN: DC-13-07-MM Approved: 11/01/2013 OMB Control Number 0938-1148 Ol\.-18 Expiration date: 10/31 /2014 814 . ·~,··· I '' •' S13a I Effective: 01/01/204 Page 1 of 6

Medicaid Eligibility Additional incremental amount Household size Standard($) (Yes (i No + I 311 X Increment amount sl + 2 395 X + ' 501 X .) + 4 610 X + 5 704 X + 6 823 X + 7 940 X + 8 1.041 X + 9 1,145 X + 10 1,246 X + II 1,323 X + 12 1.422 X The dollar amounts increase automatically each year (' Yes (i No .4'~J>C Paym'epfStand~td · in E.ffectAS of .July 16, 1996 ·• liu!o~fStanqard ~p.try - Doll~r Amount - Automatic Increase Option The standard is as follm.vs: (i Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way !Enter the statewide standard TN: DC-13-07-MM Approved: 11/01/2013 I ... Sl3a Effective: 01/01 /204 Page 2 of6

Medicaid Eligibility Additional incremental amount Household size Standard($) (. Yes ( No + I 262 X Increment amount $176 + ~ 326 X + 3 415 X + 4 507 X + 5 585 X + 6 688 X + 7 789 X + 8 87~ X + 9 948 X + 10 1,0~4 X + II 1,100 X + 12 1.176 X The dollar amounts increase automatically each year ( Yes (. No MAGI-equivalent AFDC Pay,~ent S;tandard in Eff~ct As of July 16, 1996 Inc~lne Standard Entry - Dollar A01ount - Automatic Increase Option The standard is as follows: (. Statewide standard ( Standard varies by region ( Standard varies by living arrangement ( Standard varies in some other way !Enter the statewide standard TN: DC-13-07-MM Approved: 11/01/2013 I Sl3a Effective: 01/01/204 Page 3 of6

Medicaid Eligibility Additional incremental amount Household size Standard($) l- Yes (' No + I 406 X Increment amount $1 126 I + 2 519 X + , 658 X .) + 4 800 X + 5 927 X + 6 1,080 X + 7 1.231 X + 8 1.363 X + 9 1,489 X + 10 1,615 X + II 1,740 X + 12 1.866 X The dollar amounts increase automatical ly each year (' Yes l- No AFD~ Need Stapdaf.d:'in Effe~t As of July J6, .1996 ' -,; IiJ-~o~e Staq~a,rd Entry - ,_Dollar ~mount -Automatic Iricreas~ Option ,. S13a --'- The standard is as fo llows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No Page 4 of 6

Medicaid Eligibility 1\:FDC'Payment Standard'i.ttEffect As of July 16, 1996, increased by no more than the percentage · . a.~e;.jn the .C,OJ!~~~er Pric~·lqdex ·for u,~bau~cqit:sum~rs "(CPI-:-U}sin~e such date. ' lq~ome Standard Entry "' Dollar A.mount - Automatic Increase Option The standard is as f(.)))ows: (' Statewide standard (' .Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No Sl3a MAOI::~(tu'ivale'nt AFD'(; 'P;1yment Standard 'in Effeft As:of .July .16, 1996, 'in~reased by no more 7 ~ha~ tile p.ercentag~ jncreaseJn the Ctinsum~ar Price IndeX: for ur:ban consumers (CPL-U) since such date ,. · . ' Income Sta.Qdard Entry - Dollar Amount - Automatic Increase Option The standard is as fo llows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No TANJf p~y~en! ~ta~dard. .', .. · ,, "•' . > i•'_, .. . . Income Standard Entry·;. Dollar Amount ;. Automatic Increase Option The standard is as fo llows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way T . Uv- I ,J-U -IVIIVI "'f'f'IUY.,.U . "U"LUI <J S13n Sl3a '-""''-"•"' · U IU u4 Page .'i of6

Medicaid Eligibility The dollar amounts increase automatically each year (' Yes (' No MAG};equivaie~t TA~ payment ~ta~dard ":~ ' .. Incofue Standar~ _Ent11'- Dollar ·.Amount -Automatic Inctel se Option .. S13a The stahdard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No PRA Disclosure Statement According to the Paperwork Reduction Act or 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 09381148. 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. I fyou have comments concerning the accuracy or the time estirnate(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 2 1244 -1850. TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/204 Page 6 of6

Medicaid Eligibility OMB Control 1umber 0938-1148 OMB Expiration date· I Oi31 12014 Eligibility ·Groups ::.;M,and3,tory. Co:ver~ge Parents andiOther :c aretaker- Relatives 42 CFR 435.110 1902(a)( I O)(A )(i)(l) 1931 (b) and (d) S25 ,. ~ 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. 0 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 de1inition of caretaker relative (select any that apply): D 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: All individuals related to the child by blood, marriage. or adoption. An individual related to the child through marriage can continue to be considered a caretaker relative even if the relationship ended due to divorce or other legal termination of the relationship. D 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 detinition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental supp011 or (i care by reason of the death, physical or mental incapacity. or absence from the home or unemployment of at least one parent. TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page I of J

Medicaid Eligibility (' 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 S I 0 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 I, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S 14 AFDC Income Standards. 12] The state certifies that it has submitted and received approval for its conve11ed May I, 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 12] 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, 20 I 0, converted to a MAGI-equivalent percent of FPL or amounts by household size. (' The state's effective income level for section 19 ~1 I 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 II 15 (' demonstration as of March 23,2010, converted to a MAGI-equivalent percent ofFPL or amounts by household size. The state's effective income level for any population of pnrents/caretaker relatives under a Medicaid 1115 (' demonstration as of December 31, 2013, converted ton rv1AGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page 2 of 3

Medicaid Eligibility le' A percentage of the federal poverty level: ~% (' The state's AFDC payment standard in effect as of July 16, I 996, converted to a MAG !-equivalent standard. The standard is described inS 14 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-Ll) since such date, converted to a MAGI- equivalent standard. The standard is described inS 14 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 ~ Income standard chosen: Indicate the state's income standard used for this eligibility group: (' The minimum income standard le' The maximum income standard The state's AFDC payment standard in effect as of July 16. I 996. increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-Ll) since such date. The standard is described in S 14 A FDC Income Standards. (' Another income standard in-between the minimum and maximum standards allowed ~ 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 4.15.116) and/or Infants and Children under Age 19 (42 CFR 4.15.118 l eligibility groups when determined presumptively eligible. (' Yes le' 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 infomHttion collection is 0938-1148. The time required to complete this infonnation 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. I fyou 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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 PageJofJ

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Eligibility Groups - Mandatory Coverage Pregnant Women 42 CFR 435.116 1902(a)(10)(A)(i)(Ill) and (IV) 1902(a)(lO)(A)(ii)(l). (IV) and (IX) 1931(b) and (d) 1920 S28 ~ Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. 0 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. (e Yes { No ~MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SJO 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. (e Yes { No Enter the amount of the minimum income standard (no higher than 185% FPL):~ % FPL ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant 0 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: (e' The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IIl) (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) and1902(a)(10)(A)(ii)(1Y) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/201 4 Page 1 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 percentcJf FPL. (' 185% FPL The amount of the maximum income standard is:~ % FPL ~ Income standard chosen Indicate the state's income standard used for this eligibility group: (' The minimum income standard (e' 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: (e' All pregnant women eligible under this group receive full Medicaid coverage under this state plan. l ' 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. (e' 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: DC-13-07-MM Aooroved· 11101/?1111 Effective: 01101/2014 Page 2 of 4

~~ Medicaid Eligibility (' Yes (e' No ~ 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 817 TN: DC-13-07-MM 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: O Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan O Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act O 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 0 Food Program for Women. Infants and Children (WIC) under section 17 of the Child Nutrition Act ofl966 O Is authorized to determine a child's eligibility under the Medicaid slate plan or for child health assistance under the Children's Health Insurance Program (CHIP) O 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) 0 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs 0 Is a state or Tribal child support enforcement agency under title IV-D of the Act O Is an organization that provides emer~ency 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 l Is an organization that determines eligibility for any assistance or benefits provided under any program O of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 ( 42 U.S. C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.) O 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: Approved: 11/01 /2013 Effect1ve: 01 /01 /201 4 Page 3 of 4

Medicaid Eligibility Name of entity Description 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. + Any qualified hospital Has not been disqualified by the Medicaid agency X 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. The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, [ZJ and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included. I An attachment is submitted. I 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 revie':" instructions, search existing data resources, gather the data needed, and complete and review the information collection. lf 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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page 4 of 4

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 42 CFR 435.118 1902(a)(10)(A)(i)(IIJ), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 193l(b) and (d) 830 ~ 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. [Z] 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 I 9 ~ 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. (e' Yes ("' No Enter the amount of the minimum income standard (no higher than 185% FPL) :~ % FPL ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for infants [Z] 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)(lO)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related (e' infants), 1902(a)(lO)(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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/201 4 Page 1 of 5

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)(lO)(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)(lV) (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: ~ % FPL ~ Income standard chosen The state's income standard used for infants under age one is: (i' 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)(lO)(A)(i)(lli) (qualified children), 1902(a)(l0) (' (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(lO)(A)(ii)(lX) (optional poverty level-related infants) and 1902(a)(lO)(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)(Ill) (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)(lV) (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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/201 4 Page 2 of 5

Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. ~ Maximum income standard The stale certifies that it has submitted and received approval for its converted income standard(s) for children l2J 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- le' income families), 1902(a)(lO)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(Vl) (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)(lll) (qualified children), 1902(a)(lO)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(lO)(A)(ii)(lV) (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: EJ % FPL ~ Income standard chosen The state's income standard used for children age one through five is: (e 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)(lO)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(lO)(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: DC-1 3-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page 3 of 5

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 [Z] 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 le' (low-income families), 1902(a)(10)(A)(i)(lll) (qualified children), 1902(a)(lO)(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), J902(a)(lO)(A)(i)(Vll) (mandatory poverty level-related children age six through eighteen) and 1902(a)(lO)(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: ~ % FPL ~ Income standard chosen T ~ l· nl" , ., """ • . 111n t?l\11. "'"· · · n 1 /1\1 1?1\ Pa!!e 4 of :1

Medicaid Eligibility The state's income standard used for children age six through eighteen is: le' 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)(lO)(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 C age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(lll) (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. lf higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and r 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 r 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 le' 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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page 5 of 5

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: I 0/31 /2014 1 ~!~gi6ifity ~~~ups - Mandatory Coverage ~dQlt Group . 1902(a)(l O)(A)( i)(VII I) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. (e' Yes (' No ' 832 [!] Adult Group- Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible. with income at or below 133% FPL. [Z] The state attests that it operates this eligibility group in accordance with the following provisions: [!) Individuals qualitying 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 orB 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 f~)r mandatOI)' Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. [!) Have household income at or below 133% FPL. [!) MAG I-based income methodologies are used in calculating household income. Please refer ns necessnry to S I 0 l'v1AGI-Based Income Methodologies. completed by the state. [!] There is no resource test fix 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 benetits under Medicaid. CHIP or through the Exchange. or otherwise enrolled in minimum essential coverage, as detlned in 42 CFR 435.4. (' Under age 19, or (e' A higher age of children, if any, covered under 42 CFR 435 .222 on March 23. 20 I 0: (Under age 20 (e' 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 Pregnnnt Women (42 CFR 435.116) and/or Infants and Children under Age 19 ( 42 CFR 435.118) eligibility groups when determined presumptively eligible. ( Yes (e' No TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page I of2

Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Otlicer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: DC-13-07-MM Approved: 1110112013 Effective: 0110112014 Page 2 of2

Medicaid Eligibility OMB Control Number0938-1148 r.=-::7":":::;-:;::;"'"-;-:;::""'"-:;:-:-'C:--=--::-:--:;:;TC:---::r;--::-7-,-~:----:--:---c---:c::---:::-:-:-:-:---,-...,.,.------:-------=O:....I\_ ·t..::.B-=Ex pi ration date: I 0/3 I /20 14 EU~~Mlity Gr~ups ::·Options for Coverage. 'sso Indivi~nals abov~ 133-% FPL , ' 1902(a)( I 0)( A)( ii)(XX) 1902(hh) 42 CFR 435.218 lndi\'iduals above 133% FPL- The state elects to cover individuals under 65. not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. (' Yes {e 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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page I of I

Medicaid Eligibility OMB Control Number 0938-1148 01\.'IB Expiration date· I Oi31 F'O 14 - El~gilliflt)r· Gro~ps - OR'lioiis~for Coverage . . ,. '. ,. S51 O~tion~J'i~9vefage'.of. l:"arent~; Q~d Other Caretaket·Relatives - f). ,;t.H~ i- ; • :1; :.- 42 CFR 435.220 1902(a)( 1 O)(A )( ii)( I) Optional Coverage of Parents and Othe•· Caretaker Relatives- The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. (' Yes (e' No PRA Disclosure Statement According to the Papervvork 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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page I of I

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: I Oi31 12014 Eligibility Groups - Options for Coverage Rea$onable Classification of Individuals· under Age 21 42 CFR 435.222 1902(a)( I 0)( A )(ii)( I) 1902(a)( 1 0)( A )(ii )(IV) S52 Reasonable Classification of Individuals under Age 21 - ·rhe state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at42 CFR 435.222. le Yes (' No [{]The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must quality under a reasonable classification by meeting the following criteria: ~ Be under age 21. or a lower age, as defined within the reasonable classif-ication. ~ Have household income at or below the standard established by the state, if the state has an income standard for the • reasonable classification. ~Not be eligible and enrolled for mandatory coverage under the state plan. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 MAGI- Based Income Methodologies, completed by the stnte. The state covered at least one reasonable classification under this eligibility group under its [V1edicaid state plan as of December 31, 2013, or under a Medicaid 111.5 Demonstration as of March 23. 20 I 0 or December 31. 201 3. with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. (e Yes (' No The state also covered at least one reasonab le classification under this group in the Medicaid state plan as of l'v1arch 23. 20 I 0 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. \- Yes (' No Reasonable Classifications Covered in the Medicaid State Plan as of March -~ 20 I 0 [{] The state attaches the approved pages from the \-1edicaid state plan as of March 23, 20 I 0 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group. I r ---------------A-.-1·-a-tt_a_c_h_ln_e_n_t-is __ s_u_b_n_Ji-tt_e_d·- . --·------------~, TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page I of 4

Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 20 I 0. provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit andior income standard used must be no higher than any age limit and/or income standard covered in the 1vtedicaid state plan as of December 31. 2013 or under a Medicaid 1115 Demonstration as of 1v1arch 23. 20 I 0 or December 31. 2013. Higher income standards may include the disregard ofall income. (.' Yes Indicate below the age under which all children are covered under this eligibility group. based on a specific age group used previously in the 1v1edicaicl state plan or under a Demonstration, which is equal to or higher than the age group for coverage of all children in the Medicaid state plan as of March 23, 20 I 0. (.' Under age 21 (' Under age 20 (' Under age 19 (' Under age 18 Enter the income standard used for this age group. The standard must be higher than the mandatory income standard for the individual's age, not more restrictive than that used in the Medicaid state plan as of March 23, 20 I 0 and not less restrictive than that used in the Medicaid state plan as of December 31. 2013 or under a Medicaid 1115 Demonstration as of March 23, 20 I 0 or December 3 1, 2013. ~ Income standard used ~ 1\:1 in imum 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 inS 14 AFDC Income Standards. ~ Maximum income standard No income test was used (all income was disregarded) for this classification either in the Medicaid statt: plan as of December 31. 2013. or under a Medicaid 1115 Demonstration as of March 23. 20 I 0 or December 3 I, 20 IJ. (' Yes (.' No TN: C-13-07-MM The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the lZJ maximum income standard to be used for this classification of children under this eligibility group. An attncbment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classilication) is: The state's effective income level for this classitication of children under the l'vledicaid state plan (.' as of March 23, 20 I 0, converted to a MAG !-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state rlan (' as of December 31. 2013. converted to a MAGI-equivalent rercent of FPL or amounts by household size. Approved: 11/01/2013 Effective: 01/01/2014 Page 2 of 4

~....!!!. Medicaid Eligibility (' Yes r.' No [!] 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. tist ~f;Quali~~d En,tities : ,;• .. $17 TN: DC-13-07-MM 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: O Furnishes health care items or services covered under the state's approved fV1edicaid state plan and is eligible to receive payments under the plan O 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 f()f which financial 0 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 0 Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act ofl966 O 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) O Is an elementary or secondary school. as defined in section 1410 I of the Elementary and Secondary Education Act of 1965 (20 l.I.S.C. 880 I) 0 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs 0 Is a state or Tribal child support enforcement agency under title IV-D of the Act O 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 otlice or entity involved in enrollment in the program under Medicaid, CHIP. or title IV-A of the Act ls an organization that determines eligibility for any assistance or benefits provided under any program O of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 ( 42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 410 I et seq.) O 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: Approved: 11/01/2013 Effective: 01/01/2014 Page 3 of 4

Me.dicaid Eligibility Name of entity Description A qualified hospital is a hospital that: Pm1icipates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration. notities the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. + Any qualified hospital Has not been disqualified by the Medicaid agency X 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. The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, !2J and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included. I An attachment is submitted. l PRA Disclosure Statement According to the Papervvork 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 tor 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. I fyou have comments concerning the accuracy of the time estimate(s) or suggestions tor improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Repot1s Clearance Officer. Mail Stop C4-26-05. Baltimore. Maryland 21244-1850. TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page 4 of 4

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: I Oi31 /20 14 ~itgi~q~~ ~~p,~ps -(;lption~ for C~verag~,r CltUdten·~i~~ ,:Npn IY-E Adoption Assist~nce 42 CFR 435.227 1902(a)( I 0)( 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 0 The state attests that it operates this eligibility group ii1 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 S I 0 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, 20 I 0 or December 31, 2013. r. Yes (' No The state also covered this eligibility group in the Medicaid state plan as of March 23. 20 I 0. (.' Yes (' No S53 ~ 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, 20 I 0 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 20 I 0 or December 31. 2013. r. 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 conve11ed to MAGI-equivalent. This standard is described in S 14 AFDC Income Standards. ~ [VIaximum income standard TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01101/2014 Pae.e I of2

Medicaid Eligibility No income test was used (all income was disregarded) for this eligibility group either in the rvtedicaid state plan as of March 23, 20 I 0 or December 31, 2013, or under a rvtedicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. (. Yes (' No [!] No income test was used (all income was disregarded) for this eligibility group under (check all that apply): D The Medicaid state plan as of March 23. 20 I 0. ~ The l'vledicaid state plan as of December 31.2013. D A Medicaid 1115 Demonstration as of March 23, 20 I 0. D A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). [!] Income standard chosen Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age: (' The minimum standard. (. This eligibility group does not use an income test (all income is disregarded). (' Another income standard higher than both the minimum income standard and the effective income level for this eligibility group in the state plan as of March 23.2010. converted to a IVIAGI-equivalent. [!] There is no resource test for this eligibility group. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1 148. 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. I fyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please wri't:e to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore. Maryland 21244-1850. TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page 2 of 2

1902(a)( I O)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u}(2)(8) Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: I Oi31/20 14 854 Optional Targeted Low Income Children- The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4. who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. (' Yes (e' 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 infom1ation 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. I fyou 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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page I of I

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31 /2014 ~~~~~~--~~--~--~----------~------------------~------~-- Eiifti~iJ,~~~Jtiiij(J$ ·- ~pijon$ Jor Coverage lqdi~I~lJ.!ds ·lri.t.ll Tu.lf.erculosis . · .. 1902(a)( I O)(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 (e' 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 tor 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 acc~racy of the time estimate(s) or suggestions tor 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: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page 1 of 1

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10i31 /2014 Eligibility Groups - Options for Coverage l~deperident Foster C~re Adolesc.ents ' 42 CFR 435.226 1902(a)( I O)(A )(ii)(XV II) 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 Joster 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 [Z] The state attests that it operates this eligibility group iu accordance with the following provisions: ~ Individuals qualitying 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 bi1thday. ~ 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. 857 ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S I 0 1\:IAGI- 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, 20 I 0 or December 31, 2013. (.' Yes (' No The state also covered this eligibility group in the Medicaid state plan as of March 23, 20 I 0. (' Yes (.' No The state covers children under this eligibility group. as follows (selection may not be more liberal than the ~ most liberal coverage in the state plan as of December 31. 2013, or under a Medicaid 1115 Demonstration as of March 23, 20 I 0 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 conve1ted to MAGI-equivalent. This standard is described in Sl4 AFDC Income Standards. ~ Maximum income standard Page I of2

Medicaid Eligibility No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of December 3 I. 20 I 3. or under a Medicaid 1115 Demonstrationas of 1\1arch 23. 2010 . (e Yes (' No The state's maximum standard for this eligibility group is no income test (all income is disregarded). ~ I nco me standard chosen Individuals qualify under this eligibility group under the following income standard: (' The minimum standard. (e This eligibility group does not use an income test tall income is disregarded). (' Another income standard higher than the minimum income standard. ~ There is no resource test for this eligibility group. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- I I 48. 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 Repm1s Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- I 850. TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 ... Page 2 of2

Medicaid Eligibility OMB Control Number 0938-1148 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~O~N~t ~B Expiration date: .I0/31 /2014 Eligibility Groups - Options for Coverage ~In_d~_i_v_W_u_~~~~_E_ · I~ig~i_b_le_{l_o_r_F_~_m_i~iy~P_Ia_n_n_m~g~Se_rv __ ic_e_s ____________________ ~'------·~~ - · _· _______ .''~ "''_ · __ 85 _9~ 1902(a)( 1 0)( A}( ii)(XXl) 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 lim ited to family planning and related services and in accordance with provisions described at 42 CFR 435 .2 14. (' Yes (.' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons <Jre 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 0938-11 48. 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 <Jnd 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 Secmity Boulevard, Ann: PRA Reports C:lc<Jrance Oflicer. Mail Stop C:4-26-05, Baltimore, Maryland 21244-1850. TN: DC-13-07-MM Approved: 11/01/2013 Effective: 01/01/2014 Page 1 of 1

Table of Contents State Name: D.C. State Plan Amendment (SPA) #13-09MM This file contains the following documents in the order listed: 1) Approval Letter 2) CMS-179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 ~··~-· "- f CMS CENTERS FOR MEDICARE & MEDICAID SERVICES Region III/Division of Medicaid and Children's Health Operations SWIFT #102520134019 NOV 2 0 2013 Dr. Linda Elam, Ph.D., MPH Deputy Director/Medicaid and CHIP Department of Health Care Finance 899 North Capitol Street, N.E.- Suite 6037 Washington, D.C. 20002 Dear Dr. Elam: The Centers for Medicare & Medicaid Services (CMS) has completed its review of the District of Columbia's State Plan Amendment (SPA) 13-09MM. SPA13-09MM identifies the non- finanCial eligibility requirements for both citizens and non-citizens and incorporates them into the District of Columbia's State Plan in accordance with the Affordable Care Act. The effective date ofthis SPA is January I, 2014. As the District elected not to amend its state plan pages for this SPA, the District should incorporate the attached S89 form and the superseded pages into their approved State Plan. Notwithstanding any other provisions of the District of Columbia State Plan, the financial eligibility methodologies described in SPA 13-09MM apply to all MAGI -based eligibility groups covered under the District of Columbia's State Plan. The MAGI financial methodologies set forth in 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups. If you have any further questions regarding this SPA, please contact Sabrina Tillman-Boyd at 215-861-4721 or by email at Sabrina.Tillman-Boyd(Q{cms.hhs.gov. Enclosures cc: Claudia Schlosberg, DHCF M. Diane Fields, DHCF (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

DC.0223.ROO.OO- Jan 01, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Statefferritory name: Dist. of Columbia Transmittal Number: Page 1 of 1 Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits of the submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. 13-09 Prop~~~~- ~-~~~-~~~ye .J?.~te 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulati~n Ci~ation Patient Protection and Affordable Care Act of2010, approved March 23,2010 (Pub. L. No. 111-148, 124 Stat I Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 20 15 Subject of Amendment $0.00 $0.00 Amount S89: Non-Financial Eligibility Citizenship and Non-Citizen Eligibility Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal '\? Other, as specified Describe: 820-199, Budget Support Act of2013 Signature of State Agency Official Submitted By: Diane Fields Last Revision Date: Oct 31,2013 Submit Date: Aug 23,2013 file:///G:/DMCH/Medicaid/DC/SPAs/DC%20SPA%2013-09-MM/DC 0223 ROO 00%2... 11/20/2013 - - (b) (1) (A), (b) (b) (1) (A), (b) /S/

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-09 MM District of Columbia PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility Attachment 2.6-A: Page 2a, TN 09-08 Attachment 2.6-A: Page 2b, TN 09-08

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10i31/2014 ~9,n'!:Fim}p~ial EligibUity Gltizenship-and' N on"'Citizen Eligibility 1902(a)(46)(8) 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 ' . jss9 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 veriiication 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 veri tication 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. r. Yes ("No The date benefits are furnished is: (" The date of application containing the declaration of citizenship or immigration status. ("The date the reasonable opportunity notice is sent. (.'Other date, as described: First day of' the month of application containing the declaration of citizenship or immigration status. Page I of 3

Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 ofPRWORA (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 IZJ Pregnant women IZJ 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: I. 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. I I 0 I (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 LJ.S.C. 1182(d)(5) tor less than 1 year. except for an individual paroled for prosecution. for deterred 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 LJ.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 30 I of Pub. L. I 01-649. as amended; ~ Under Deferred Enforced Departure (OED) 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. I 158, or tor withholding of removal under 8 U.S.C.I231 , or under the Convention Against Torture who- ~ Has been granted employment authorization; or TN: D~ 31-s!IJ.MMr the age of 14 and has had an atJI:P~i® 1JI.llb~ for at least 180 days; Effective: 01/01/2014 Page 2 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. Exc~Qlion: 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 (I) through (9) of this definition. D Other The state assures that it provides limited Medicaid services tor treatment of an emergency medical condition, not related to an organ transplant procedure. as defined in 1903(v)(3) ofthe SSA and implemented at 42 CFR 440.255. to the following 0 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)t 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 Ol'viB control number. The valid OMH 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 tor 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: DC-13-09-MM Approved: 11/18/2013 Effective: 01/01/2014 Page 3 of 3

Table of Contents State/Territory Name: District of Columbia State Plan Amendment (SPA)#: 13-00llMM This file contains the following documents in the order listed: 1.) Approval Letter 2.) Summary Form (CMS 179) 3.) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CMS CENTERS fOR MEDICARE & MEDICAID SERVICES Region III/Division of Medicaid and Children's Health Operations SWIIT #112520134006 NOV 2 6 2013 Dr. Linda Elam, Ph.D., MPH Deputy Director/Medicaid and CHIP Department of Health Care Finance 899 North Capitol Street, N.E. -Suite 6037 Washington, D.C. 20002 Dear Dr. Elam: I am writing to inform you that we have reviewed the District of Columbia's State Plan Amendment (SPA) 13-00llMM entitled, S33: Eligibility Groups- Mandatory Coverage: Former Foster Care Children. This amendment sets forth the eligibility requirements for former foster children under the age of 26 years in accordance with the Affordable Care Act. We are pleased to inform you that, after extensive review, this amendment is approved; its effective date is January 1, 2014. A copy of the approved SPA pages and signed CMS-179 form is included under this cover. If you have any further questions regarding this SPA, please contact Sabrina Tillman-Boyd at 215-861-4721 or by email at Sabrina.Tillman-Boyd@cms.hhs.gov. Enclosures cc: Claudia Schlosberg, DHCF M. Diane Fields, DHCF S,inc.e.I:.e l Y.r /S/ •r cis C~h ocmte Regional ~1mstrator

DC.0473.ROO.OO- Jan 01, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) State/T errito.-y name: Dist. of Columbia Transmittal Number: Page 1 of 1 Please enter the Transmittal Number (TN) in the format ST-YY -0000 where ST"" the state abbreviation, YY = the last two digits of the submission year, and 0000"" a four digit number with leading zeros. The dashes must also be entered. DC-13-0011 Propos_~ ~.!!:~!!~_!_>a~~ 01/01/2014 (mm/ dd/ yyyy ) Federal ~tatute/Regulation Citation 42 CFR 435.150; 1902(a)(lO)(A)(i)(IX) Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment $685000.00 $ 1100000.00 Eligibility Groups- Mandatory Coverage Former Foster Care Children · Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: Amount No reply received within 45 days of submittal '"· Other, as specified Describe: 820-199, Budget Support Act of20 13 Signature of State Agency Official Submitted By: Diane Fields Last Revision Date: Nov 4, 2013 Submit Date: Nov 4, 2013 IS/

Medicaid Eligibility Eligibility Groups · Mandatory Cove~e Former Foster Care Children 42 CFR 435.150 1902(a)(10)(A)(i)(IX) .. OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 js33 ~ 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. 0 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~ state at the time they turned 18 or aged out of the foster care system. (e' 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. (e' No PRA Disclosure Statement According to the Papenvork 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. Transmittal Number: 13-0011 MM Approval Date: 11/22/2013 Effective Date: 01/01/2014 Page 1 of 1

Table of Contents State/Territory Name: District of Columbia State Plan Amendment (SPA)#: 13-0013MM This file contains the following documents in the order listed: 1.) Approval letter 2.) Summary Form (CMS 179) 3.) Superseding Pages Notice 4.) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEDICAID SERVICES Region lli/Division of Medicaid and Children's Health Operations SWIFT #111820134013 NOV 18 2013 Dr. Linda Elam, Ph.D., MPH Deputy Director/Medicaid and CHIP Department ofHealth Care Finance 899 North Capitol Street, N.E. - Suite 6037 Washington, D.C. 20002 Dear Dr. E1am: Enclosed for your records is an approved copy of the following District of Columbia State Plan Amendment (SPA) 13-0013MM. SPA 13-0013MM incorporates the MAGI Based Income Methodologies into the District of Columbia's State Plan in accordance with the Affordable Care Act. • Transmittal #13-0013MM- MAGI-Based Eligibility Groups (Effective January, 1, 2014) Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back ofthe District of Columbia's approved State Plan. Notwithstanding any other provisions of the District of Columbia State Plan, the financial eligibility methodologies described in SPA 13-0013MM apply to all MAGI-based eligibility groups covered under the District of Columbia's State Plan. The MAGI financial methodologies set forth in 42 CFR §435.603U) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect t the MAGI-based eligibility groups. If you have any further questions regarding this SPA, please contact Sabrina Tillman-Boyd at 215-861-4721 or by email at Sabrina.Tillman-Boyd@cms.hhs.gov. Enclosures cc: Claudia Schlosberg, DHCF M. Diane Fields, DHCF Sincerely, (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

DC.0353.RCO.OO- Jan 01, 2014 Page 1 of2 Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Dist. of Columbia Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits of the submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. -- -··---- DC-13-0013 Prop~~-~~-~!!~~!!~~ D!!t~ 01/01/2014 (mm/ dd/ yyyy) Federal S!~-l!~~~egu!!l!ion Citation 42 CFR Section 435.603 Federal Budget lm pact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment $869652.00 $ 1609070.00 MAGI-Based Income Methodologies (S 1 0) Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal (~, Other, as specified Describe: 820-199, Budget Support Act of2013 Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Diane Fields Sep 23,2013 Sep 23,2013 Amount ;b~~/Ol.i[~~ (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: DC 13-0013 District of Columbia PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): Notwithstanding any other provisions of the District of Columbia's Medicaid State Plan, the financial eligibility S I 0 - MAGI Income Methodology methodologies described in State Plan Amendment DC 13-13 will apply to all MAGI-based eligibility groups covered under the District of Columbia's Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.6030) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Medicaid Eligibility 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: 0 The pregnant woman is counted just as herself. ('The pregnant woman is counted as herself, plus one. (e•The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: ~Current monthly household income and family size C Projected annual household income 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: [gl Include a prorated portion of a reasonably predictable increase in future income and/or family size. lXI 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 (e No TN: DC 13-0013MM Approval Date: 10/04/2013 Effective Date: 01/01/2014 Page 1 of 2

Medicaid Eligibility ~ The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: (e,Age 19 0 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: DC 13-0013MM Approval Date: 10/04/2013 Effective Date: 01/01/2014 Page 2of2

Table of Contents State/Territory Name: District of Columbia State Plan Amendment (SPA)#: 13-00lSMM This file contains the following documents in the order listed: 1.) Approval letter 2.) Summary Form (CMS 179) 3.) Superseding Pages Notice 4.) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEDICAID SERVICES Region III/Division of Medicaid and Children's Health Operations SWIFf #102520134024 NOV 19 2013 Dr. Linda Elam, Ph.D., MPH Deputy Director/Medicaid and CHIP Department of Health Care Finance 899 North Capitol Street, N.E. -Suite 6037 Washington, D. C. 20002 Dear Dr. Elam: Enclosed is an approved copy of the District of Columbia State Plan Amendment (SPA) 13-0015MM, which was submitted to CMS on August 29,2013. SPA 13-0015MM incorporates the MAGI-based residency requirements into the District of Columbia's Medicaid State Plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014. Enclosed is a copy of the new State Plan pages, the Summary Page (CMS-179), and an attachment to be incorporated within a separate section at the end of District of Columbia's approved State Plan: • S88 (Residency) If you have any further questions regarding this SPA, please contact Sabrina Tillman-Boyd at 215-861-4721 or by email at Sabrina.Tillman-Boyd@cms.hhs.gov. Enclosures cc: Claudia Schlosberg, DHCF M. Diane Fields, DHCF (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

DC.0260.ROO.OO- Jan 01, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Dist. of Columbia Transmittal Number: Page 1 of2 Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits of the submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. DC-13-0015 Proposed Effective Date 01/01/2014 (mm / dd/ yyyy) Federal Statute/Regulation Citation 42 C.F.R § 435.403 Federal Budget Impact Federal Fiscal Year Amount -----··---- First Year 2014 $0.00 Second Year 2015 $0.00 Subject of Amendment Non-Financial Eligibility State Residency (S88) Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: ,-------···-----·-------------- ------·-----·-··-·-------·----------:j ! L_. __ . -----------------------------------------·---·--····-··--·--·--· No reply received within 45 days of submittal @ Other, as specified Describe: 820-199, Budget Support Act of2013 Signature of State Agency Official Submitted By: Diane Fields Last Revision Date: Nov 12,2013 Submit Date: Aug 29,2013 file:///C:/Users/Gcc7/AppData!Local/Microsoft/Windows/Temp ... 11/21/2013 (b) (1) (b) (1) (A), (b) (b) (1) (A), (b) /S/

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0015 MM District of Columbia PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): S88 Non-Financial Eligibility- State Residency Attachment 2.6-A: Page 3, TN 09-08

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Non-Financial Eligibility State Residency 42 CFR 435.403 State Residency ,., ~,,~j . ·.- " . .. " ?!' [Z] 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: \sss ~ 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 slate 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 Transmittal Number: 13-0015 Approval Date: 11/19/2013 Effective Date: 01/01/2014 Page 1 of 4

Medicaid Eligibility [!] Otherwise meet the requirements of 42 CFR 435.403. Transmittal Number: 13-0015 Approval Date: 11/19/2013 Effective Date: 01/01/2014 Page 2 of 4

Medicaid Eligibility Meet the criteria specified in an interstate agreement. r. Yes ('No ~ The state has interstate agreements with the following selected states: ~ Alabama ~ Illinois ~ Montana ~ Rhode Island ~ Alaska ~ Indiana ~ Nebraska ~ South Carolina ~ Arizona jgl Iowa jgl Nevada jgl South Dakota ~ Arkansas ~ Kansas ~ New Hampshire jgl Tennessee jgl California jgl Kentucky ~ New Jersey jgl Texas ~ Colorado rzl Louisiana rzl New Mexico ~ Utah ~ Connecticut ~ Maine D New York ~ Vermont jgl Delaware IZl Maryland rzl North Carolina jgl Virginia jgl District of Columbia jgl Massachusetts ~ North Dakota jgl Washington ~ Florida jgl Michigan IZl Ohio IZl West Virginia jgl Georgia jgl Minnesota jgl Oklahoma ~ Wisconsin IZl Hawaii jgl Mississippi IZl Oregon D Wyoming ~ Idaho jgl Missouri jgl Pennsylvania ~ The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): jgl Are IV -E eligible 0 Are in the state only for the purpose of attending school 0 Are out of the state only for the purpose of attending school 0 Retain addresses in both states 0 Other type of individual The slate has a policy related to individuals in the state only to attend school. (' Yes le' No ~ Otherwise meet the criteria of resident, but who may be temporarily absent from the state. The state has a definition of temporary absence, including treatment of individuals who attend school in another state. (' Yes r. No PRA Disclosure Statement Transmittal Number: 13-0015 Approval Date: 11/19/2013 Effective Date: 01/01/2014 Page 3 of 4

Medicaid Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The t.ime required to complete this infom1ation 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. Transmittal Number: 13-0015 Approval Date: 11/19/2013 Effective Date: 01/01/2014 Page 4 of 4

Table of Contents State Name: Washington, D.C. State Plan Amendment (SPA) #: 14-0001MM This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

/s/

DC.0820.R00.00 - Jan 01, 2014

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory

name:

Dist. of Columbia

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

DC-14-0001

Proposed Effective Date

01/01/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation [42 CFR 435.1110

Federal Budget Impact Federal Fiscal Year Amount

First Year | 2014 $] 6300000.00 $] 9600000.00

Second Year

Subject of Amendment

Presumptive eligibility determinations by hospitals.

Governor's Office Review O Governor's office reported no comment

© Comments of Governor's office received Describe:

O No reply received within 45 days of submittal © Other, as specified Describe:

B20-199

Signature of State Agency Official Submitted By: Diane Fields Last Revision Date: May 14, 2014 Submit Date: Mar 21, 2014

file:///G\/...dicaid/DC/SPAs/2014%20SPAs/DC%20SPA%2014-0001-MM%20Hospital%20PE/DC%20SPA%2014-0001MM%20179.htm[05/22/2014 10:20:10 AM]

CCMs Medicaid Eligibility

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

Presumptive Eligibility by Hospitals $21

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: [m@) 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

[Mi] 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

[i] 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 CNo

[®] The eligibility groups or populations for which hospitals determine eligibility presumptively are:

[fm] Pregnant Women

{m) Infants and Children under Age 19

[mi] Parents and Other Caretaker Relatives

[i] Adult Group, if covered by the state

[Mi] Individuals above 133% FPL under Age 65, if covered by the state

[m] Individuals Eligible for Family Planning Services, if covered by the state

(@] Former Foster Care Children

[i] Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state

[-] Other Family/Adult groups:

(J Eligibility groups for individuals age 65 and over

[] Eligibility groups for individuals who are blind

(J Eligibility groups for individuals with disabilities

[[] Other Medicaid state plan eligibility groups

X] Demonstration populations covered under section 1115

Describe: {Under presumptive eligibility by hospitals, the District will cover childless adults up to 216% FPL.

TN: DC 14-0001MM Approved: 05/19/2014 Effective: 01/01/2014 7 Page | of 3

The state establishes standards for qualified hospitals making presumptive eligibility determinations.

Ss Medicaid Eligibility

@Yes CNo Select one or both:

& The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period.

The District has established the following standards: DeSean Ustaaatds 90% of presumptively eligible determinations must results in the submission of a full Medicaid application no later than 5 days from the date of the visit or prior to discharge, which ever is later.

The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the — submission of an application before the end of the presumptive eligibility period.

The District has established the following standards:

Des-riptionior standards 85% of individuals determined eligible under hospital based presumptive eligibility are

determined eligible under full Medicaid.

[m] The presumptive period begins on the date the determination is made. {m] 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.

[i] Periods of presumptive eligibility are limited as follows: C 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.

C Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes C No

C 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.

TN: DC 14-0001IMM Approved: 05/19/2014 Effective: 01/01/2014 Page 2 of 3

Medicaid Eligibility

COREE TOM METIRORAR A AMON ICT

[Mi] 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 [ii] 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)

im 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.

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: DC 14-0001MM Approved: 05/19/2014 Effective: 01/01/2014 a Page 3 of 3

HEALTH

LINK

Get the facts. Get covered.

Application for Presumptive Eligibility Medicaid

Use this form to find out if you qualify for presumptive eligibility Medicaid in the District of Columbia. If you meet the eligibility requirements for Medicaid, presumptive eligibility offers you and your family immediate access to health care while you apply for regular Medicaid or other health

coverage.

To find out if you qualify for full Medicaid or other health coverage, you must complete the DC Health Link application. Go online to DCHealthLink.com, call DC Health Link Customer Service toll-free at (855) 532-5465/TTY (855) 532-5465, go to any ESA Service Center (call DC Health Link Customer Service for the nearest service center), or fax a completed DC Health Link application to (202) 671-4400.

While you wait to learn if you qualify for full Medicaid or other health coverage, you can get your health services through presumptive eligibility for Medicaid.

Who can qualify for presumptive eligibility for Medicaid?

Need help with your application?

TN: DC 14-0001IMM

You can qualify for presumptive eligibility Medicaid if you meet all of these rules:

= Your income is below the monthly Medicaid limit

= You area U.S. citizen, U.S. national, or have eligible immigrant status

= You do not already have Medicaid

= You have not had presumptive eligibility Medicaid in the District of Columbia within the past two (2) years. Or, if you are pregnant, you have not had presumptive eligibility Medicaid during this pregnancy.

= You are in one of the groups that qualifies for presumptive eligibility Medicaid:

Children under age 21

Parents and caretaker relatives

Pregnant women

Adults without dependent children age 21-64

People under age 26 who were in foster care at age 18 (no income limit)

Women under age 64 in treatment for breast and cervical cancer (no income limit)

Ask your hospital representative or call DC Health Link at 1 (855) 532-5465. Para obtener una copia de este formulario en Espafol, llame 1 (855) 532-

5465.

If you need help in a language other than English, call 1 (855) 532-

5465 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1(855) 532-

5465.

Approved: 05/19/2014 Effective: 01/01/2014

Name (first, middle, last)

Home address (Check here if you are homeless CJ )

City State ZIP code

Mailing address (if different from home address)

Phone number (if you have one) Email address (if you have one)

Social Security Number (optional) Check here if you do not have or do not know your Social Security Number CI

Tell us about your family

2 List yourself and the members of your immediate family who live with you. Include your spouse and the children under age 19 whom you care for. If you are under 19, include yourself, your parents, and siblings if they live with you. Do not list other relatives or friends even if they live with you.

Name Date of Relationship | Applying for Already has | U.S. Citizen, U.S. National, or] Resident of the

(first, middle, last) birth to you presumptive Medicaid? | have eligible immigrant District of (XX/XX/ eligibility for (YesorNo) | status? (Yes only) Columbia? XXXX) Medicaid? (Yes or No)

If the answer is No, leave

(Wesior'No) this section blank)

Answer for family members who are applying. If a person is not applying, you do not have to answer these questions for that person.

(Same as above) (Self)

Questions? Ask your hospital representative, Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener

una copia de este formulario en Espafiol, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532- 2

5465 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call TN: Dfj44-0001MM Approved: 05/19/2014 Effective: 01/01/2014

Other questions

Answer these questions for yourself and your family members listed in Section 2. Your answers will make it easier to find out if you and any family members qualify for presumptive eligibility Medicaid.

ls anyone pregnant, even if she is not applying for presumptive eligibility Medicaid? O Yes O1No

If yes, who? (first, middle, last) How many babies does she expect?.

Is anyone who is applying for presumptive eligibility Medicaid a parent or caretaker relative of a child under age 19?) Yes 11 No For example, a grandparent whois the mainperson taking care of achild.

If yes, who? (first, middle, last)

Was anyone who is applying for presumptive eligibility Medicaid in D.C. foster care and enrolled in O Yes O1No D.C. Medicaid at age 18 or older?

If yes, who? (first, middle, last)

ls anyone who is applying for presumptive eligibility Medicaid being treated for O Yes No breast or cervical cancer? If yes, who? (first, middle, last)

4 Tell us about your family’s income

Write the total income before taxes are taken out for all family members listed in Section 2.

v Countable Income includes:

e Wages, salaries, tips, and other earnings from a job e Credits or offsets of state and local income taxes e Income from a business or self-employment (may subtract e Capital gains, IRA distributions certain business related expenses) e Pensions and annuities Unemployment benefits e Income from real estate rentals or royalties, such a Farming or fishing income (may subtract certain business copyright or patent related expenses) e Income from partnerships, S corporations, trusts e Taxable investment income, such as taxable interest, e Foreign earned income for Americans living abroad

dividends, and taxable refunds

Write in the total monthly household income received from the sources listed above for all family Amount $ members listed in section 2.

Tell us about your current insurance information

Are you or any of your family members listed in | If yes, who? (first, middle, last) section 2 currently enrolled in health insurance?

Yes [| No [|

Sign this form here

By signing, you are swearing that everything you wrote on this form is true as far as you know. We will keep your information secure and private.

What is the name of the health insurance?

Policy Number

oe eee mocsecaes ero ATR

Your signature: Date:

Questions? Ask your hospital representative, Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener una copia de este formulario en Espajiol, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532- 5465 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call TN: D§4414-0001MM Approved: 05/19/2014 Effective: 01/01/2014

The Presumptive Eligibility Determination FOR CERTIFIED APPLICATION COUNSELOR USE ONLY

Identify and Circle which of the 4 below groups matches the information from the patient’s Application

GROUP Pregnant Child under Individuals Parents and Other Childless Adults (age 19-64) Women Age 19 Age 19-20 Caretaker Relatives STANDARD 324% FPL 324% FPL 221% 221% FPL 215% FPL

Applicant’s Standard FPL (from above chart)

Applicant’s Household Size (from Section 2 of application)

Standard Household Size =1 Household Size = 2 Household Size = 3 Household Size = 4 FPL Standard Income Standard Income Standard Income Standard Income For Larger 215% $2,091 $2,818 $3,546 $4,273 een 221% $2,149 $2,897 S$ 3,645 $4,392 Refer to Provider 324% $3,151 $4,247 $5,343 $ 6,440 Handbook INCOME ELIGIBILITY DETERMINATION 1. Applicant STANDARD INCOME (Income limit from above chart) $ 2. Applicant MONTHLY HOUSEHOLD INCOME (Section 4 of this application) $ ls STANDARD INCOME more than MONTHLY HOUSEHOLD INCOME? yes [] no [] If YES, individual is eligible for presumptive eligibility based on the circled category above. If NO, individual is not eligible for presumptive eligibility based on income FORMER FOSTER CARE CHILD ELIGIBILTY DETERMINATION 3. Applicant is AGE 18-25 YES [] NO 4. Applicant was a ward of the D.C. foster care system at age 18 or older yes [] no (] 5. Applicant was enrolled in D.C. Medicaid at age 18 or at the time of aging out of foster care? YES [_] NO O All answers must be YES for individual to be eligible for presumptive eligibility based on former foster care status. If any answer is NO, individual is not eligible for presumptive eligibility based on former foster care status. BREAST CERVICAL CANCER ELIGIBILTY DETERMINATION (Breast and Cervical Cancer Early Detection Program - BCCEDP) 6. Applicant has been screened for breast or cervical cancer by a BCCEDP? YES O NO O 7. Applicant is under AGE 65? YES {] no oO

All answers must be YES for individual to be eligible for presumptive eligibility based on breast and cervical cancer treatment. If any answer is NO, individual is not eligible for presumptive eligibility based on breast and cervical cancer treatment.

APPLICANT ATTESTED TO DISTRICT RESIDENCY Yes [] No APPLICANT ATTESTED TO CITIZENSHIP OR ELIGIBLE IMMIGRATION STATUS YES oO NO ie] DETERMINATION

ELIGIBLE [_] INELIGIBLE [_] Reason:

You MUST provide the applicant with the appropriate letter of eligibility or ineligibility for Presumptive Eligibility Medicaid CAC Signature CAC Printed Name

QUALIFIED HOSPITAL NAME/ADDRESS IDATE

(CAC EMAIL ADDRESS

Questions © Ask your hospital representative, Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener una copia de este formulario en Espafiol, lame 1-855-532-5465. If you need help in a language other than English, call 1-855-532- 5465 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call TN: Df{14-0001MM Approved: 05/19/2014 Effective: 01/01/2014

4

If you qualify for presumptive eligibility Medicaid, what happens next?

= You can start using your presumptive eligibility for Medicaid coverage right away for services such as doctor visits, hospital care, and prescription drugs. You can go to any health care provider who accepts Medicaid, starting the day you are approved.

+ To start using your presumptive eligibility for Medicaid, the hospital will give you a letter with your Medicaid number on it saying you are approved. Use the letter to get services until you get a card in the mail. The Medicaid card should arrive within

5 business days. If you lose the letter, you can call DC Health Link Customer Service at 1-855-532-5465 to obtain your Medicaid number.

+ If the letter says you qualify for presumptive eligibility for Medicaid because you are pregnant, you can get care at outpatient clinics or other places in the community. For pregnant women, presumptive eligibility for Medicaid will not cover the cost if you are admitted to a hospital.

= If you do not fill out and send the DC Health Link application to see if you qualify for full Medicaid or other health

coverage, your presumptive eligibility for Medicaid coverage will end on the last day of the month after the month you are approved.

For example, if you qualified for presumptive eligibility for Medicaid in January, it will end on the last day of February.

= To see if you qualify for full Medicaid or other health coverage, you must complete the DC Health Link application. Go online to DCHealthLink.com, call DC Health Link Customer Service toll-free at (855) 532-5465/TTY (855) 532- 5465, go to any ESA Service Center (call DC Health Link Customer Service for the nearest service center), or fax a completed DC Health Link application to (202) 671-4400.

The hospital will give you an application and assist you with completing it.

If you do not qualify for presumptive eligibility Medicaid, what happens next?

You will get a letter from the hospital saying you were not approved. You cannot appeal the hospital’s decision. BUT, you can still apply for full Medicaid or other health coverage using the DC Health Link application.

Go online to DCHealthLink.com, call DC Health Link Customer Service toll-free at (855) 532-5465/TTY (855) 532- 5465, go to any ESA Service Center (call DC Health Link Customer Service for the nearest service center), or fax a completed DC Health Link application to (202) 671-4400.

© Questions? Ask your hospital representative, Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener una copia de este formulario en Espaiiol, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532- 5 5465 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call TN: D444-0001MM Approved: 05/19/2014 Effective: 01/01/2014

For all applicants, these are eligible immigration statuses:

If the person is an individual under the age of 21 or a pregnant woman, these are additional eligible immigration statuses:

Lawful Permanent Resident (LPR, or "Green card" holder)

Asylee

Refugee

Cuban or Haitian entrant

Individual paroled into the U.S. for at least one year

Conditional entrant granted before 1980

Battered spouse, child and parent Victim of Trafficking and his/her spouse, child, sibling or parent

Individual granted Withholding of Deportation or Withholding of Removal Amerasian Immigrant

Iraqi and Afghan Special Immigrants Member of a federally-recognized Indian tribe or American Indian Born in Canada

Veterans or individuals on active duty in the Armed Forces and their immediate family members

Individual with Non-immigrant Status (includes worker visas, student visas, and citizens of Micronesia, the Marshall Islands, and Palau)

Individual with Temporary Protected Status (TPS) or Applicant for Temporary Protected Status (TPS) (with Employment Authorization)

Individuals with Deferred Enforced Departure (DED)

Family Unity beneficiary

Individual with Deferred Action Status

(Except Individual with Deferred Action for Childhood Arrivals (DACA). DACA is not an eligible immigration poe lecanaut=ti for Special Immigrant Juvenile Status

Applicant for Adjustment to LPR Status

Applicant for Asylum

Applicant for Withholding of Deportation or Withholding of Removal, under the immigration laws or under the Convention against Torture (CAT)

Applicant who has filed for creation of record of lawful admission for permanent residence (Registry Applicants) (with Employment Authorization)

Individual released on an order of Supervision (with Employment Authorization)

Applicant for Cancellation of Removal or Suspension of Deportation (with Employment Authorization)

Applicant for Legalization under IRCA (with Employment Authorization)

Legalization under the LIFE Act (with Employment Authorization) Individual Lawfully Admitted with Temporary Resident Status Resident of American Samoa

Individual granted administrative order staying removal issued by the Department of Homeland Security

Questions? Ask your hospital representative, Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener

una copia de este formulario en Espajiol, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532-

5465 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call

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Table of Contents

State/Territory Name: District of Columbia State Plan Amendment (SPA) #: 15-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

/S/

/S/ /S/

State: District of Columbia Supplement 3 to Attachment 3.1-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

FAMILIES RECEIVING TRANSITIONAL MEDICAL ASSISTANCE (TMA) BENEFITS PROVIDED IN ACCORDNCE WITH § 1902(a)(52)

A. The Department of Health Care Finance (DHCF), or its designee, may provide Transitional Medicaid Assistance (TMA) to households with dependent children who were receiving Medicaid under section 1931 of the Act and became ineligible due to the increased earnings of a parent or other caretaker relative.

B. DHCF, or its designee, may provide TMA for up to twelve (12) consecutive months. TMA begins on the date of loss of Medicaid eligibility under section 1931 of the Act.

C. TMA shall include the full range of benefits under the District of Columbia Medicaid

program. TN No. 15-001 Supersedes Approval eld PR 09 20 ective Date January 1, 2015 up

TN No. 90-10

Revision: CMS-10283 SUPPLEMENT 12 TO October 2009 ATTACHMENT 2.6-A OMB No.: 0938-1070 Page 3 ‘

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: District of Columbia

ELIGIBILITY UNDER SECTION 1925 OF THE ACT TRANSITIONAL MEDICAL ASSISTANCE

The State covers low-income families and children for Transitional Medical Assistance (TMA) under section 1925 of the Social Security Act (the Act). This coverage is provided for families who no longer qualify under section 1931 of the Act due to increased earned income, or working hours, from the caretaker relative’s employment, or due to the loss of a time-limited earned income disregard. (1902(a)(52), 1902(e)(1)(B), and 1925 of the Act)

The amount, duration, and scope of services for this coverage are specified in Section 3.1 of this State plan.

For Medicaid eligibility to be extended through TMA, families must have been Medicaid eligible under section 1931 (months of retroactive eligibility may be used to meet this requirement):

X___ During at least 3 of the 6 months immediately preceding the month in which the family became ineligible under section 1931.

For fewer than 3 of the 6 previous months immediately preceding the month in which the family became ineligible under section 1931. Specify:

The State extends Medicaid eligibility under TMA for an initial period of:

6 months. For TMA eligibility to continue into a second 6-month extension period, the

family must meet the reporting, technical, and income eligibility requirements specified at section 1925(b) of the Act.

_X 12 months. Section 1925(b) does not apply for a second 6-month extension period.

The State collects and reports participation information to the Department of Health and Human Services as required by section 1925(g) of the Act, in accordance with the format, timing, and frequency specified by the Secretary and makes such information publicly available.

TN No. 15-001 Approval Date APR 0 9 2015 ~ Effective Date January 1, 2015 Supersedes TN No. NEW

Table of Contents State/Territory Name: District of Columbia State Plan Amendment (SPA) #: 15-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

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

150 S. Independence Mall West

Suite 216, The Public Ledger Building

Philadelphia, Pennsylvania 19106-3499

CENTERS FOR MEDICARE & MEDICAID SERVICES

Region I11/Division of Medicaid and Children’s Health Operations

SWIFT # 092920154132

NOV 2 4 2015

Claudia Schlosberg, J.D.

Senior Deputy Director/State Medicaid Director Department of Health Care Finance

441 4" Street, N.W., Suite 900 South Washington, D.C. 20001

Dear Ms. Schlosberg:

I am writing to inform you that we have reviewed the District of Columbia’s State Plan Amendment (SPA) 15-0010, Childless Adult above 133% of the Federal Poverty Level (FPL). This amendment will enable the District to cover individuals under age sixty-five with incomes

above 133% and up to 210% of the FPL.

Weare pleased to inform you that, after extensive review, this amendment is approved; its effective date is January 1, 2016.

A copy of the approved SPA pages and signed CMS-179 form are included under this cover.

If you have any further questions regarding this SPA, please contact Alice Robinson Penn at 215- 861-4261 or by email at Alice.RobinsonPenn@cms.hhs.gov.

Sincerely,

aie

Enclosures

cc: M. Diane Fields, DHCF

DC.2082.R00.00 - Jan 01, 2016 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Dist. of Columbia

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

[DC-15-0010

Proposed Effective Date [01/01/2016 | (mm/dd/yyyy)

Federal Statute/Regulation Citation | 1902(a)( 10) A)(ii)XX); 1902(hh); 42 CFR 435.218

Federal Budget Impact Federal Fiscal Year Amount

First Year $[41468759.00 |

Second Year |2017 $| 52810636.00 |

Subject of Amendment Individuals above 133% of FPL

Governor's Office Review ‘.) Governor's office reported no comment ~* Comments of Governor's office received Describe: _

f cee ine

i

‘No reply received within 45 days of submittal

@ Other, as specified Describe: PR21-282

4%

Signature of State Agency Official

Submitted By: Diane Fields Last Revision Date: Nov 6, 2015 Submit Date: Sep 30, 2015

https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 11/10/2015

Medicaid Eligibility

State Name:|District of Columbia OMB Control Number: 0938-1148

: DC - 15-0010 Expiration date: 10/31/2014

Transmittal Numbe

1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218

Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218.

@ Yes (No

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:

[Ml Are under age 65.

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

Are not otherwise eligible for and enrolled for optional coverage under the state plan in accordance with [Ml section 1902(a)(10)(A)(ii)(1) - (XIX) of the Act, 42 CFR 435, subpart C, based on information available from the application for Medicaid.

{] Have household income that exceeds 133% FPL but is at or below the standard set by the state.

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

[lM] The income standard for this eligibility group is: |210 % FPL

[m] 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 [Ml is receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4.

C Under age 19, or

@ A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: C Under age 20 @ Under age 21

{m] 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 # 15-0010 APPROVAL DATE 11/20/2015 EFFECTIVE DATE 1/1/2016 SUPRSEDES TN # 13-07

Page 1 of 2

ccms. Medicaid Eligibility

C Yes @©No

The state elects to phase-in coverage to individuals in this group. The phase-in plan must be reasonable and may not provide Medicaid to higher income individuals without providing Medicaid to lower-income individuals.

C 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.

V.20140415

TN # 15-0010 APPROVAL DATE 11/20/2015 EFFECTIVE DATE JANUARY 1, 2016 SUPRSEDES TN # 13-07

Page 2 of 2

- Table of Contents

State/Territory Name: District of Columbia State Plan Amendment (SPA) #: 16-0001 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

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

150 S. Independence Mall West

Suite 216, The Public Ledger Building

Philadelphia, Pennsylvania 19106-3499

‘cms

CENTERS FOR MEDICARE & MEDICAID SERVICES

Region IM/Division of Medicaid and Children’s Health Operations SWIFT # 031520164119

April 27, 2016

Claudia Schlosberg, J.D.

Senior Deputy Director/State Medicaid Director Department of Health Care Finance

441 4" Street, N.W., Suite 900 South Washington, D.C. 20001

Dear Ms. Schlosberg:

I am writing to inform you that we have reviewed the District of Columbia’s State Plan Amendment (SPA) 16-0001, Non-Financial Eligibility- State Residency for Title IV-E Foster Care children. This amendment lays out the residency authority for enrolling new and maintaining

existing Title 1V-E Foster Care children.

Weare pleased to inform you that, after extensive review, this amendment is approved; its effective date is April 1, 2016.

A copy of the approved SPA pages and signed CMS-179 form are included under this cover.

If you have any further questions regarding this SPA, please contact Alice Robinson Penn at 215- 861-4261 or by email at Alice.RobinsonPenn@cms.hhs.gov.

Sincerely,

7 Digitally signed by Francis Francis T. T. Mccullough -S

Date: 2016.04.27 10:33:20 Mccullough -S "sy

Francis McCullough Associate Regional Administrator

Enclosures

ec: M. Diane Fields, DHCF A. Weiss, DHCG

DC.2521.R00.00 - Apr 01, 2016

Medicaid State Plan Eligibility: Summary Page (CMS £79)

State/Territory

name:

Dist. of Columbia

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

DC-16-0001

Proposed Effective Date

04/01/2016 ; (mm/dd/yyyy)

Federal Statute/Regulation Citation

| 42 CFR 435.403

Federal Budget Impact Federal Fiscal Year Amount

Subject of Amendment

Non-Financial Eligibility - State Residency for Title IV-E Foster Care Children

Governor's Office Review O Governor's office reported no comment

© Comments of Governor's office received Describe:

No reply received within 45 days of submittal

ors)

Other, as specified Describe:

District of Columbia PR21-559

Signature of State Agency Official Submitted By: Diane Fields Last Revision Date: Apr 12, 2016 Submit Date: Mar 4, 2016

Approval Date: April 21, 2016 Signature: Francis McCullough /s/

file:///Ro-PHI-ADHOME/HOME/Gc37/DC-SPA-16-0001_179.htm[04/27/2016 8:39:43 AM]

State Name: [District of Columbia | OMB Control Number: 0938-1148

Transmittal Number: DC - 16 - 0001 Expiration date: 10/31/2014 —— = ; 5

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:

rT 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:

[i] Intends to reside in the state, including without a fixed address, or [i] Entered the state with a job commitment or seeking employment, whether or not currently employed.

Ty 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

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

al 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:

Ty 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

al 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

{a institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state.

fl 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.

{@i] IV-E eligible children living in the state, or

Otherwise meet the requirements of 42 CFR 435.403.

IN # DC-16-0001 APPROVAL DATE: April 21, 2016 lof SUPERCEDES TN# DC-13-0015 EFFECTIVE DATE: APRIL 1, 2016Page | of 3

Medicaid Eligibility

Meet the criteria specified in an interstate agreement.

@ Yes (C No

XX] Alabama [X] Illinois

X} Alaska i<] Indiana ix] Arizona <] Iowa

><] Arkansas dX] Kansas

><] California Xx] Kentucky [Xx] Colorado [X] Louisiana [X] Connecticut [X] Maine

x] Delaware {] Maryland [1 District of Columbia KX] Massachusetts DX] Florida Bi Michigan XX] Georgia [><] Minnesota ><] Hawaii X] Mississippi x} Idaho XX] Missouri

Are IV-E eligible

(7 Retain addresses in both states

Other type of individual

[Hi] The state has interstate agreements with the following selected states:

Montana

Db] Nebraska

<] Nevada

[><] New Hampshire [X] New Jersey [I<] New Mexico (1 New York

><] North Carolina [><] North Dakota [X] Ohio

[X] Oklahoma

XX] Oregon

Pennsylvania

LD Are in the state only for the purpose of attending school

1 Are out of the state only for the purpose of attending school

Xl

Rhode Island >] South Carolina bX] South Dakota [X] Tennessee [X] Texas

><] Utah

><] Vermont

XX] Virginia

><] Washington X] West Virginia ] Wisconsin

[1 Wyoming

fal The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply):

Name of Type

Description

IV-E Eligible Children Placed Out of District

Medicaid Coverage of Title IV-E Foster Care Children Placed Outside of the District SPA Attachment. This document sets out the requirements for enrollment in the

of District Medicaid program for otherwise eligible individuals 4 who are not residents of the District. Further, the attachment establishes a process for determining when enrollment in the District's Medicaid program may not be in the child's best interest.

TN # DC-16-0001 APPROVAL DATE: April 21, 2016

SUPERCEDES TN# DC-13-0015

EFFECTIVE DATE: APRIL 1, 2016

Page 2 of 3

entrain see feccc were

Medicaid Eligibility

The state has a policy related to individuals in the state only to attend school. C Yes @ No

[B] Otherwise meet the criteria of resident, but who may be temporarily absent from the state.

The state has a definition of temporary absence, including treatment of individuals who attend school in another state. @ Yes C No

Provide a description of the definition:

An individual who is absent from the District of Columbia, but otherwise meets the criteria of a resident, if the individual:

Considers the District to be his or her fixed place of residence to which he or she will return to following temporary absences with the intent to reside; and

(a) Is absent from the District for less than ninety (90) days; or (b) Is absent from the District for more than ninety (90) days for good cause as determined by the State Agency. (Good cause may include, but is not limited to, the following:

(a) School attendance: an individual under the age of twenty-one (21) who is away from the District for the sole

purpose of attending a boarding school or other educational facility, if otherwise eligible, may retain Medicaid eligibility;

(b) Medical care: an individual in-need of medical care outside of the District, if otherwise eligible, may retain Medicaid eligibility so long as the need for medical care continues; or

(c) U.S. military service: an individual with full-time employment in the U.S. military service, if otherwise eligible, may retain Medicaid eligibility while away from the District due to a duty assignment.

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

V.20140415

IN # DC-16-0001 APPI ATE: April 21, 204 SUPERCEDES TN# DC-13-0015 EFFECTIVE DATE: APRIL 1, 2016 Page 3 of 3

Table of Contents

State/Territory Name: District of Columbia State Plan Amendment (SPA) #: 16-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Cer(ers fo¡ Medirare & N4edic¿id Seryices 150 S. Indepenclence Mall West Suite 2lo, f'lìe Public Ledger Buildil|g Philadelphia, Pennsylvania 19106-3499 Regiqn Ill{Division of Medicaid and Children's Heâlth Operationscrvrs cfNl[[s [oR MIDIC^RI & MtDtc^tD STRV|C¡S swtFT #t 11720164007 February 7,2017 Claudia Schlosberg, J.D. Senior Deputy Director/Med icaid Director Department of Health Care Finance 441 411' Street, N.W.,9tl'floor, South Washington, D.C. 20001 Re: Approval of Health Home State Plan Amendment DC SPA 16-0012 Dear Ms. Schlosberg: The Centers fot'Medicare & Medicaid Services (CMS), has completed its review of the District of Columbia State Plan Amendment (SPA) Transmittal Number 16-0012, My Health GPS. This SPA implements Health Homes as authorized under Section 2703 of the Patient Protection and Affordable Care Act (1945 ofthe Social Security Act). Individuals eligible to receive Health Home services include beneficiaries with rnultiple chronic cond¡tions. We approve District of Columbia State Plan Amendment (SPA) Transmittal No. l6-0012 on February 6,2017 with an effective date ofJuly l, 2017. Enclosed is a copy ofthe approved pages fol incorporation into the District of Columbia State plan. ln accordance with the statutory provisions at Section I 945 (c)'(1 ) of the Social Secur.ity Act, for payments l¡ade to health horne providers undel this amendment, during the first eight fiscal quarters that the SPA is in effect, July l, 2017 through June 31, 2019, the federal medical assistance percentage (FMAP) rate applicable to such payments shall be equal to 90 percent. The FMAP rate for payments made to health home providers will return to the state's published FMAP rate June 30,2019. The Form CMS-64 has a designated category of service Line 43 for. states to repoÍ health home services expenditures for enrollees with chronic conditions. Please share with your staff my appreciation for their time and effoft throughout this process. If you have any questions regarding this Health Home State Plan Amendment, please contact please contact LCDR Frankeena Wright at 215-861-4754 or by enail at Flankeena. Wli {¡htlZr,tcrns. lihs. gov. Sincerely,

Francis McCullough Associate Regional Adl¡ inistrator Enclosures cc: Alice Weiss, DHCF Sabrina TiÌlman Boyd, CMS

2J6t2017 DC - Submission Package- DC2016l\lH0001O - (DC-1G0012) Records / Submission Packages DG - Submission Package - DC2016MH0001O - (DC-16-0012). 1\ ReqLrest Sysler$ ljclp . All Reviewable ljnits Vì(Jw Co¡rt)âra Ooc Submission - Summary lùlEDlCAlD - Heâlth Homes - lvly lleallh GPS - DC - 2016 cMs-10434 ot\¡B 0938¡188 No( Stãded ln Prcgless CompletÈ Package Header Package lD DC2016[4H0001O Submission TypG Official - Rêview 1 Apptoval Dale 21612017 Superseded SPA N/A ID State lnformat¡on State/Terr¡tory District of Columbia Namè Submission Çomponent Suþm¡ssion Type ,' Official Submission Pâckage Draft Submission Package sPA rD DC-16-0012 lnit¡al Subrnission 11/10/2016 Date Effêctive Ðäte July 1,2017 Vr€v,/ l¡rplcme¡lâho¡ì Guidc }YT:"'f11 Key Contacts Name T¡tle V\biss, Alce Di¡ector/HCPRA SPA lD ancl Effective Date DC 16-0012 Supersoded SPA N/A Medicaid Agency Oepadment of Health Câre Finànce Nañe CHIP Allow th¡s ofl¡cial package to be viewable by other state3? .No Phone Number (202)442-91O7 Effeclive Dâle: July 1,2017 CI\¡S Approvâl: Feburary 6, 2017 EmâilAddress alice.weiss@dc-gov

26t2017 sPA tD DC-16-0012 Executive Summary DC - Submiss¡on Package - DC2016I/ H0001O - (DC-1G0012) Proposed Effective Date Reviewable Un¡t Health Homes lntro Health Homes Population and Enrollmenl Cnlerìa Health Homes Geographic Lrmrlal,ons Heâlth Homes Servicos Health Homes Paoviders Health Homes SeNice Delivery Syslems Health Homes Payment l\¡ethodologies Health Homes Monitoring, Olallty IVleasurement ãnd Evalualion 7t1t2017 71112017 7t1t2417 7t1t2017 7t1t2017 7t1t2017 7t1t2017 71112017 Summáry The District of Columbia's (DC) Department of Health Câre Finance (DHCF) developed DC's Heâllh Home (HH) state plsn benefil lor Descript¡on benelcisries w¡lh chronic conditions. The goals of DHCF's HH program for benefrciaries with chronic condit¡ons âre lo improve the lnctud¡ng Goals integGlþn of medrcal and behavioÊl heálth, community suppofts and social servicos; to lower rales of avoidable emergency department and Obiectives (ED) use, to reduce prevontablo hospital admissions and ¡e-âdmissions; to reduce heålthcãre costs; to improve the expeñeñce of ca.e, ' quality of life and beneficiary satisfaction; and to improve heâllh outcomes. lJnde. DHCF'S ãpproãch, the HH will be lhe central point for coordiñêti¡g palien{-cent6red and population{ocused care for beneficiaies wilh multiple chronic conditions. HH providers will bo embedded in the primary care selting to effeclively mânåge the full breâdth of beneficiâry needs A beneficiary can only be enrolled ând receive HH seNices from one HH al a time. DHCF will ensure payments lo HH providers do not duplicatê paymenls for comparable sêNices financed by IVlediôaid. HH seNicos will be consislenl wilh, but not limited to, those sel forih under 42 C. F.R. S 440.169. Dependency Description 1t- Oescription of âny dependencios between thìs sr¡bmission package anal any otheÌ submission package unciergoing review D¡saster-Related Submission This submission ¡s related to a disaster i4l No Federal Budget lmpact Federal Fiscal Year Fißt 2017 Second 2O1A $3,589,998.00 $7,229,023.OO Fedêral Budgét lmpact and Statute/Regulation C¡tat¡on Federal Statute / Regulat¡on C¡tation 42 USC S 1396w-4 DC 16-0012 Superseded SPA: N/A Efleclive Dater July 1 2017 Cl\,4S Approval: Feburary 6, 2017 Page 2 z3

216t2017 Governor's Office Review DC - Submission Package- DC2016MH0001O - (DC-1G0012) Desc¡ibê D.C. Act. 21-463 : ' No response w¡1hin 45 dâys *, Olher Authorized Submitter The follow¡ng ¡nformation w¡l¡ be provided by the 6ystem once the package is subm¡tted to CIVS. Name of Claire de Jong Autho¡izecl Subm ¡tter li{le None Phone number 20247 ø9293 Enìa¡l address claire.dejong@dc.gov Authorized Claire de Jong Suhmittêr's Signalure ,r I hereby cedify that ¡ am authorized to submit lhís package on behalf of the N4edicâid Agency. âverage 40 hoL!rs per rêspônse, includrrrg lhe time lo ¡eview inst¡uclions, search exrsiing dala reso(lrces, galher lhe dala needed. aùd conrplele and r€v ew ihe Boulevard Altn:PRA Reporrs Cfeârance Offcer, lllail Stop C4-26'05, Ballinrore,lvlaryland 21244-1850. DC 16-0012 Superseded SPA: N/A Efiective Dale: July 1, 2017 C[¡S Approvâl: Feburary 6,2017 Page 3

z6!2017 DC - Submiss¡on Package - DC2016L'1H0001O - (DC-1G0012) Records / SuLr¡issiôn Packages DC - SubmÍssion Package - DC2016MH0001O - (DC-16-0012) r.*.' ' ReqLresl Systorn Help V¡ew Compare Doc Submission - Medicaid State Plan IVEDICAID - Heâilh Hornes - Nly Health GPS - DC - 2016 cl\,1s-1 0434 0l\¡B 0938-11 88 Nol Staded Package Header PackagelD DC2016N¡H0001O Subm¡ssion Type Officìal- Review 1 Apptoval Dafe 21612017 Superseded SPA N/A ID Subm¡ss¡on - Med¡caid State Plan sPA tD DCl6-0012 lnitial Submiss¡on 11/10/2016 Date Effêct¡ve Date July 1,2017 ln Progress ComÞlete VÌew lmplerìentalÌon Guide lhe submission inclLrdes the followìng Benefits Health Homes Program " Create new Health Homes progtam Amend existing Health Homes p¡ogram Term¡nâte existing Heâlth Homes program Copy from exist ng Health Homes program ß Create n€w program from blank form Name of Health [4y Heâllh GPS Homes Program PRA Dlsclossre Staternent Accord¡ng to ihe Pâpefwork Reduction Aclol1995, no persons are requ¡red to respond to a colleclion of¡nformallon unless xdìsplays a vålid averase 40 ho!rs per respoñse. i¡cltlding the lime 1o review instrucfons, sesr¿h exisling dâla resources galher the dalâ needed, and complete ând rcview lhe Boulevârd Attñ:PRA Repods Cfearance Ofllcer, [¡arlStop C4-26-05, Ballinrcrc, [¡âry¡ând 21244-1850. DC 16-0012 Superseded SPA: N/A Effective Dateì July 1,2017 CIVS Approval: Feburary 6, 2017 1t1

2J6t2017 Dc - submission Package - DC20161v1H0001O - (DC-1G0012) Records / Subrnissio¡ Packaíes DC - Submission Package - DC2016MH0001O - (DC-16-0012)j'"",.. ReqLrest Sysïer¡ i-Jalp Vìew Cornpåre Doc . All Rev¡ewâble Units Submission - Public Gomment IMEDICAID - Heallh Homes -[4yHeâllh GPS - DC -2016 Cl\,1S-1 0434 Olì¡B 0938-11 88 Package Header Package lD DC2016[¡H0001O Submission Type Official- Review 1 Apprcval Date 21612017 Superseded SPA N/A ID Name of Health Nly Heallh GPS sPA ID DC-16-0012 lnitial Submission 11l10/2016 DátE Effective Date July 1,2017 Corrlplele Viev,, lmplenìe¡tati{rn Gurde Nol Slarled ¡rì Progress lndic¿to whether public comment was solic¡ted w¡th respect to th¡s submiss¡on. Public notice was ñot required and comment was not solicited e Public notice wEs not tequired, bul comment was solicited Public notice was requ¡red and comment wâs solicited Nêws pêp6r Annou ncêmenl Publication in stateb adminislrative record, in accordance w¡th the admiñislrative procedures requiremênls Email to Eleclronic f\¡ailing Lisl or Similar Mechanism Website NotÌce Public Hea ng or lÍseling Dâte of Publicât¡on Sep 30, 2016 Other rnethod Upload cop¡es of publ¡c not¡ces and other documents used Name DC...Reg rs le r_Vol_63-No-4'l-Septefir be r_30.-.201 G-P aqes-0 11 73 g-ihru-01 2283 Upload w¡th this application a writt€n summary of public comments roce¡ved (optlonal) Nalne Date created Date Caeated 1012A12016 4:12 PM EDf Type ffi DC 16,0012 Supersedêd SPA: N/A Eí€ctive Dâte: July 1, 20'17 CIMS Approvâli Feburåry 6,20'17 Page 5 1t2

21612017 DC - Submiss¡on Package - DC2016l\l H0001O - (DC-1G0012) No items availâble lnd¡cate the key ¡99ues raised dur¡ng lhe public comment period (opt¡onal) I Quality , Cosl Payrnenl methodology Elisibilily Benefils SerVice delivery : Other issue PRA Disctosure Shtement Accordrng to ihe PapeMork Reduclion Aclof 1S95, no persons are requircd lo respond to å collectiôn of ¡nformation unless il displays a vâfjd averâge 40 hours pefresponse, incfuding rhe time lo review insrfucûons, search exisling dâta fesoufces, gather lhe data needed, and compleie and revrew {he Bôulevard. Atln: PR,A Repoß clearance Ofiicer. l¡ail Stop C4-26-05, Ballimore Marylaîd21244-1850. DC 16-0012 Superseded SPA:N/A Effective Date: July 1,2017 CMS Approval: Feburary 6, 20'17

26t2017 DC - Suþmission Package - DC2016l\¡H0001O - (DC- 1G0012) Records / Subìrission Packages DG - Submission Package - DC2016MH0001O - (DC-16-0012). 'r"r Reqlest System ilalp VìÕw Corrìp¡(rc Doû Submission - Tribal lnput lvlEDlCAlD - Heal[h Homes - i\.4y Healih GPS " DC - 2016 ct\¡s,10434 0[48 0938-1188 Noi Staie.l ln Progless C.rmplele Package Header Package lD DC2016[¡H0001O Submission Type Offrcial- Review 1 Approval Date 21612017 Superseded SPA N/A ID sPA lD DC-'16-0012 lnit¡al Submiss¡on 11/10/2016 Date Effective Date July 1,2417 Vr€vr' lmplcmentà1 on Gr ¡de Homes Próqrãm One or more lndian hGâlth programs or urban lnd¡an Organizat¡ons furnish health care services ¡n this state Yes "j No average 4o hou.s per response. includrng lhe lime lo review r¡structÌons, s€a¡ch exisling d€ta resoürces, gather lhe daÌa needed. ard complele and review the rnforntation cotlect¡o¡. tl you have commenls concerning lhe accuracy of the lime esiiñate(s) or suggeslions lor ¡mproving thÌs form, please write io:CÀ¡S 7500 Securily Bo!levard, Attn:PRA Repods Clearance Off¡ce¡, [4ailSiop C4-26-05 Baltiflor€. f\4aryland 21244-1850. 1t1 DC'16-0012 Superseded SPA: N/A Effective Dale July 1, 2017 CI\,4S Approval: Feburary 6,2017

217t2017 DC - Submission Package - DC2016l!1H0001O - (DC-1G0012) DG - Submission Package - DC20l6MH0001O - (DC-16-0012) ¡'\ flequest System llelp Vìew Colnpare ooc Submission - SAMHSA Gonsultation IMEDICAID - Heâlth Homes - lvly Heâllh GPS - OC - 2016 Records / Subrnission Packâges c[,1s10434 ol\¡B 0938,1188 Noi Slad€d Package Header Pâckage lD DC2016l\¡H0001O Submission Type Officiêl- Review l Apptoval Datè 21612017 Sup¿rsecled SPA N/A .lD sPA lD DC-164012 lnit¡al Subln¡ss¡on 11/'10/2016 Date Effect¡ve Oate July 1,2017 ln Prog ess Complele V¡ew lnìplementâ1ron Gurd€ Name of Heâlth [¡y Health GPS Homes Progrâm The State providos assurance that al has consu¡led and coordinated wilh the Substance Abuse and fvlenlal Hoallh Seruices Administralion (SA[4HSA) in âddressing issues regarding tho prevenlion and treatment of menlal illness and subslance âbuse añonq eligible individuals with chronic conditions. Date of consultat¡oñ 61912016 PRA Dìsctosure Statement According to fhe PåpeMork Reduci¡on Actof1995 no persons are required lo¡espond toa collection ofinformalron unlessitdisplays å valrd average 40 hours per respoñse, ircl!dÌng lhe time to review inslructions, search €xisling data resources, gâther the dala needed ånd complete ând review lhe informaton cotlection. lf you have commenls concerning ihe accuracy oflhe lime estimate(s) or suggeslrons for improvinq this form, pleâse wrùe 10: Clls,7500 Securily Boulevãrd, Aün: PRA Reports Clearance Offcer. lr4aÌlSlop c4-26-05 Baliinrore, [¡arylånd 212441850. DC 16-0012 Superseded SPA: N/A Effectivs Date: July 1,2017 Cl\¡S Approval: Feburary 6, 2017 Pâge I 111

27t2017 DC - Submission Package - DC20l6l\¡H0001O - (DC-1G0012) Recofds / Sullmissiôn Pâckâges DC - Submission Package - DC20l6MH0001O - (DC-16-0012) r*- Reqlesl Systefl Halp View Conìpare Doc Health Homes Intro l\¡EDICAID - Heallh Homes - lly Heallh GPS - DC -2016 c[4s¡ 0434 0 ¡B 0938-1188 Not Staied ln Progress Cor¡Þ1e1e Package lD DC2016l\¡H0001O Stlbm¡ssion Type Officìal- Review 1 Approval Date 2/6/2017 Suporsodêd SPA N/A ID sPA lD DCl6'0012 lnitial Submissíon 11/10/2016 Date Effêctivê Dato 7/1/2017 Package Header Program Author¡ty View lnrplemenLaùon G ide 1945 of the Social Securily Act The stato elects to implêment lhe Heallh Homes slate plan option undor Seclion 1945 of ihe Social Securily Act. Name of Health N¡y Health GPS Hollles Pro0ram Execut¡ve Summâry ).L Provide an executive sunmåry of this Health Homes p¡69ram ¡rìcludíng the goals and objéctives of the prograÍì, the populâtion, providers, services and sewice del¡vely model used The Districl of Columbia's (DC) Department of Hêallh Care Finance (DHCF) developed DC's Health Home (HH) staie plan benefit for beneficiaries w¡th chronic conditions. The goals of DHCF's HH program for beneficiarios wilh chronic conditions âre to improve lhe iñtegrâlion of mêdicâl and bohavioÉl health, comúunity supports and social services; to lower râtes of avoidable emergency dopartment (ED) use; lo reduce preventable hospital admissions and rs- ådrhissions; to reduce hêallhcare cosls; to improvo the experience of care, quelily of lifê and beneficiary salisfaction; and lo improve health oulcomes. Undêr DHCF's approach, the HH wil¡ be the central point for coordinaling palient'cenlered ând populationJocused car€ for beneficiarios wilh multiple chronic conditions. HH providers will be ornbedded in the p¡imá¡y care selting to effeclivêly manâge {he fulÌ breadth of bêneficiary needs. A beneficiary can only be ênrotled end recêiv€ HH services from one HH at a lime. DHCF will snsure payments to HH providers do not duplicate paymonls for comparable services financed by [4edicaid. HH seNices will be consislenl wilh, but not limited to, those set forth under 42 C.F.R. S 440.169. General Assurances jl. The state provides âssurance that eligible individuals will be given a free choice of Heallh Homes providers. r The states provides assurânce thãt it will not provenl individuals who are duâlly eligible for MedicaÞ and Nledicaid from rsceiving H6âlth Homes services. :(, The state provides assurânce that hospilals participating under the state plan or a waiver of such plan will be instructed to establish procedures for refertÌng eltgible individuals wth chronic condllions who seek or need treatment in a hospital emergency deparlmenl to design8ted Hoalth Homes prov¡ders DC 16-0012 Effeclive Dâte July 1' 2017 Page I Superseded SPA: N/A Cl\¡S Approvâlì Feburâry 6' 2017 1t2

z7l2o17 DC - Submission Package - DC2016|\¡H0001O - (DC-1G0012) ", The state provides assurânce thât FIVIAP for Health Homes servicos shall be 90o/o for the first eight fiscâlquÊdors Írom lhe êffêctivê date ofthe SPA. After lhe frrst eight quârteß, expendilur6s will be claimed ât the regular matching râte. l{ The state provides assLrrance that il will have the systems ¡n placo so that only one 8-quader period of enhanced Flt¡AP for each health homes enrollee will be cl6imed. ir' The state provides assurånce thal there will be no duplication of services and paymenl for s¡milar seNices provided under olher l\4edicaid autho¡ìlies. PRADisclôsureSlaternenlAccordrngtorhePaperworkReductionActofl99S,nopersonsâferequircdlorespondloacollêêlionofinformationunlessridisplâysâvalid average 40 hours per response, including the linìe lo review inst¡uctions, search existing data resources, gâlher the dala needed, and cornplele a¡d review the Boulevârd AtlniPRA Reporls Clearance Offcer NlailSlopC4-26-05.8altirnorc,Màryland21244-1ø50. DC 16-00'12 Superseded SPAI N/A Effective Dateì July 1, 2017 CIVS Approvâl: Feburary 6 2017 Page l0 z2

27t2017 DC - Submissìon Package - DC2016l\¡H0001O - (DC-1e0012) fìêcords / Submission Packages DC - Submission Package - DC20l6MH0001O - (DC-16-0012). .*a Reqlesl Systcnr Help View colnpare ooc -- All Rèv¡ewâble Units Health Homes Population and Enrollment Criteria [¡EDICAID - Health Homes - fvly llealih GPS - OC - 2016 c[4s-10434 OfvB 0938-1188 ln Progress Package Header Categories of lndiv¡duals and Populat¡ons Prov¡ded Health Homes Services The state w¡ll mâke Health Honìes services ávailable to the following calegorjes of Medicaid part¡cipants I categorically Needy (l¡andatory a¡d Options for coverage) Eligibilily Groups lr, N¡edicaily Needy Eligibility Groups Nol S1âded Complête Package lD DC2016MH0001O Submission Type Official- Review 1 Apprcval Dale 21612417 S¡rpersecled SPA N/A ID sPA tD DC-16-0012 lnitiâl Subrn¡sÊion 11l10/2016 Date Eliectìvê Dâtè 7 I 1 12017 View lnplernenl¿l oñ Guide 3;Á,:f* | Ilrandalorv l\¡edicallv Nêedv .r'' Medically Needy Plegnanl Women :d. Medically Needy Children underAge 18 Ootional Mêdicallv Needv lselect the orouos included in the ooÞulation) Famìlies and Adolts .; Medically Needy Children Age 18 thrcugh 20 lr' Medically Needy Parents ând Oiher Caretaker Relâtivos Aged, Blincl and Disabled .{. [,ledicslly Needy Aged, Blind or Disabled .r: [redically Neêdy Blind or Disabled lndividuals Eligibl6 in 1973 Population Criteria :1. Two or morê chronic condil¡ons DC 16-0012 Superseded SPA: N/A Spec¡fy the cond¡tions inclùded 1r. f\Iental Health Condition ld. subslánc6 Llsê Drsorder ?.1 Asthma Effeclive Date: July 1, 2017 CÍVS Approval: Feburary 6, 2017 Page 1'1 1t3

27no17 DC - Subm¡ssion Package - DC20l6MH0001O - (DC-1d0012) t Diâbetes ..{'' Heerl Disees6 ' I Bf\ ov6r 25 .4 Other (specify) Name Chronic Obstructive Pulmonary Disease Cerebrovascular Diseâse Chronic Renal Failure Hopatitis Human lmmunodeficiency Vrrus Hyperlipidemia HypeÍension Il¡alignancies Paralysis P6nphsrel Athetosclerosis Sick16 CetlAnemiá [4orbid Obesity ,4 4 1-12 of 12 t' ,1 Oescr¡ption On diâlysis N/A NiA BÀrl ov€r 35 ' : One chronic condition and lhe risk of developing anolher ì One serious and pêrsistent montal hoalth condition Entollment of Partic¡pants Parlicrpation in a llealth Homes is volunlâry. lndicate the method the state will use to enroll elrgible l/ledicaid individuals ¡nto a Health Home :' Opt-ln to Heallh Homes p¡ovider 'n) Reforâl and assignmenl to Health Homes providerwilh opt-out . Other (descibe) Describe the process used DHCF ìs implementing an opt-oui ¡nethod to enroll elig¡ble [¡edicaid benoficiariês into HHs. Under this melhodology, eligible beneficiaries will be allo-assigned based on past 6xp6Íence with HH provìders, using up io a lwo year,ook back of l\4edicãid claims. lf a beneficiary does not heve a pdor relationship with a HH providêr, lhê beneficiary w¡ll be aulo-assigned based on geography and/or providêr capacity. Once a benêficiary is âssigñed lo â HH, DHCF will commun¡catê inforßâlion aboul the HH program to lhe beneficiary, including the beneficiary's rjghts under the opt-out process. Specificelly, DHCF will send a letter lo the eligible beneficiary lo notily the beneficiary of HH oligibilily, prov¡de information on the beneficiary's assigned HH, and 6xplain the benefrciary's dghts to choose ênother HH if desired or to opt-oul of tho program, as well as the p¡ocesses fhrough which the beneficiary may exercise these rights. DHCF wifl also communicate information about the HH program lo HH and non-HH provide¡s w¡th pasl exper¡enco with lhe beneficiary to help onsure lhe beneficiêry is receiving consrstent i¡formation fiom their network of providers. Additional information and prolocols for informing beneficiañes of their eligibilily for HH sorvices and their option of service providers will be desc¡ibed ¡n the DC Nlunicipal Regulations (DCMR). 'd Thê stete provides assurance that il will clearly communicato tho indivÍduâl's righi lo opl out of lhe Hêalth Hor¡es benefit or to change Heafth Homes provideß at any time ând âgÍees lo submil to CIVIS a copy of any letlor or comÍìunicalion used lo inform the individuals of the Health Homes benefit and thek rights lo choose or change Health Homes prcvideß or lo elect not to receive the benefil Name Date Created Type Hl-{2 Bere Nol lcationLtt (2)Jts 2016 .09.07 1ot2812o16 4146 PM Ë PRA Disclosurê Stâtemenl According lo the PapeMork RedLrction Act of 1995, no persons are required to respond lo a collection of 'nfornìaiion unless it displays a vâlid averâge 4o hÕuß per respo¡sê, ¡ncluding lhe lime io review ißstructions, search exisling daþ reso!rcès. gathêr thê dalâ nêèdêd, ãnd compl€iè and review the DC 16-0012 Effeclive DâlerJqly 1,2017 Pase12 Superseded SPA: N/A CI\¡S Approvâl Fehutary Ê,2017 2J3

2n12017 DC - Submission Package - DC2016l\4 H0001O - (DC- 1G0012) Boulevard Atin: PRA Repods Cleå¡ance Otrìcer, rlailSrop C4-26-05 Bållimore, f\¡arylañd 21244-1850. DC 16-0012 Superseded SPA: N/A Effeclive Date: July 1,2017 Cfì,4S Approval: Feburâry 6, 2017 Page 13

27t2017 DC - Submission Package - DC2016lMH0001O - (DC-rG0012) Rêcords / Subìlìission Packages DC - Submission Package - DC2016MH0001O - (DC-16-0012) r'': Iic.!ricsl lìtsicIl ]1clì.i VieÌv ConÌpare Doc - All Revìêwable Unifs Health Homes Geographic Limitations MEDICAID - Heâllh Hofiìes - [¡y lleahh GPS' DC - 2016 c[¡s-1 0434 0À¡B 0938-1188 Nol Stârled Complete View lnlplemenlâhon GLldc Package Header Package lD DC2016N¡H0001O Sulrmisiion Typê Official- Review 1 Approvãl Date 2/6/2017 Supersecled SPA N/A ID SPA ID ln¡tial Subm¡ss¡on Date Effectivc Dâtè DC-16-0012 1111012016 7t1t2417 rt Heallh Hor¡es services will be availâble slatewide Heallh Hornes services will be limíled to the fol¡owing geographic êreês : Heallh Homes services will be provided in a geographic phâsedjn âpproâch PRADrsclos!reSlalemerllAcørdrnglolhePapelworkReductionAclofl99S,nopersonsarer€quiredtorespondloåcollectionofinformâlionunlessildisplaysâvalrd êverâge 40 hours per response, includiñg the lime to review inslruclions, seãrch existing daia ¡esources, gãlher lhe dala needed, and conìpleie and rcvlEW lhe Boufevard, Attn: PRA Repoñs Cfearance Oflcer, I\4ail Stop C4-2ô-05, Ballimore, lvlaryland 21244-1850. DC 16'0012 Superseded SPA' N/A Effective Date: July 1, 2017 Cl'rs Approvål: F€burary 6, 2017 Page 14 111

2t7t2017 DC - Submission Package- DC2016l\4H0001O - (DC-1G0012) Records / Submission Packages DC - Submission Package - DC2016MH0001O - (DC-16-001211:''* : Rôqlrest Syslem Help V¡ow Cornpare Doc - Áll Reviewable Units Health Homes Services MEDICAID-Heållh Homes-NrlyHeallhGPS-DC-2016 cÀrìs-104 34 0lìlB 0938-1188 Nol Stâded l¡ Prog€ss Complelê Packãge Header Package lD DC2016MH0001O Submission Type Oficial" Review I Apptoval Date 21612017 Suparsecled SPA N/A ID sPA lD DCr6-0012 lnitial Subrnission 11/10/20'16 Date Effect¡ve Date 7/1/2017 Serv¡cé Definit¡ons Provide the state's def¡nit¡ons of the follow¡ng Health Hornes serv¡ces and the spec¡fic activit¡es performed under eech service Comprehens¡ve Care Management Oefinition Comprehensive care mânagemenl (CC[¡) is the creation, documentation, execulìon, and updating of a person-centered plan of care. CCNI services address stãges of health and disease to mãxlmize current funclionâl¡ty and prevent beneficia es from developing additional ch¡onic conditions and complicalions. These se¡vices include, but are not limited to conducling a comprehens¡ve biopsychosocial needs assessmenl to detemine ihe risks and whole-pelson View lnrpfemenlat on Ouide t4* Ail R*" +l- plan. l¡any activities of lhis HH componenl msy be provided by any HH team member, bul are ddven by protocoìs and guidelines developed by the Nurse Care lvlanager or comparable health care professional, Describe how Health lnfornation lechnology will IJe írsed to link this service in a comprehènsivè approach across thè care continuum All HH providers wi¡l be required to utilize a certified EHR technology which will allow providers to repod and review ân HH beneficiary's intake, assessmenl ¡esults, assigned HH team, inlegraled HH câre plans clinicalbaselines and data related lo chronic condilions, aswellas HHseryices provided, suchâs rofeÍels made and health promotion activities completed. HHs will bo responsible for establishing an informed consent process, including â process for oblaining consenl to share pâli6nt datâ across tho HH provider continuum. Addil¡onâlly; - HHs will bo requi¡ed to utilize CRISe or other HIE sorvices ás dirocled by DHCF, to receive hospital evenl aleds (e.9. emergency deparlment visits; hospital admissions, kansfers and discharges) that will help HHs creêle a person'centered HH caro plan - HHs may heve eccess to a Dynamic Palient Care Profile iool curenlly being developed through C[4S lmplementation Advanced Plânning Document (lApD) fundinó support. The tool wìil be an 'onlemând' document msdo aveilable to l\4eaningful Use Eligible Provideß (EP) and Eligible Hospitals (EH), in ådditión lo members of their câre team, that would display Bn âggregalíon of crjlicai dala (both clinical ând ãdministralive) for a selected patient. - HHs may have access lo Eleckonic Clinical Quálity Mêasurement Tool and Dashboard, añ electronic clinical quãl¡ly meãsurement (êCQI\¡) tool to roulo inbound Conti;uity of Care documents (CCD) (as oullined in 2015 Edilion Health lnfo¡mation Technology Cedification Criteda, 2015 Edition Base Electronic Health Record Deiiniiion, and ONC Health lT Cerlificalion Program Modifications or subsequent releases) from eligible I\Iedicaid hospitals and praclices lo support required quality calculâtions and repoÍíngi dovelop a populalionlevel dashboard accessible by EPs end EHs for pâtient panel mânagemenl - Htls may träve aicêss lo an Analylical Palient Population Dashboard, also beiñg doveloped wilh supporÌ from IAPD funds to enãble EPs and EHs to Dc 16-0012 Effoclive Daler July l, 2017 Page 15 Superseded SPA N/A CI\¡S Approval: Feburary 6' 2017 1t-7

Z7l2O17 DC - Submissioñ Package - DC2016Iil H0001O - (DC-1G0012) pedorm panel]evel ânalysis on lheir associated palient populations - HHs are expected lo share struclured data utilizing Consolidated Clinical Documenl Archiloclure (C-CDA) (âs oritlined in 2015 Editioñ Health lnformation Technoiogy Cedificãtion C teriê, 2015 Edition Base Electronic Health Record Defìnilion, and ONC Health lT Certificatjon Progrâm [4odifcations or slbsequenl reìeases) or other certified data exchange slandards lo a designated HIE enlity(ies) in the District. Scope of service The service can be prov¡ded by the following provider types : I Behâvioral Heallh Professionals or Spec¡alists r , Nuße Practitioner . Nuße Câre Coodinators , . Nuees ' , [redical Specialisls ' . Physicians Physician's Assistanls : . Pharmacisls : , social wofters : , Doctors of Chiropraclic ' I Licgnsed Comp¡ementary and altemallve lì¡edicin6 Practitìone¡s ' ì DieticÌans i : Nulritionists ìd Other (specify) Provider Type FOHCs; Clinicãl Clinical Practices and Group Practices Descript¡on lvlany êctivities of lhis HH component may be provided by any HH team member, but ar€ driven by protocols and guidelines dèveloped by the Nurse Care l\¡anager or compârable hêâlth câro plofessional Care Çoordination Def¡nition Care coordinalion is the implementation of the HH care pian through appropriâte linkages, referrals, coordination and follow-up lo n€6ded services ånd supporl. Care coordinalion includes, but is not liñited to: - ãppointment scheduling and providing telephoñic remindêrs of appointments; - âssisting thÊ b6n6ficiary in navigating health, behaviorâl hoalth, and social services syslems, ¡ncluding housing as noededl - commlnity-based oulreach and follow-up, including fâceìoJace conlacl with benefrciaries in settings ¡n which they reside, which may include she'le¡s, streets or olher locations for unsholtered persons; - telephonic outreâch and follow-up to beneficiã es who do not rêquir€ fâc6lo-face contactl - ensudng that all regular screeñings ere conducted lhrcugh coordination wlth the primary caro or other appropriale providers; ' assisting with medication reconciliationl - assisting with arangements such as transporlation, directions ând coñplelion of durable rnedical equipment requests ' obtâining missing records and consullâtion r€ports; - encouraging lhe benefìciary's decision-mêking ând conlinued participâtion in HH care ptan: - pa¡ticipating in hospilal and emergency depaÍtment transihon care; ' documentalion iñ tho cerlified EHR technology; and ' Ensuring that beneficiary is conñected lo ând maintains eligibility for any public benefits to which the beneficiary may be enlitled, including llredicâid HHs will havg partnorships with DC N¡edicaid MCOS, primary care providers, spscialisls, and behavioral health providerc, as well as communily basod organizations. W¡thin these partneßhips, the rclês ând responsibilitiês for each pârly will be cleârly defined, and guided by the DCI\¡R, in order to âvoid duplicalive effods, and to ensure timely communication, uso of ovidence-based refeÍals, and follow-r]p consultêlions. HHs will ensure lhat screenings appropriate for specific chronic condilions arê conducted through coordinalìon wilh the approp alo providers. Ca¡e coord¡nation services may be provided by any member of the Health Home team, bul are driven by protocols and guidelines developed by the Nurse Câre lvlanager or comparâble heallh care professional, in collaboration with any olher approp¡iate health care professional (e.9. lho beneliciary's menial health and subslance use disoder (SUO) practilioneß). Doscribo how Health lnformation Technology will be usod to Iink th¡s serv¡co in a compreheng¡ve approach across thê cârc continuum HHs witl use thei¡ certified EHR technology 1o repoÍ and rev¡ew referrals made to oulside providers, social and communily resources and individual and family supports. Through this system, HHs will have access lo èâch boneficiary's historicâl sorvice utilization which will allow better trâcking of the beneficiary's needs, seNices received, ând the identification of opportunities lor improved care coordinâlion lo Ênable critical informatlon exchange, alt HHs will utilize CRISq or olher HIE se¡vices as dirÊcted by DHCF, 10 receive hospital event alorts (e.9. emergency depañmenl visits; hospital ãdmissions, tÉnsfers and discharges) ând both generate and receive conlinuily of care information. Additionêlly, HHs may be âble to benefit from the historical infonîâtion (updated in near r€al-time) th¡ough the Dynar¡jc Pât¡ent Care Profile ênd the capabìlities in the Analylical Patieni Population Dashboard to lnform the care coordination services delivered DÇ 'lO-0012 Effective Date: July 1,2017 Page 16 Superseded SPA: N/A CÀ¡S Approval Feburary 6 2017 217

2J712017 DC - Submission Package - DC2016lvlH0001O - (DC-1ô0012) The service can bo prov¡ded by the following prov¡der types ì Nuße Practilioner I . Nulse Care Coordinators i Nurses : I Medicâl Specialrsts . Physicians : . Physician's Assistants 'Pharmacists I r SocialVl/orkers : Doctors of Chiropractic 1.ì Licensed Complemenlâry and allemative Medicine Praciitioners , Dieticians ,. Nukitionists r.1. Other (specify) ProvidorTypê Oescript¡on FQHCs; Clinicâl Pråctices and Clinical Group Care coordination soNices may be provided by any member of lh€ Health Home team, but arê driven by prolocols and guidelines developed by the Nurse Care Manager or comparable health c8re pmfessionsl, in collêborêtio'l with âny other âppropriêto h6ahh care professional (e.g. the beneficiary's menlal heallh and substance use diso¡der (SUD) prêctitioners). Health Promot¡on Definition Health promotion ìs the provision of health education lo lhe beneficiary (êñd family momb6r/significanl olher whon appropriât€) specilic lo his/her chronic conditions or needs as identified in his/her HH care plan. lhis service includes, bul is nol limited to, assistance w¡th ñedication reconciliation and provides assistance for the beneficiâry 10 dev€lop e self-managemenl plan, solf-monitoring and management skills and promotion of a healthy lifestyle and wellness (e.9. substance abuse prevention; smoking prevenlion ånd cessãlion; nutn{ion counseling; increâsing physicalactivity; elc.)- Heallh promoiìon máy álso involve connecting tho benefrciary with peer/recovêry supporls including self-help/self-management and advocacy groups, providing support for improvìng a beneftciary's social nelwork, and educâting lhe beñelciary aboul accessing care in appropriale settings. Health promolion mây also involve lhe âssessment of the bêneficiary's underctanding of their heallh condrtions and motivatioñ to engage in self-managemenl and using coaching and evidence-based praclices such as motivational inlerviewing io enhånce underslanding and motivalion to achievo heallh and social goals. HH team members will document lhe results of health promotion activities (e.g. benefjciary ¡equestìng addilional nutdlion counseling; beneficiary selecting a date to quit smoking; successful linkage with a community-based suppod group) in the benefic¡ary's care plân, and ensu.e health promotion aclivities alÌgn with the beñefic¡ary's slaled health and social goals. Each HH w¡ll use data to identify and prioritize particular aress of need with regard to health promotion; reseârch best-practice intervenl¡ons: implemenl the activilies in group and indÌvidual settingst êveluale lhe effectivenoss of lhe interuentions, and modify them accordingly. Health prcmolion services may be provided by any member of the Heâlth Home team, but ale ddven by protocols and gu¡delines developed by lhe Nurse Ca¡e l,lanager or comparable health ca¡e profess¡onal in collaboration with tho boneficiary's mental heålth and subslance usê disordor (SL,D) prâctitioneß. Descr¡be how Health ltìfornation Tèchnology w¡ll be used to link this s€rvice in a comprehensivè approach across the care continuunì All HHs will usè theìr certifiod EHR technology lo docum6nt, review ând reporl health promotion seryices delívered lo each beneficiãry. Addilionally, clinical data such âs height, weight and Blr4l will be recoded and roporled in the cedified EHR technology. Additionally, structured data shared through C-CDAS or C' CDA equivalent approaches and the capabilities of the Analylical Palient Population Dashboard holds lhe polential to support heallh promotion âclivities of HH providers. Scope of serv¡ce The serv¡ce can lre provided by the follow¡ng Prov¡der types i.. Behavioral Health Professionels or Specialìsts r..., Nurse Prectition€r I . Nurse Care Coordinators ì Nurses i, [,]êdical Specialisls I : Physicians DC 16-0012 S!persedod SPA: N/A Effective Dâle: July 1, 2017 CMS Approvali Feburary 6, 2017 Pagè 17 5n

2,712017 DC - Submiss¡on Package - DC2016MH0001O ' (DC-1C0012) . Physician'sAssistants ì Phármacists i. Social V\brkers ì Docloß of Chiroprâctic ' ì Licensed Complementary and Êltemalive Ivediciñe Practitioners ' Dlelicians I : Nutriiionisls :r. Other (specify) Provider Type Descriptìon FQHC5: Clinrcal He¿lth promotiol seryices may be provrd6d by any me¡.berof the Health Home leam. bul âre dr'ven by protocols ênd guidellnes Prâcticés and Ctìnicat develoóed by the Nurse Care í,lanàger or coniparáble health care professional in collaborâlion with the beneficiâry s menlãl health Group Praclices and subslance uso disorder (SUD) praclitþnêrs. :.. Dieticians I Nulritionists DC 16-0012 Comprelrensivc TrarìsitioIal Care frorn lnpatient to Other Setthgs (including appropriate follow-up) Def¡nition Comprehensive lrânsilional câre is the planned coordinalion of lrânsitions between health câre providers and settings in oader to reduce hospital emergency department and inpatient ådmissions, readmissions añd lenglh of slay. An aim of comprehensive lransitional care is lo increase the beneficiary's and lamily members'ability to manage care and live safely in lhe community, shifting the use of reactive or emergency care and fealmont to proactive health promolion and setf-menagemênt. HHs will automaticâlly recoive notificalions of emergency room visits, âdmissions, dischårges and lransfors (ADT) from hospitals ås pad of HHs'enroltment in CRISP, and wjll contact hospitâls from which notificãtions aro received lo ensLrre appropriaie follow-up care after I ransilions. HHs will conduct in-peßon outreach pnor lo discharge or up to twenly-four (24) hours after dischârgo lo supporl transilion lrom inpaiient to other care settings. They will schedu¡e visits for benêficiades with a prìmary care provider and/or sp€ciâlisl within one (1) week of dÌscharge. HHs will have a clear protoco¡ for respondi¡g to ADI alerts from hospilals or any other inpatient facilrly lo facìlitate collaborallon in treatment, discharge, and safê trånsitional caro. S€rvices as part of beneficiary conlåcts during trênsltions include but are not limited lo: a) reviewing lhe discha.gê summary and instruclions; b) pedorming medicalion reconciliation; c) ensuring thal follow-up appoinlmenls ând l6sls are scheduled and coordinated; d) assessing the patient's risk slatus tor reâdmission lo the hospital or otherfailure to obta¡n âppropriate, community-based care; e) arranging for follow-up câre management, if indicated in the dischârge planl and f) planniñg âppropriate care/place to stay postdischarge, including fâcilitaling linkages to teñporary or permansnl housing and ananging transporiation as needed fortrânsilional care and foilow'up medical appointments. This HH component is provided prjmarjly by the Nurse Care l\¡anâger and Cãre Coordinator or compalable prcvider, Describe how Health lnformation Technology will be used to link this seruico in a comprehens¡ve approach across the care conl¡nuum To enable critical information exchange, êll HHs will enroll with CRISP, or other HIE services âs dirocled by DHCF, to receive hospital event alens (e.g. eme¡gency depãrlment visits; hospìlal admissions, kansfers and dischargês) and both generâte and receive conlinuity of care informalion. lvlCOs âlso recoivo hospital alerts through CRISP. To the exlent thal hospitals and other inpâtient sotlings have care transilion programs, HHs are êxpected lo coordinate with hospital discharge plannerc to prevont dupllcation of señices and lo ensure thâl all €ss€ntial functions of an effective carc transition have been pedomed. Addilionâlly, HHs may benefit from the histor¡cal informåtion (updaled in neâr real-timo) through lhe Dynamic Patient Care Profile, slructured dala sha.ed through C-CDAS or C-CDA equivalent app¡oêches, and the capabilities in the Analytical Patient Populãtion Dsshboard lo infom lrensilionel cale efforts. The serv¡ce can be provid€d by the follow¡ng prov¡der types I r Behavioral Health Professionals or spociâlisls I Nurse Praclrtioner i Nurse Câre Coordinato¡s : Nurses :. NledicalSpecialisls ' Physicians i : Physician's Assislants . : Phamâcists : , Sociai Vvorkers ' : Doctors of chìropractic , Licensed Complemontary and allenative [¡edicin€ Prâctitionors SLrperseded SPA] N/A Effeclive Date: July 1, 2017 Cf\¡S Approval: Febürâry 6, 2017 Page 18 4t7

217t2017 3, Othêr (spêc¡fy) Provìder Type FOHCSi Clinical Practices and Cl¡nical Grcup Practices Description This HH componênt is provided pdmarily by the Nurse Care Manager and Care Coordinalor or comparable provider I Nurce Care Coordinators i Nurses f . Ivledical Specialists : Physicians ì Physician'sAssistanls i Phârmacists : Social Workers : : Doctors of Chiropraclic : r Licensed Complementary and altemative l\,4edicine Practilioners i , Dielicians I r Nutrìtioñists .r' Other (specify) Provider Type Ðescript¡on FOHCS; Clinical This HH componenl is provided by ãny member of the HH team, but will bs primâily fâcjlitaled by ihe Carc Coordinator or practicès and Clinical comparable provider, iñ line with the bôñeficiary's care plan, and driven by prolocols ând guideliiìês developed by the Nurse Care Gfoup Precticss Manager or comparable provider Referral to Commun¡ty and Soc¡alS(lpport Services Dèfinit¡on RefeÍal to community and social suppoft services is lhe prccess of connecling HH beneficiar¡es to a wide array of support services that will help them ove¡come acces s or ¡ervice bariers, increas e s elf-ñanagement s k ills, and achieve overall health. These señices incllde, bul are not lirniled lo, facililatìng access lo suppod and assistance for beneficiades to address medical, bêhavioß|, educátional, economic, social and community issues that may lmpacl ovolall health. For persons experiencing homeìessness, this support may include individual housing transition seNices, as described in the J!ne 26, 2015 Centêr for lvledicaià & CHtP S;vices (CMCS) lnfomational Eulletin. Thê lypes of community and social supporl services to which beneficiãriês will be referred may jnclude, but sre not timited toì a) wellness progrêms, including smoking cessãtion, fitness, weight loss prog.amsi b) specialized support groups (e.g. cancei; diâb€t€; support groups; etc.); ò) substanòe tiealment supporl groups, recovery coaches and 12-step programs; d) housing resources, including oÇ 16-0012 Effeciive Dãte: Julv 1, 2017 Page ts Superseded SPA: N/A clMs Approvâl: Feburary 6' 2017 DC - Submission Package - DC2016N¡ H000lO - (DC-1G0012) Indiv¡dual and Family Support (which includes autlror¡zcd ref¡rescntatives) Definitiorl lndividual and family suppod services are aclivities that help lho beneficìary and their support team (includiñg family ând âuthodzed represeñtâtives) in ideñtifyi¡9 and ßeeting theia ra¡ge of biopsychosocial needs and accessing resourcos. These services include, but are nol limited to, medical lranspodation, language interpretatìon, appropdate literacy matorials, housìng assislance, and âny olher needed señices. lhe señices provide for continuity in relationships between the beneficiary/family with their physiciån and othor hoalth service providers and can ¡nclude communicaling on the beneficiary and family's behalf. These services may also educât€ lhe beneficiary in self-manâgemeñt of their chronic condltions, provide opporlunities for the family to partrcipate in assessment and development of lhe person{entered plan of care, and eñsure that HH êervices arê delivered in ê mânner lhât is culturâlly ánd linguislically appropriale. Additionally, these services may include referals lo suppol services and to facilitate linkages that are available in the bêneficiary's com¡nunity and assist with ìhe eslablishmenl of and conneclion lo "nalural supports.'These seruices may promote personal independonce, assist and support ihe beneficiary in stressor situations, empower lhe boneficiary to ¡mprove theÍr own environhent, include the beneficiary's family in lhe quality improvemenl process including suNeys io caplure their expeiencê wilh HH services, and allow beneficiaries/families access to electronic health rGcord information or other clìnicai infoma{ion. \ /hêrê appropriaie, the HH will develop family suppo¡t matedals and services, including creating fâm¡ly support groups. This HH comÞonent is provided by any member of the HH team, but will be primêrily facilitâted by the Câre Coordinalor or comparable provide[ in li¡e wth lhe beneficiary's care plan, and driven by protocol6 and guidelines developed by the Nuße Câre l\¡ânager or comparable provider. Descflbe how Heâlth lnformat¡on Technolo(ty w¡ll be used to link this service in a comprehens¡ve approach across the care corìt¡nuum All H Hs will us e their cedified E HR technology to documenl, review and report fam ily s upporl services del¡vered lo eac h beneficiary. Additionally, HHs may benefit from the hislorical infomation (updated in neâr real-time) lhrough the Dynamic Patient Care Profile and the câpabilili6s in lhe Analylical Patienl Populalion Dashboard to inform individuâl ând family support etforls. The seru¡ce can b€ provided by the follow¡ng provider Vpes I I Behavioral Health Professionals or Specialists 517

2712017 DC - Submission Package - DC2016M H0001O - (DC- 160012) addil¡onal housing and tenancy sustÊinìng s€rvices; e) social integralroni f) financial assistance such as Temporary Câsh Assislânce for Needy Fâmìlies (TANF) or Social Securìly; g) Supplemental Nutrition Assistânce Program; h) empìoyrnenl and educalional program or lrainingi i) legâl âssislanco resources; j) faith-bâsed organrzalionst and k) child carc. HHs will êssist in coodinating the services lisled above, facilitaling linkages and helping address bârriers to áccessing services, añd following up with bèñefrciaries to ensurc that needed soñices have been receìved. The HH will develop ând monitor cooporative agreements with community and social support agencies in ordor lo establish collaboration, follow-up, and reporting standards and provide training and lechnicâl assislance âs needed regarding lhê speciål nêeds of lho population. This HH componÊnt is provided by âny member of the HH leam but will bo primerily fâcililated by the Care Coordinator, in line with the beneliciary's care plan, and driven by protocols and guidelines developed by the Nurse Care Manager or comparable provider Descr¡be how Health Information Technology w¡ll be used to link this sêru¡ce in a colllprehensive approach across the care continuum Atl HHs will use certified EHR technoìogy to document, reporl and roviow refen-als to commun¡ly-based resources. Addilionally, HHs may bonofit from the historicãl informalion (updatêd in near real-time) through lhe Dynamic Patíent Care Profilo. Scopè ofs€rvice The seryice can be prov¡ded by the following prov¡dêr types ' Behavioral Heallh Prof€ssionals or Specialists '. Nurse Praclilioner ' Nurse Care Coordinalors . Nußes ì i Medical Specialisls i Physicians Physician's Assistanls 1. Pharmacists r. . Social Workers l. , Doctors of Chiropraclic , I Licensed Complementary ând êltemative lvledicine Practil¡oners .. Dieìiciañs . Nutritionists l/ Othor (specify) Descr¡ption FQHCS; Clinical This HH componenl is provided by any member of lhe HH leam, but will be p marily facilitated by the Care Coordinator, in ljne Prâcticès and Clinicâl with the beneiiciâry's càro plan, and driven by protocols and guidolines developed by the Nurse Care Manager or comparable Group PÉclices provìder Health Homes Patient Flow +/- D€scribe tho pat¡ent flow through the state's Health Homos system. Submit with the state plan amenciment flow-charts ôf the typ¡cãl process a Health Hôlnês ind¡vidr,âl would encounter An eliglble HH beneliclary will receive wrjtten notace from DHCF aboul being auto-assigned to a HH. This nolice will include information aboui lhe HH program, including the beneficiary's rights under the opt<ll process (i.e. assignmenl to a HH lêam, HH se¡vicês are free, enrollmenl is optional, nol onroll¡ng does not impact cunent services) This ¡otice will be supplemented by HH provider oltroach, which will be inilìated once DHCF communicates informaliôn ãboul the HH pógram to HH and non:HH providers wi{h pasi exFer¡êncê wlth the benoficiary. This noiice is to hêlp ensurê thê beneficiary is receiving consìstent infori¡allon from their network of provide¡s. Subsequenlly, lhe beneficiary can anticipate oulreach from the HH p¡ovider thât will includo an infomed consent process. The provider must document the benefciâry'Ê written informed consenl to padicipate in tho HH program, which the beneficiary may provide during a planned or newli scheduled visit. At th6t v¡sit, the beneficisry should expect to parlicipate in an assessmenl to inform the developrnent of a comprehensive care plan. As pad of ihis process, lhe beneficiary should also añticlpale that the HH providerwill gather health informal¡on from lhe beneflciâry's other healthca¡e provìdors G.g. [¡COs; spêciâlists; etc.) and¡onduct health risk screøns (e.9. depression; substance abuso; êtc.). The benelciary should afso anlicipale lhat the Nursê òaie wlanager (NClVl) or comparâble prcvjder and wìll reviewdiscuss assessrnenl resulls, health goals and heallh care priodties wilh the benoficiary during the visit. Tho b;neiiciary and mull!disciplinary HH team will agree upon and documont a comprehensivê HH carê plan that addresses wellñess and self' management goals ior any assesse¿ neeàs. Subsequently, lhe benoficiary can expect the HH leam to deliver HH services thêt enable the bensficiary to meet fhe g;âls oulli;ed in the cãre plân. Moving fo¡lvard, the beneficiâry should expect the HH leam to work with thei primary care provider and othêr providers ês nec;ssary; and to bo ìinked with any âdd¡ional ptuvidsrs ¡f necessar]. The benefcisry will be monitored dâily by the HH team lhrough reviews of hospilal ADT feeds to áetermine if the beneficìary us6d the ER or was admitted to lhe hospital. The boneliciary wìll be moñitorod wêekly by ihe HH teám through case rounds to track progress and plan âccordingly for ¡ñteñ€ntions/interâctions based on patiênl acuity and need. Tho bêneficiary will be r¡onitored quartedy through reviêws of -updated regisldes and cãre plan stâtuses conducted by the NCM. lf lhe NCI¡ identifies emerging iss!ês warlanting chânges, lhe beneficiary should a;ticipate f;llow-up {e.g. ro-assessmenl, rovised/¡ñcroased levels of êctivity). Beneficiary issues that may tdgger âddilional levels of activ¡ly in;lude, but are;ot li¡¡ited lo, meãication management, care complianco, outlier lâb vâlues, ancl progress conkolling BMI levels, tobacco use and motabâlic screåning values. The bensficiary should anti¿ipate lh€ir HH care plan being updated al teast every thrèe hundred sixty-five (365) days orwhen there is â significant change in their conditioñ. Dc 16-0012 Effeclive Date: July 1,2017 Page 20 Superseded SPA| N/A CÀ¡S Approvalr Feburary 6, 2017 6n

272017 Namê DC Pâtre¡t Flo\,,/ lor SPA docx Date Created '10/28/2016 5:33 P[.4 EDT DC - Submission Pâckage - DC2016l\4H0001O - (DC-1ê0012) Type m PRA Drsclosure Slatement According lo the Papenxork Reduction Act of 1995, no persons åre requrred lo respond to â collecl¡on of informâlion unless it displays 3 valid average 40 hours per response, including the lime to review inslruclio¡s, s€arch exislrng dala resources, galher lhe datå neede¿ and compleleând reviow lhe Boulevard Attn;PRA Repo¡ls Clesrance Of¡cer, À¡ail Stop C4-26-05, Bâltinlore, t!'laryland 21244-1850. DC 16-0012 Superseded SPA: N/A Effeclive Oale: July 1,2017 ClìrS Approval: F€burary 6, 2017 Page 21 7n

2712017 DC - Subm ission Packâge - DC2016MH0001O - (DC-1È0012) Records / Submission Pãckages DC - Submission Package - DC2016MH0001O - (DC-16-0012):'1\ Request SysLem Help VieÌv Cornpâre Doc Health Homes Providers MEDICAID ' Heallh Homes - À¡y Heallh ôPS'DC -2016 c¡1ls-10434 0[¡B 0938-11A8 Nol Slaned Package Header Types of Health Homes Providers { Designated Providers DC 16'0012 ln Progress Complele Package lD DC2016l\1H0001O Submiss¡on Type Official - Review'1 Apptoval Dale 21612017 S0perseded SPA N/A ID sPA rÐ DC-16-0012 lnÌtial St¡bmission 11/10/2016 Dâte Effective Dâtê 7/1/2017 View l plemantat on Gurde lnd¡cate tho Health Homes Des¡gneted Prov¡dels the ståte ¡ncludes ¡n ¡ts program and the prov¡der qual¡f¡cations and standards . .. Physicians J Clinical Practices orClinical Group Practices Descr¡be thè Prov¡dêr Qualilicat¡ons ancl Standards The HH leãm of health care prcfessionals will be embedded in the primary carc setting to effectively manage the full breadlh of bêneficiâry ñeeds. Eåch HH benefìc¡ary w¡ll be attribuled lo a designated clinical practice or cliñ¡cal group practice lhat wÍll serve as his/her HH. ln eddition to the scope of services normally deìivered by the clinical practice or clinical group practice, ihis entily will construct an inlêrdjsciplinary leem to deliver HH 6eruices. Spocific HH services will include; assessÍng the HH beneficiary to develop a compreheñsivo care plañl r¡anaging chronic iflnesses; coordinaling specialty câte and refeÍals to social, community, and long-term care suppo¡tsi providing compEhensive care managemenl; ând twentyjour (24) hou¡, seven (7) day a week access lo clinical advice. HH providers will be paíd a per member per month (PMPfvl) fee for HH servicos- A risk adjustment lool will stretify the population inlo lwo acuity cohortsr Group 1 (lower rìsk) and Group 2 (high6r nsk), with a hrgher PlvlPl\¡ fee for HH serv¡ces delivered to beneficiaries in Group 2. Eâch HH leam must b€ ad6quelely stêffed by heallh care professionals that, at a minimum, are capable of providing specifc funciions lo meet Federal and Dislricl HH slandards, and must be comp¡ised of practitioners (or comparablo practitioners approved by DHCF) who fll the following roles for each ecuity group of HH beneficiaies: Group 1, Lowe¡Acuity: '1) HH Director- lvaôtor's level education in a health- related fieldi 2) Nurso Câro lì/lânagoÊ nurse with ân advanced p¡actic e liôense Superseded SPA: N/A Effective Date: July 1, 2017 CI\¡S App¡ovalì Feburary 6, 2017 Pagø 22 1t4

2J7t2017 DC - Subm¡ssion Package - DC20f6l\¡H0001O - (DC-1G0012) or Bâchelor of Nuasing with approprlate câre management expenonco and 3) Peer Navigator- a lrained hoalth educâtor capâble of linking beneficiafies with th6 hoalth and soc¡al señices they need to achieve wellness; and Group 2, HigherAcuily: 1) HH DirectoF Maslor's level education in a hoalth- related field; 2) Nurse Care Manager- nurse with ên ãdvanced practice licensê or a Bachelor of Nursing with appropdete care managemeni expedence; 3) Peer Navigator - a lrain6d heâllh educator capable of linking beneflciaries with the health and social services lhey need to âchieve wellness, 4) Care Coordiñâtor- a Bachelor-level social wo*or or an ind¡vidual with â Bâchelor's degree ¡n a heaìth-relãted fjeld wilh lreining in a health carc, human services field or equivalonl experience; ând 5) Clinical Pharmaclst - a Doclor ol Phârmacy with educalion and llaining in direct patient care environments, including medicâl cenle¡s, clinics, and other health care settings. HH team members must meel all applicabl€ licensure and cediftcation requirements of the District of Columbia Health Occupat¡ons Revisions Acl of 1985, effective March 25, 1986 (D.C. Láw 6-9S; D.C. Otficial Codo SS 3- 1201.01 et seq. (2012 Repl. & 2015 Supp.)) and âttendant regutations contâined in Itle 17 of lhe DCI\¡R- Thê minimum ratio for eâch required HH staff member lo HH beneficiary will be listed in the DCI\4R. DHCF wllt eslâblish a process to allow HHs to request approval to utilize an altemalive compelable slaffing model. Finelly HHs are encourâged lo add âdditional roles to HH teams that reflecl thê noeds of their empanelod members (e.g. dietician). :..i Rural Health clinics : Community Hêalth Centers . i Community Menlal Health Centers .. Home Hêatth Agencie 1... Case fulanagement Agencies ..-l Community/Behavioral Health Agencies :{: Federally Qualifiêd Health Centers (FQHC) oescribe the Provider Quâlifications and Standards Tho HH teêm of heãlth care professionals will bo embedded iñ the primary care setting to effectively manage thê flll breâdth of beneficiary needs_ Each HH beneficiary will be alt¡ibuted to a designated FQHC lhat wlll s€rve âs his/her HH. ln addilion lo the 6cope of services detiverod as a pnmary care provider (e.9. âcute and prevenlive câre), lhe FQHC will conskucl an interdlsciplinary team to deliver HH services. Specifc HH services will includei assessing the HH bêneficiâry lo develop â comprehensive care plan; managing chronic illnossesi coordinaiing specialty cere and refêrals to sociâ|, communrly, ând long-lem care supporis; provlding comprohensive care managemeñt; and twentylour (24) hour, seven (7) day I week access to clinicâl adv¡ce. HH providers will be paid a PIVIPÀ, fee for HH services. A risk âdjustment toolwill stlatify the populâlion into two acuity cohorts: croup'1 (lower risk) and Group 2 (higher risk), with a higher PI\4PM fee for HH seryices dolivered lo beñeficiaries in Group 2. Each HH team musi be adequately slatfed by health care professionals that, at â mìñimum, åre capable of providing spec¡fic functions lo meel Federal and Districl HH slanda¡ds, and musl bg comp¡ìsed of practitioners (or comparable practitioners approved by DHCF) who fill the following roles for eâch acuity group of HH beneficiariesl Group 1, LowerAcuity: 1) HH DiiectoF l\IEsler's level educalion in a health- related field; 2) Nurse Care f\¡anageÊ nurse wilh ân advanced p¡aclice license or a Bachelor of Nursing with ãpptopiale care management experience; and 3) Peer Nãvigator- a lrained hoallh educáto¡ capable of linking beneflciaries with lhe health and social setuices they need lo achieve wellnesst and Group 2, HigherAcuily; 1) HH Oirector- l\¡asler's level educalion in a heallh- related fieldt 2) Nurse Care l\rânager- nu¡se with an advanced practico license or a Baêhêlor of Nlrsing with appropriate care managemenl experience; 3) Peer Navigãlor- a kained health educaior capable of linking bêneficiâñes with tho health ênd social services they need lo achievo wellness, 4) Care Coodinator- a Bachelor-level social worker or ên individual wilh a Bechelois degree in a heallh-related field wilh training in a health câre, human services field or equivalent expsrionce ând 5) ClinicEl Pharmacisl - a Doclor of Phamacy with education and training in direct patient care enviroñments, including medical centers, clin¡cs, and other health cåre settings . HH leam members must meel of the District of 1201.01 et seq. (2012 Repl. & contalned in Tjlle 17 of the DCIMR. DC 16-0012 Superseded SPA: N/A Effeclive Dâler Jlly 1, 2017 CI\¡S Approvâli Feburary 6, 2017 Supp.)) and altendanl ¡egulations Page 23 z4

2nt2017 DC - Submission Package ' DC20'16MH0001O - (DC-1G0012) The minimum ratio foreach required HH staff member to HH beneficiåry will be listed in the DCN¡R. DHCF will eslablish a process to allow HHs to request approval lo ulilize an alternative comparable slaffing model. Finally, HHs are encourâged lo add additional roles to HH teams that reflecl the needs of lheir empaneled members (e.g. dietician). . Other (Specify) i Teams of Health Care Professionâls ' Heallh Teams Provider lnfrastructure ) t- Descr¡be the infraskucture of provider arrangemenþ for Heâlth Home Services Designated providers of HH sorviceô for boneficiaries with chronic conditions will be Clinicâl Practices, Clinical Group Practices or FQHCS identified by DHCF to meet the standards of a HH. The Clinical Praclices, Clinical Group Prâctices or FQHCs will leâd s leam of hêaìth care professionals who deliver HH s6Nices to HH beneficiaries. Additionally, lh6 Clinical Practices, Clinical Group PÉctices or FQHCs are responsible for developing working relationships and padnership agreements, as appropriate, wilh rnanâged câre organizalions (l\¡COs), other communily-based señice providers, hospitals and other heallh-related entilies that del'ver services to lheir enrolled beneficiaries in oder io âdequâtely deliver HH services. HHs will use thei cerlified EHR technology lo facililale the delivêry of the six (6) corê HH services, ând will use their EHRs lo caplure ánd lrack services provided to enrolled HH bêneficiaries. Supports for Health Homes Providers The HH Descrihe the methods by which the state will support prov¡ders of Health Homes serv¡ces in address¡ng the following componênts 1. Provide qualily¡ñven, cost€ffective, culturâlly appropriato, and person- and family- centered Hoalth Homes señices 2. Coordinate ând provide access to high quality health care señices informed by evidence-based clinical practice guidel¡nes 3. Coordinate and provide access lo prevenlave and health promolion services, including provention of menlal illness ând substance use disorders 4, Coordinate and provide access lo mental health and substânce abLrse servic€s 5, Coordinate and provide âccess lo comprehensive caro management, care coordinâtion, and transitional caro across settiñgs, Transitionalcare includes appropriate follow-up from inpâlionl to olh6r seltings, such as participation in discharge planning and facilltating lransfêr from â pediatric to an adult syslem of heallh care 6. Coordinal6 and provide access lo chronic disease management, including sellmanagemeñt supporl to individuals and their farniliês 7. Coordinalo and provide âccess to individual ãnd fam¡ly supports, including refeÍal {o community, social support, and recov€ry serurces L Coordinâle and provide access to long-term car€) supports and señicee 9. Develop a person{entered care plan for each individual that coodinâtes and integrâtes all of h¡s or her clinical and non-clinical heallh-care relaled needs and services 10. Demonslrale a capacity to use heâlth informâtion lechnology to link services, facilitatê communicalion among team mêmbers and between the health teâm ãnd individual and fâmily caregivers, and provide f€êdback to practices, as feasible and appropriate 11. Establish a continuous quality improvement prcgrem, and collect and repoñ on data thal pêrmils an evalualion of incÊêsed coordination of cáre ând chronic disease management on individual-levol clinical outcomes, experience of care oulcomes, and qualily of care outcomes at the populalion levêl Description overseen by DHCF. DHCF is commilted to, directly or indi¡ectly, provido t6chn¡cal assistance with, but not limiled E) ãnd care manãgement to aide in lhe suêcoss of the HHs. The types of assislance may include: a) training to support engâgement their enrolled beneficiâdes through lo olher agencies, health care providers, and HHs as lhey coordinate the delivery of heslth CRISP, añd furlher support via á coordinaled DHCF will communicate externally to facilitate HH refenals and lhe collaborative those entilies with HH caro plan embêdded in their cêrtifi€d electronic hoallh record technology. The HH care plan includes primary, acuto and long lerm health care informalion to achiêve an individualized, comprehênsive epproach for h6allh care treatment and self-management. lt wiÌl also serve as a source of information for moniloring and evaluation purposês. DHCF will work collaboratively wth HHs to monilor program jmplementâtion, respond to loaming needs that emeqe, âñd eslablish HH pêrformancê monitoring âchvities lo €nsurê HHs' services meet District añd federal iñdividuâlized and population{ocused stsndards. Other Health Homès Provider Standards The state s rêquírements and expectations for Heâlth Homes p¡oviders are as follows HHs will operate under a 'whole'person' approêch to care within a culture of continuous quality improvemênl that looks at a HH beneficiary's full aray of clinical and non4tinical hêalth cârc needs ând señices and social needs ând services. HHs will deliberately organize cullurally appropriate, person-cenlered care activities and share information among all practitioners directly invoived with a person's cêre to âchieve sâfêi mo.e effective care and improved health outcomes. The below stendards were devoìoped with input f¡om a variety of stakeholdors inclilding primâry care phys¡cians, FQHCS, hospitals, cliñics, and housing providers. Representalives from DC's Deparlmênls of Health, Bohavioral Heallh, and Humân Servìces, DC's Heelth lnformation Exchange Policy Board, ãnd DC's lnteragency Council for Homelossness also parlicipaled in the development of lhese slandards. The standârds set the foundalion for âssuring thal HH beneficiaries receive appropnate, and lirfìely access to medical, behavioral, and social setuicês ln a coordinaled and integEted mannel A. Eligibility Standadsi lñ ord6r to be eligible to serve as a HH providêr in the DC Medìcaid program, entii¡es must atminimum; Dc 16-0012 Eff€ctive Date July 1' 2017 Pagè 24 Supers€ded SPA: N/A CI\¡S Approval: Feburâry 6, 2017 314

2mm17 DC - Subm¡ssion Package - DC2016[¡ H0001O - (DC- 1G0012) 1. Be enrolled as a DC l\¡edicaid provider, 2, Not hâve cunenl or pêndi¡g exclusions, suspensions, or debârment f.om any Drstricl or federal health câle plogrâm; and 3. IVIâìñtâiñ compliance with the Enrollment and l\¡âintenânce Standards in Seclions B and C, as outlinod bêlow B. Enroltment Standards: ln order to be enrolled ãs a HH provider in the DC Modicaid program, eniities must apply lo becomo a HH provider DHCF will review the applicâtion based on the folìowing enrollmenl standárdsl 1. Having NCOA Patienfoentered lúedicâl Home (PC[4H) Level 2 rocognition (or future corrcsponding NCQA PC[4H equivaleni level recognition) or proof of beginning the NCQA PCI\¡H application p¡ocess. 2. Using cedified EHR lechnology to create end execute â person{enlered câre plan for each beneficiary basod on HH assessments, hospitâl data and infomalion gathered from olhor extemal heâlth care providers. 3. Pto\/iding2417 access to clinicâl âdvico, including culturally appropriate translêtion and intePt€tation services for beneficiaries with limited English profìciency; 4. Domonslrating sufficient core team mombercapacity to soNô eligible beneficiâdes including, al a minimum, qualified praclitionerc to frll the following roles for each acuity group of HH beneficiaries: Group 1, Lower Acuity: HH Directot Nurse Caro Manager, and Peer Nâvrgâtor, añd Group 2, Higher AcuÌty: HH Diroctor, Nurse Care Managêr, Peer Navigalo[ Care Coordinaloi ãnd Clinical Pharmacisl. DHCF will eslablish protocols fo¡ HH providers to report program changes in order to mainlain compliance wiìh Seclìon A, B, and C. 5. DemonstEting ábility to deliver core HH seNices, es well as document lho processes used to perform the following functions; a. Providing qualitydiven, cosl-effeclivo cullurally app¡opriâte, and person-and family-ceñtered HH servicesl b. Coordinatiñg ênd providing access to high-quality heallh care services informed by evidence-bâsed clinical praclice guidolinesl c. Coordinaiing ând providing access lo preventive and hoalth promotion seNices, including p¡evention of mental illness and substance use disolders; d. Coo¡dinal¡ng and providing accoss lo mental health ând substance abuse sêrvices; e. Coordinaling and providing access to comprohensive carc managemonl, care coordinâtion, and transitional care across settings. Transitional care includes appropriâte follow-up and inpalient lo other settings, such as pa¡ticipations in discharge planning and facilitat¡on transferfrom a pediatric to an adult syslem of health care; f. Coordinaling and providing access to long-term care suppods and se¡vices; g. Developing a person-centered care plan for each beneficiâry that coordinates and integrates all of his or hér cllñical and non{linical healthcare related needs and seNices; and h. Establishing a continuous qualily improvement program. 6. Demonstraling that lh6 HH will be âble to diroctly provide or subcontracl for lhe provision of, HH services. lhe HH remains responsible for all HH program requirements, including servìces provided by th6 subcontractol: 7. DÊveloping a plan to estâblish and maintain communicâtion prolocols with exlernal health ca¡e partners, including legally compliant dala shâring âg|eemeñts, to âssuro effective coofdinalioñ ând monitodng of beñeficianes' health care services and for efficienl transitional care; and 8. Enrolling or demonstrâting enrollmeni an CRISP to recerv€ hospital and ER alorls lor onrolled beneficianes. C. Maintenance standards: ln order to mainlain enrollment as a HH provider in the DC l\4odicaid program, eniities must: 1. Particìpate in activities suÞpo¡ting the successfrll imp'emeniation and slstainabillty of HH seryices. Activities may incl!do, bul are nol limited to: trainings to losler profêssional competency and best practice dgv€lopment related to person-centered planning, chronic disease self-managemenl, and other topicsì continuous qualily improvemeñt lasks, monìtoring and porfo¡mance reportiñg; and CMS and DHCF-requìred evalualions. 2. [¡aintain complianco with the Eligibility and Enrollment Standârds idontified in Sections A and B, âs oullined above. DHCF will establish protocols for HH providers lo report program chângês in orderlo r¡ainlain compliance with Seclions A and B, as outlined ãbove. Name Dâte Created TYP" No ilemô availâble pRA Disclosur€ Statement According to the PapeMork Reduclion Aclof 1995, no persons âre r€quired lo respond lo a coìleclion ofinfornralion unless itdisPlâys â valld average 4o houß per.esponse, inctudi¡g the timê to rev¡ew instruêlions, search existìng daia resources galherihê dâta nêeded. ¿nd complele ãnd @view ìhe Bo!levard Arin:PRA Reports Cleara.ìce Offc€r, l¡allStop C4-26'05, Ballir¡ore Marylaîd 21244'1a50 DC 16-0012 Supêrseded SPA: N/A Effeclive Date July 1,2017 Cf\rS Approval: Feburåry 6, 2017 Page 25

2,7t2017 DC - Submission Package - DC2016lvlH0001O - (DC-1C0012) Records / Sullmiss ùn PáckãfJes . - AII Rev¡êwablê Units DC - Submission Package - DC2016MH000lO - (DC-16-0012):'l...-. F{eqlrest Sysienr Help View Compare Doc Health Homes Service Delivery $ystems [¡EDICAID - Heall,h Homes - [4y Heâllh GPS - DC - 2016 c[¡s-10434 0MB 0938,1188 Nol Stañed ln Progress sPA tD DC-16-0012 Ê.Îf ecfiv e Dale I I 1 I 20 1 -/ Complete View lnlpleûìentairon Guide Package Header Package lD DC20'16MH000'1O Suhmission lype Officìal ' Review 1 Apptoval Date 21612017 Superseded SPA N/A ID lnìtial Subm¡ssion 11/10/2016 Date ¡dentify the service delivery sy6tem (s) that will b€ used for individuâls receiving Health Homes serv¡ces ? Fee for Service . PCC|\4 r' Risk Bêsed Managed Care The Health Plans w¡ll be a Oes¡gnâted Prov¡der or part ol ¿ Team of Health Gare Profess¡onals lnd¡cate how duplìcation of payment tor care coordination in the Health Plans'current capilâtioñ rate will be avo¡ded . : The cunent capitalion rate will be reduced { The Stale will impos€ additional conkact requiremenls on the plans for Heâlth Homes enrollees l¡odifcations to the curent Medicaid Iì¡CO conlracts will be execuled to ensure MCOs and the downslr6am HHs included wilhin thei¡ I\¡CO provider netwo*s implemeni functional collaboration in primary, acute, behavioral health, and longle¡m services and suppotts int6gration. l\¡COs will be expeclod to leverage rêlalionships b6twê6n thÊ HH and their lvloo-enrolled beneficiaries in meeling lholr contractuâl population- basêd 6eruice coordination mandâtos, For benefrciades enrolled in both a HH and an N4CO, the HH and MCO will esteblish a lì/lemorendum of Agreomenl (ll,4OA) that sêts lhe communication f¡equency and protocol fori l) idenlifying beneficiaries recoiving s6rvicês from bolh entilres. 2) devoloping a joinl caro plân or aligning individual care plans for each shared beneliciary, and clear division of lâborfor the provision of care coordination and case managemenl services, reflecled in each entity's respective care pìan for eâch shared beneficiary; 3) outlines types of HH seNices deliv€rêd or thal will bê delivered to the shared beneficiaryi 4) flagging each other on new informalion necessary for coordÍnating services, such as fâilure to pick up mèdication, rocenl housing status, new community- based supports and others; and 5) establishing aud¡t and program moniloring arrangements. This N¡OA will specify the point of contact for each entity. MCOS are expected to follow DHCF's established process to link eligible beneficraries to an âppropriâle HH. Page 26 1t2 Provide a summary of the co¡ìtract language for the addìtional reqúiremênts DC 16-0012 Superseded SPA: N/A Efleclive Date July 1,2017 Cf\¡S Approvâl Feb!rary 6, 2017

217t2017 DC - Submission Package - DC2016l\¡H0001O - (DC-1e0012) .. i Other ' Olher Sorvice Delivery Syslem PRA Disctosure Stateme¡r According to the Papefwork Reducrion Actof 1995, ño persons are req!ired lo respond lo a collection of ¡nformation unle6s Ìt drsplays â vâl¡d âverage 40 hours per ¡esponse, i¡cluding the lime lo review inÉtruclions, search existing dâla resources, gatherihe dala needed, and complele and rev¡ew lhe Boulevârd. Atlrì: PRA Repôds Cle¿¡ânce Offrcer, [4ail Stop C4-26-05, Bâltimore Maryland21244-1a5o. DC 16-0012 Superseded SPA N/A Effectivo Date: July 1,2017 CMS App¡oval: Feburâry 6 2017 Page 27

2J712017 DC - Submission Package - DC2016l\4H0001O - (DC-lê0012) Records / Subl'nission Pâckages DC - Submission Package - DC2016MH0001O - (DC-16-0012) . ","y Reqlrest SysLem Heip Vi€w Cornpare Doc Health Homes Payment Methodologies lvlÊDlCAlD - Healt\ Honìes - ftlly Heallh GPS " DC - 2016 c[4s-10434 ofvB 093E,1168 Nol Starled Package Header Payment Methodology DC 16-0012 ln Progr€ss Conrplele Package lD DC2016[,1H0001O Suhmission Type Official - Review 1 Apptoval Dale 21612017 Supersedad SPA N/A ID sPA lD DC-16-0012 ln¡t¡al Submission 11110/2016 Oate Éfia|tivè Dàlè 71112A17 VJew lnlplementåì on Guide \4ew All Responses The State's Hoalth Homes payment methodology w¡ll conta¡n the follow¡ng features { Fee tor sefvrce ' lndividual Rates Per Seryice d. Per IVIembet Per l\4onth Rales ! r Comprehensive lì¡ethodology lnc¡uded in the Plan :./ì Incentive Pâymenl Reimbursement .4 Fee for Señice Rates based on ,4 Severity of each iñdividuâl's chronic conditions :4 Capabilities of the teãm of health care professionals, designaled provider, or hoallh teâm l l orher .{. Fee for Service Rates based on I Severity of each individual's chronic conditions . I Cãpâbilities of thê team of health care professionals, designated provider, or heallh têam l¿ other Dêscr¡be below DHCF plans lo implement a pay-foÊperfo¡mance component ihat provides incentive paymenls to HH prov¡ders f or achÌeving quãlity/performance benchmarks. DHCF wrll onsure the melhodoloqv used Page 2A-' Superseded SPA: N/A Effeclìve Dâte July 1, 2017 C[¡S Approval: Feburâry 6, 2017

217t2017 DC - Subm¡ssion Package - DC2016l\4H000'1O - (DC-1G0012) The aoencv râtes are set as of tho lollowinq date and are etfeclive for seturces provided on or aíter that dêlo - -ð¿iê-o-(jìã ' - Eflective Dâte Julv 1,2017 to calculale and disburse incentive payments is consislenl with lho HH program goals of efflciency, economy end quâlily. ln only the flrsl quarter of the frrst year of the program, HH providerc will be eìigible for a one time incentive payment lo supporl the dêvelopmênl of care plans (as doscribed in the definitioñ of Comprchensive Caro Management) for HH beneficiaries. Further guidânce on lhe incentive paymenl will be outlinod in lhe DCÀrR. HH providors will also be elig¡ble to receive an annual payJoÊpelomance bonus payment, ño sooner than lhe last quarter ol the sêcond flll Fiscâl Yêar aft6r the effective dale of the proqram HH provider porformance will be evaluated by process, efficiency, ãnd oulcome câlegories. DHCF will inform HH providers prior to the start of each Fiscal Year lhe larget porformance for each measur€ calegory, based on ân anâlysis of prior performance. HH providers will be subject to a percentage withhold of their PlvlPfvl, no sooner than the frrsl quarter of the second full FiscãlYear after the effective dale of the progrâm. The HH provider mlst achieve the târgel peformânce fo¡ each meâsure in lhe calegory to achleve the incentive payment for that calegory. HH providors may earn ân incentivo paymenl highêr than lhê amouñt wilhheld. Furiher guidance oñ the pay-for'pedormance componenl will be oullined in the DCMR, âvailablo ati wwwdcregs.dc.gov, with an effective date of July 1, 2017. DHCF will use two (2) pe¡ member per monlh (PMPM) raies to reirnburse for HH services lha{ differ based on the assêssed acuity of the I\¡edicãid benefrciary. DHCF developed these rålos by analyz¡ng FY 2014 ând 2015 l\¡edicaid claims data to idenlify thê most common chronlc conditions associâted with more frequent ER use and/or hospital âdmissions. Through lhe anafysis, DHCF identified the top sixteen (16) chronic conditíons, which include; mental health conditions (depress¡on, personalily disorders)t substanco usê disorders; Descr¡bê âny va¡iatìons irr payment based on prov¡der ôuât¡fi¿ãriôns. asthma (+COPD); diebelÊs; hêarl drsease (CHF, conduction dìsordeß/cardiac dysrhyihmies, myocardiâl infârction, pulmoñary heârl inOiv¡¿ual ca¡e disease), Blvll over 25 (morbid obêsily only); cerebrovascular disease; ch¡onic renalfailure fon dialysisl; hêpatitis; HIV; hypedipidemiai hypertension; malignanciesì paralysis; peipherâlãlhsrosclêrosist âñd sickle cellanemia. DHCF will utilize a risk adjustment loolto ,-l:--::l :; ::l: deternrine the risk for future hospital utilizãtioñ, ând târget and strâtify the populâtion inlo two acuity cohod6: Group 1 (lower ¡ìsk) and - "ll'-"ÏlY,::-'l: croup 2 (higher risk). The melhodology wjll be used to ¡lâce lhe high;r risi b;noficiarios in croup à and the remai;der of eligible beneficiarìes in Group 1. The two (2) resulting rates are based on the DHCF HH stâfiing model and reflect the average expecled sorvice intensity for those receiving HH services, and will beset in accordance wilh Section 1902(aX30XA) of the Social Security Act (42 U.S.C S r396a(ax30) (A)). DHCF will pay a higher PMPM aale for bgneficiarios in Group 2 (higher acuity) due to a higher expecled need for HH seryices and requisite slaff. The base PMPIVI rates for both Group 1 (lowor êcuily) âñd Group 2 (higher acuity) account for the regionally adjusled salades for the required HH slatf (including fringe costs) and is adjusted based on staffing râtios pêrâcuily group. lwo (2) paymenl enhancements âre added on top of both base rates: 1) to reflecl overhead or administrative cosls; and 2) to support HH providers in meeting the heålth informalion technology r6quirements. The payment methodology and rates will be further outlined iñ the DCMR. DHCF will review the HH rates ânnually ånd re-baso as necessary. ¡n ord6r lo receive the fìrst PI\¡PM payment for an eligible HH bonoficiâry, a HH provider must inform the HH beneficiary about available HH sorvices, receive the beneficiary's consent lo receive HH servicos, ând begin the deve,opment of a care plan. The development of the care plan will follow standards for Comprehens¡ve Care lvlanagemenl descdbed below HH prcviders rnusl doliver at least on6 (1) HH seruice within the calendêr rnonth to tho elig¡ble HH beneficiary in order to receive a PMPIVI that month. For beneficlaries in Group 1, the HH se¡vice does nol need to be dêtiv€¡ed in-person for the provider to be eligible for lhe PMPM peymênt. For benefrciãriês in Group 2, âl least one (1) HH service needs to be delivered in-person for the provider lo bê oligible lor the PMP[¡ payment. Providers will subrnit claims via MIVIIS using a specific procedLÍe code for health home services. Additionally, providers will be required lo utilize ê modiiiêr on lhê procedure code that ilemizes which of lhe health homê seruices was dolivored. lnformalion on the PMPM rates will be made available lhrough the DCI¡R, available al: w\¡rwdcregs.dc.gov wilh an etfective dale of JulY 1,2017 HH râtes will be made available on the DHCF fee schedule ai hltps://w\rwdc-medicaid.com/dcwebpodal/home. L PCCI¡ (description included in Señice Delivery section) . , Risk Based À4ânaged Care (desc¡jption included in Service Delivery section) l : Aliernative models of paymenl, other than Fee fo¡ Service or PlVlPl\I payments (desc be below) Agency Rãtês Any claim for progrâm services shall be supported by writlen documenlalion in the EHR and the DCMR will prcvide cleâr instructions on minimum documentation requirer¡ênls. All claims for heêlth home services will be subject to regular audits to ensure ihal l\4edicaid paymenls rnade to hoãllh home providers are cons¡slenl wilh efficiency, êcoñomy ând quality of care, and made in accordance with federal ând District conditions of paymenl. Describs the rates usêd l-l-s Rãt6s rñcluded rn dan G, comprehensive metho¿ology included in plÊñ Superseded SPAi N/A Cl\lS Approvâlì Feburary 6, 20'i7 Page 29 2J4

2,7t2017 DC - Submission Package - DC2016MH000lO - (DC-1G00121 Rate Development comprehensive DHCF wll use two (2) per momber por month (Plì¡PM) rates to reimbuße for HH services lhal diffor basod on the ass6ssed acuity oJ lhe DescriptÌon Medicaid beneficiary. DHCF developod lhese rates by analyzìng FY 2014 and 2015 lì¡edicaid claims dâtâ to identify the most common chronic conditions associated with mo€ frequent ER use and/or hospital admissions. Through lhe analysis, DHCF identrled the top slxteen (16) chronic conditions, which include: menlal health conditions (depression, personality disordors)t substanco uso disorders; âsthmâ (+COPD); diâbêlesi hoart diseasê (CHF, conduction d¡sorders/cardiac dysñythmies, myocardial infârclion, pulmonâry heart d¡seâse); BIì/ll over 25 (moùid obesity only)i cerebrovascular disease; chronic reñal failure lon dialysis]; hepatitis; HIV; hyperlipidemia; hypertensiont malignancies; paralysis; pedpheral atherosc¡erosis; and sickle cell anemia. DHCF will ulfizo a risk adjuslrnont tool to determine the dsk for futuro hospilal !tilizalion, and target and stralily {he population into two acuily cohodsr Group 1 (lower risk) and Group 2 (higher risk). lhe methodology wfl be used to placo tho higher risk beneficiades in G¡oup 2 and the rcmainder of eligible beneficiaries in Group 1. The two (2) resulting rates aro based on thê DHCF HH slaffrng model and reflect the avorago expected seNice inlensity fo¡ those receiving HH services, ând will be set in accodance with Section 1s02(aX30XA) of the Social Securily Act (42 U.S.C. S 1396a(a)(30) (A)). DHCF will pay â higher PI\¡PIl¡ rate for benef¡ciaries in Group 2 (higher âcuity) due to a higher oxpected need for HH servìces and requisite staff. The base PIt PM rates for bolh Group 1 (lower acuity) and Group 2 (higher âcuity) account for the regionally adjusted salades for the required HH staff (including fringe cosls) and is adju6lod based oñ slêffing ratios pe¡ âcuily group. Two (2) paymenl enhâncements are added on lop of both base rates: 1) to reflect overhead or administrat¡ve costst and 2) to suppon HH providers in meeting the health ìnfomation lechnology requirements. The payment methodology and r¿les will bo furlhor oullined in thê DCMR. DHCF will review the HH rales annually ând re-bâse âs necessâry. ln order to receive lho first Pf\¡Pl\¡ payment lor an eligible HH beneficiary, a HH provider m!sl infom the HH benelciary about available HH seNices, receíve the beneficiary's consent to receive HH seNices, and begin the development of a cero plan. The devolopment of the care plan will follow slandards for Comprehensive Care Management described below HH providers must deliver at least one (1) HH service within the c6lendâr monlh lo lho oligible HH ben€ficiary in ordêr lo roceive a P[rPl\¡ lhal month. For beneficia¡ies in Grcup 1, the HH selvice does not need to be delivered in-person for tho provider to be eligible for the PMP¡/l payment. For bonêficiaries in Group 2, at leasl one (1) HH service needs 10 be delivered in-person for the provider to be eligible for the P[¡PM payment. Providers will submit claims vi6 [4MlS r]sing a specific procedur6 code for health home seNices. Additionally, providers will be required to utilize a modifier on the procedure code thal ilemizes which of the health home services was delivered. Any claim fo¡ program servac€s shall be supportêd by w¡itten documentati0ñ in the EHR and the DCI¡R will provide cloar inslruct]ons on minimum documenlalion requirements. All claims for heallh home seNicos will be subject to regular audits lo ensure that Nledicaid payments mâde to heallh home providers sre coñsislênl úlh gfficiency, economy ând quality of câre, and made in accordance with fedorâl and Districl conditions of paymeñt. lnformation on the PMPI\,,1 râles will b6 made available through the DCMR, available al: www.dcregs.dc.gov, with ân effoêlive dalê of Jþly 1, 2017. HH ratês will bs made âvailable on the DHCF fee schedulo al hltps://ww!v.dc-medicaid.com/dcwebportal/home. Assurances Provide a comprehensive descript¡on ¡n the SPA of the mônner in which rates were set 1. ln lho SPA pleaso provide lho cost datâ and assumplions thal were used to develop each of lhe rates 2. Pleâse identify the reimbußable unit(s) of seruice 3. Please desc¡ibe the minimum level of activitles that lho state agency requircs for providers lo receive pâyment per tho defined unit 4. Please desc¡ibe the slale's standards ând ptocess roquired for service documentation, and 5. Please dÊscribê in lhê SPA the procedures for reviewing and rebasing tho Íales, including " lhe freqlency with which the stale will reviewlhe råles, and o lhs factoß lhat will bê reviowed by the state ìn order to undersland if lhe rales are economic and efficient and suffrcienl to ensure quålity seruices. '{. The State provides assurance that it will ensure non-duplication of paymenl for services similar to Heallh Homes services thal are offered/covored !ndor a different statutory authority, such as '1915(c) waivers or largeted câse menâgement. Describe below duÞlicát¡on of pâyment will lre DHCF will ensuro that HH selvice payments will not dupljcâte payment for lìredicaid-funded services offered through ãnother melhod (i.e. managed care, '1915(c) waiveß, any future HH st€te plan bonefits, and olher slate plan serurc€s). DHCF will ulilize thê DCIMR, provider guidance mater¡âls, and l\¡OAs lo clarify roles of providers offering similar seNices lo promolê a complomentary syslem of seruices lhat advances whole-pefson care and ensures non¡uplicalion of payment or señices. ln instâñces of known duplicalion, DHCF will leverage ìls MedicÉid [,4ênagement lnformation System (MMIS) to syslomalically reôtricl duplicative provider paymenis. Progrâms wilh seNìces similar lo HH and DHCF's slrategy lo eddrsss lhem are outlined below. DC hâs two 1915(c) waivers, the Eldedy end P€rsons with Physicål Disåbilities (EPD) Waiver and tho lndividuals wrth lntellectual and Developmenlâl Oisabilities (lDD)\ bivor. Both wâivers provide lìredicaidreimbußâllle cêse manâgemenl señicês. Currêntly, EPD case managers receive reiÂrbursement lo develop ênd execute a person-centered cate plan fot beneficiaties eñrclled in the EPD \'Vaiver program, Functions providod by EPD case managers also include assessmenls to determiñe unmel needs telêtod to waiver services, planning of seryices provided undêrthe waive[ submission of requests for the suthorization of waiver services, and moniloring ol señico provision. Similarly, IDD service coordinators currenlly receive Íeimbursement to coordinate ând facilitate the provìsìon ol quality señices end supports, reviêw th6 implementation ând dêlivery of se¡vices and supports identified irì the lndividuãl Supporl Plân (lSP), take coîective aclaon as necessary âssist with problem solvrng and advocate for lhe person and his/her family. To prevenl duplicâlion of services, DHCF wlll establish a process to ensure beneficigries recoiving case management services frcm the EPD or IDD waiverwill not concunently receive HH services, HH soñlces will add to, and not duplicate, tho clinical care coordinålion Êervicês provlded under the Adult Substance Abuse RehabitÌtative S€ryices (ASARS) Medicard State Plan ben6fit, where clinical coordinato¡s focus on wâys to ensure care plans include services thât address a beneficiary's substance use disorder To prevent dupl¡cation of servicos, DHCF will establlsh a process to ênsure HH providers coordinâte and collaborâte with lhe ASARS providers ând ìeverago lhoirwork in o¡der to âdvance the "whole- person" approach to care and supports lho beneficiâry's full anay of clinical and non-clinicêl h6âlth care needs DC 16-0012 Superseded SPA: N/A Effective Dâte: July 1, 2017 CI¡S Approvâl Febutary 6, 2917 Page 30 3t4

27t2017 DC - Submission Package - DC2016M H0001O - (DC- 1e0012) HHswill partnerwith DC lt edlcaid [.4COs lhrough MOAs containing cloarly defined rotes and responsibilities foreach party Addilionel guidanco will bê supplied to HHs âñd [4COs in the DC[¡R and IVICO conlracts in o¡dêr lo avoid duplicalive offorts and to ensure timely communication, care lransition plañning, lse of evidence-based referals, and follow-up consultâtions with appropriale heallh seNice providêrs. HHs will inciude the MCO, as appropriate, when creating or updating lhe HH care plan. The HHs añd [rCOs will be expected to develop protocols for shanng infonnalion on câre planning and pa{rent care. HHs will identify any gaps in seNice needs for HH enrolled beneficiaries regardloss of the programs from wlìrch tho boneficiaries receive sorvices. l /hen applicable lo a particular HH providor that is othelwise reimbursed for providing care management or coordination soNices, DHCF will prevent duplicalive pâymenls by fumishing a ditferenlial payment to that provider, reducing pâyment by lhe âmount of the duplicâtive seruice. Additioôally, a bêneliciary may not bê enrolled ln more than ono HH in a givon month. DHCF does not cover targeted caso managomenl seNices under 1915(g). As such, there is no dsk of dLrplicalìon of payment for targeted case management seryices, ,r: The Stal€ meets lhe rêquirements of42 CFR Pêrt 447, Subpart A, and sectioñs 1902(aX4) 1902(aX6), 1902(a)(30XA), and 1903 with r€spect to non- paymenl for provider-preventable condilions. k The Sta{e provides assurance that all governmental and privaie providers âre reimbursed according to lho same rato schedule, unless othe¡wise described above. .'' lhe Stête provid€s assùrance that it shall reimburse provide¡s directly, excepl when there a¡e employment or conkactuâl arrangeñents consistent wilh section l902(aX32). PRA Disclosure Stalement According lo lhe Pâpen/r/ork Reduclion Actof 1995, no persons âre required to ¡êspond lo â colleclìon oiinformêlion unless il displays a vålid âverãge 40 hours perrespoñse ìncludtng the limeto review instruclion s, se¿ rch exìslin g data resources. gatherthe data needed, ând complele ând revLelv lhe Boulevârd AttnrPRA Reports Clearanc€ Offcer,l\ilailSlop C4-26-05, Bâltimore,Maryland 21244-1850. DC 16-0012 Superseded SPA: N/A Etfective Date: July 1,2017 C[4S Approvâli Feburary 6, 2017 Page 31 414

27t2017 DC - Submission Package - DC2016l\4H0001O - (DC-1G0012) Reèo¡ds / SLll)mission Packages DC - Submission Package - DG2016MH0001O - (DC-16-0012),t\-- Req!¡esl Syslern Help . AII Reviewable Units View Compâ¡e Doc Health Homes Monitoring, Quality Measurement and Evaluation f\¡EDICAID - Heallh Homes - fìly Heâllh GPS' DC '2016 Cl\4S-10434 O[¡B 0938-1188 Noi Slãded ln Progress Conrplete Package Header Package lO 0C2016MH0001O Submission Type Officiaf- Roview 1 Apptoval Date 21612017 Supèrssded SPA N/A ID Quality Mèasurement and Evaluation DC 16,0012 ln¡tial Submission Þate SPA ID Effêctive Date DC-16-0012 1111012016 71112A11 View lnlplementairon Guide -t".^Ãñ; Mon¡tor¡ng tt- Descr¡be the state's methodology for câlculeting cost saving (and roport cost savings annually in Quality Meâsure Report). lnclude savings that tesult from ¡mproved coordinat¡on of care and chton¡c disêase menagement achieved lhrough the Heãlth Homes ProgÍan, ¡ncluding data sources and measurement spec¡fícations, as well as any savings associated w¡th duâl eligibles, and if lr4ed¡care data wãs âvaìlable to the state to utilize in arriving at its cost€avings est¡mateg DHCF will use historicel claims ând encounter datê from Fiscal Years 20'14 through 20'16 to establish a baseline and expecled lrend on mêdical spending for the eligible HH population. DHCF w¡ll then compare expecled spending with actuâl speñding The difference between expected spending and aclual spendìng will represenl cost savings. DHCF may afso compare a cohort of beneficiaries who have enrolled rn lhe HH program with a cohorl of similar beneficiarìes who are el,gible for the program but not enrolled. DHCF will also compare costs related to services or utihzation including, but not limiled lo, emergency room ulilizãtion, hospitalizâlions, nursing facilily admissions, and pharmacy utilizâtion. This will enâble DHCF to undorstand the overall impaci of lhe program, nol just on lotal spending, but on [hether utilizalion reflects the types of services expected for á given paliont (pharmacy, primary care, subslânce abusê lreâlmÊnt, elc.) or is found in åreâs that could slill indicate poor cere coordinêtion (liko ÊR and hospilal inpalient). DHCF will analyze each HH for its overâll impâcl on total cost of care and health care ulilizalion, and theñ compare their performanco to other HHs in DC lo inform future policy decisions ãnd ways lo promole conlinuous quality improvement. Oescr¡he how the state w¡ll use health information technology irì providing Health Homes services and to ¡mprove serv¡ce delivery and coordination across the care cont¡nuum (including the use of w¡reless pat¡ent technology to ¡mprove coord¡rìat¡on ând rnanagement of câre and patient adher€ncê to recommendations made by their provialer) All HH providers will be required to ulilize cerlified EHR technology whlch wll âllow providers to report and reviow a beneficiary's intako, assêssment rêsults, ãssigned HH team, integrated HH c€re plans, cliñical baselines and dâta related to chronic conditions, as well as HH services prcvided, such as refenals made and hêalth promotion activities compleled. Additionally, HHs âre expecled to use dâta from CRISP, orolherHlE services as diÍected by DHCF, to receive hospital event alerls (e.9. emergency depadment visitst hospital admissions, tÊnsfers and discha¡ges) that will help HHs create a peßon-cenlered HH care plan. lhe HHs may also heve access to Dynamic Pêtienl Care Profile tool cunenlly being developed thrcugh CMS IAPD funding support. The toolwill be an "ondemand" documênt made availâble to lvleaningful Use EPs ând EHs, in addition to members of their care team, that would dìsplay an aggregátion of critical daia (bolh clinical and administrative) for a selecled patient. The HHs may have access to Electronic Clinical Quality ll¡easuremenl Tool and Dashboard, an electronic clinicâl quality measu¡ement (eCQM) toollo roufe inbound CCDs from eligible l¡edicaìd hospitals and practices to support ¡equired quality calculations and ¡eporting; develop a populalionlevel dashboard âccessible by EPs and EHs for patient panel managemenl. The HHs may also have accoss to an Analytical Palìenl Population Dashboard, also being developed wlh supporl from IAPD funds to enable EPs and EHs to perform panel-level analysis on their associaled patient populations. Finally, all HHs will be requÌred lo share C-CDA or C-CDA equivalênt structured dalâ lo one of the designated HIE entities in the Dislrict. Superseded SPA N/A Effeclive Dâte: July 1, 2017 CI\¡S Approval Feburary 6, 2017 Page 32 1t2

2712017 DC - Submission Package - DC2016l!l H 00010 - (DC-1G0012) ..r', The state provides assurance thal âll Health Homes providers report to the state on all appticâble quâlity measures as â condition of recervrng pay;ont from thê stel€ :{ The state p¡ovides assurance thal it will ideniify measureâble goals for its Heâllh Homes modol and inteñention and also ¡dontily quality meâsures related to each goal to meâsure its success in achieving the goals la Tho slate provides âssurâncê thât il will report to CMS info¡mation submitted by Heallh Homes providers to inform evalual'ons, as well as Reports to Congress as doscrìbed in Section 2703(b) of lhe Affordable Care Act and as descdbed by CIl¡S I The state provides âssurance that il will lrack avoidâblo hospital readmissions and aepod ânnually in the Quality fuìeasures report Go Ìo llHQlv,l Repons PRA Disclosure Slaienrent According to the PapeMo.k Reduclion Act of 1995 no OÀ,'lB control number The valid Oì\48 conlrol numþer fo¡ th¡s informalion collection âverâgê 40 hours per responsè including the limè to review instructio¡s, search existing dal€ resources, r€spond 10 a colleclio¡ ofinfonrìation unless itdisplays a valid to complete thìs informâtìon côlleclíon is estimåted lo l Boulevard. At1n: PRA Reports Cleârânce Ofllcer. f\¡ail Stop C4-26-05, Ballimore . Marylatd 21244-1A50. DC 1ô-0012 Superseded SPA: N/A Ef€ctive Datei Jqly 1, 2017 Cl\¡S Approval: Feburary 6,2017 Page 33

Table of Contents State/Territory Name: District of Columbia State Plan Amendment (SPA) #: 19-005 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages 3) CMS 179

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street, Suite 900 Dallas, Texas 75202

Medicaid and CHIP Operations Group

February 3, 2020

Melisa Byrd Medicaid Director Department of Health Care Finance 441 4th Street, N.W., 9th floor, South Washington, D.C. 20001

Dear Ms. Byrd:

I am writing to inform you that we have reviewed the District of Columbia’s State Plan Amendment (SPA) 19-005, entitled Program of All-Inclusive Care for the Elderly (PACE). This amendment will authorize the District to implement a PACE program, effective February 1, 2020.

We are pleased to inform you that, after extensive review, this amendment is approved; its effective date is February 1, 2020. A copy of the approved SPA pages and signed CMS-179 form are included under this cover. Please be advised that the District is required to submit a state plan amendment through the MACPro-based system to verify its coverage for the PACE-related eligibility group.

If you have any further questions regarding this SPA, please contact Ellen Reap at (215) 861- 4735 or by email at Ellen.Reap@cms.hhs.gov.

Sincerely,

Bill Brooks, Division Director

Division of Managed Care Plan Operations

October 1, 2019 February 3, 2020 February 1, 2020 Bill Brooks Division Director

19c SECTION 3 – SERVICES: GENERAL PROVISIONS Enclosure 3

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

Citation 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued)

1905(a)(26) and 1934 X Program of All-Inclusive Care for the Elderly (PACE) services, as described and limited in Supplement 7 to Attachment 3.1-A.

ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. (Note: Other programs to be offered to Categorically Needy beneficiaries would specify all limitations on the amount, duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to Categorically Needy beneficiaries would also list the additional coverage—that is in excess of established service limits—for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

20c

SECTION 3 – SERVICES: GENERAL PROVISIONS Enclosure 4

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

Citation 3.1(a)(2) Amount, Duration, and Scope of Services: Medically Needy (Continued)

1905(a)(26) and 1934

X Program of All-Inclusive Care for the Elderly (PACE) services, as described and limited in Supplement 4 to Attachment 3.1-B.

ATTACHMENT 3.1-B identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to Medically Needy beneficiaries would specify all limitations on the amount, duration, and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to Medically Needy beneficiaries would also list the additional coverage—that is in excess of established service limits—for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

Attachment 3.1-A

Page 11

Enclosure 5

Attachment 3.1-A

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

26. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 7 to Attachment 3.1-A.

X Election of PACE: By virtue of this submittal, the State elects PACE as an optional State Plan service.

No election of PACE: By virtue of this submittal, the State elects to not add PACE as an optional State Plan service.

Attachment 3.1-B

Page 9

Enclosure 6

Attachment 3.1-B

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY

25. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 4 to Attachment 3.1-B.

X Election of PACE: By virtue of this submittal, the State elects PACE as an optional State Plan service.

___ No election of PACE: By virtue of this submittal, the State elects to not add PACE as an optional State Plan service.

Supplement 7 to Attachment 3.1-A

Page 1 Enclosure 7

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

PACE PROGRAM

Name and address of State Administering Agency, if different from the State Medicaid Agency. ____________________________________________________________________________ ____________________________________________________________________________

I. Eligibility

The State determines eligibility for PACE enrollees under rules applying to community groups.

A. X The State determines eligibility for PACE enrollees under rules applying to institutional groups as provided for in section 1902(a)(10)(A)(ii)(VI) of the Act (42 CFR 435.217 in regulations). The State has elected to cover under its State plan the eligibility groups specified under these provisions in the statute and regulations. The applicable groups are:  Individuals who meet a special income level of 300% of the SSI Federal Benefit Rate (FBR) in accordance with 42 CFR § 435.236. Note: Spousal impoverishment eligibility rules under Section 1924 of the Social Security Act apply. (If this option is selected, please identify, by statutory and/or regulatory reference, the institutional eligibility group or groups under which the State determines eligibility for PACE enrollees. Please note that these groups must be covered under the State’s Medicaid plan.)

B. The State determines eligibility for PACE enrollees under rules applying to institutional groups, but chooses not to apply post-eligibility treatment of income rules to those individuals. (If this option is selected, skip to II - Compliance and State Monitoring of the PACE Program.

C. X The State determines eligibility for PACE enrollees under rules applying to institutional groups and applies post-eligibility treatment of income rules to those individuals as specified below. Note that the post-eligibility treatment of income rules specified below are the same as those that apply to the State’s approved HCBS waiver(s).

Supplement 7 to Attachment 3.1-A

Page 2 Enclosure 7

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

Regular Post Eligibility

1. X SSI State. The State is using the post-eligibility rules at 42 CFR 435.726. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee’s income.

(a). Sec. 435.726--States which do not use more restrictive eligibility

requirements than SSI.

1. Allowances for the needs of the: (A.) Individual (check one) 1. X The following standard included under the State plan (check one): (a) _____SSI (b) _____Medically Needy (c) X The special income level for the institutionalized (d) _____Percent of the Federal Poverty Level: ______% (e) _____Other (specify):________________________ 2. ____The following dollar amount: $________ Note: If this amount changes, this item will be revised. 3. ____The following formula is used to determine the needs allowance: ___________________________________________________ ___________________________________________________

Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A in items 2 and 3.

(B.) Spouse only (check one): 1.____ SSI Standard 2.____ Optional State Supplement Standard 3.____ Medically Needy Income Standard 4.____ The following dollar amount: $________ Note: If this amount changes, this item will be revised.

Supplement 7 to Attachment 3.1-A

Page 3 Enclosure 7

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

5. ____ The following percentage of the following standard that is not greater than the standards above: _____% of ______ standard. 6. ____ The amount is determined using the following formula: 7. X Not applicable (N/A)

(C.) Family (check one): 1.____ AFDC need standard 2.____ Medically needy income standard

The amount specified below cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State’s approved AFDC plan or the medically needy income standard established under 435.811 for a family of the same size.

3.____ The following dollar amount: $_______ Note: If this amount changes, this item will be revised. 4.____ The following percentage of the following standard that is not greater than the standards above:______% of______ standard. 5.____ The amount is determined using the following formula: __________________________________________________ 6.____ Other 7. X Not applicable (N/A)

(2). Medical and remedial care expenses in 42 CFR 435.726.

Regular Post Eligibility

2. _____ 209(b) State, a State that is using more restrictive eligibility requirements than SSI. The State is using the post-eligibility rules at 42 CFR 435.735. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee’s income.

(a) 42 CFR 435.735--States using more restrictive requirements than SSI.

1. Allowances for the needs of the:

Supplement 7 to Attachment 3.1-A

Page 4 Enclosure 7

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

(A.) Individual (check one) 1.___The following standard included under the State plan (check one): (a) _____SSI (b) _____Medically Needy (c) _____The special income level for the institutionalized (d) _____Percent of the Federal Poverty Level: ______% (e) _____Other (specify):________________________

2.___The following dollar amount: $________ Note: If this amount changes, this item will be revised. 3.___The following formula is used to determine the needs allowance:

Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A in items 2 and 3.

(B.) Spouse only (check one):

1._____The following standard under 42 CFR 435.121: ___________________________________________________

2._____The Medically needy income standard ___________________________________________________

3.____The following dollar amount: $________

Note: If this amount changes, this item will be revised.

4.____The following percentage of the following standard that is not greater than the standards above: ___% of ______ standard.

5._____The amount is determined using the following formula: __________________________________________________

6._____Not applicable (N/A)

(C.) Family (check one):

1.____AFDC need standard

2._____Medically needy income standard

Supplement 7 to Attachment 3.1-A

Page 5 Enclosure 7

State of District of Columbia PACE State Plan Amendment Pre-Print

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

The amount specified below cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State’s approved AFDC plan or the medically needy income standard established under 435.811 for a family of the same size.

3.____The following dollar amount: $_______

Note: If this amount changes, this item will be revised.

4.____The following percentage of the following standard that is not

greater than the standards above:______% of______ standard.

5.____The amount is determined using the following formula: __________________________________________________

6.____ Other

7.____ Not applicable (N/A)

(b) Medical and remedial care expenses specified in 42 CFR 435.735.

Spousal Post Eligibility

3.____ State uses the post-eligibility rules of Section 1924 of the Act (spousal impoverishment protection) to determine the individual’s contribution toward the cost of PACE services if it determines the individual’s eligibility under section 1924 of the Act. There shall be deducted from the individual’s monthly income a personal needs allowance (as specified below), and a community spouse’s allowance, a family allowance, and an amount for incurred expenses for medical or remedial care, as specified in the State Medicaid plan.

(a) Allowances for the needs of the: 1. Individual (check one) (A)____The following standard included under the State plan (check one): 1. _____SSI 2. _____Medically Needy 3. _____The special income level for the institutionalized 4. _____Percent of the Federal Poverty Level: ______%

State: District of Columbia

Supplement 7 to Attachment 3.1-A

Page 6

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

5. _____Other (specify):________________________

(B)_____The following dollar amount: $________ Note: If this amount changes, this item will be revised.

(C)_____The following formula is used to determine the needs allowance: ___________________________________________________ ___________________________________________________

If this amount is different than the amount used for the individual’s maintenance allowance under 42 CFR 435.726 or 42 CFR 435.735, explain why you believe that this amount is reasonable to meet the individual’s maintenance needs in the community: ______________________________________________________

II. Rates and Payments

A. The State assures CMS that the capitated rates will be equal to or less than the cost to the agency of providing those same fee-for-service State plan approved services on a fee-for-service basis, to an equivalent non-enrolled population group based upon the following methodology. Please attach a description of the negotiated rate setting methodology and how the State will ensure that rates are less than the cost in fee-for- service.

1. X Rates are set at a percent of fee-for-service costs 2.____ Experience-based (contractors/State’s cost experience or encounter date) (please describe) 3.____ Adjusted Community Rate (please describe) 4.____ Other (please describe)

B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner. Please list the name, organizational affiliation of any actuary used, and attestation/description for the initial capitation rates.

 The District engaged an actuary to conduct preliminary estimates of Medicaid FFS costs to identify the amount that would otherwise have been paid (AWOP) for PACE. The general methodology developed by the actuary for the Medicaid

State: District of Columbia

Supplement 7 to Attachment 3.1-A

Page 7

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

FFS cost estimates is described in the attachment. The District will use that methodology to ensure the final payment rates remain below the PACE AWOP.

C. The State will submit all capitated rates to the CMS Regional Office for prior approval.

III. Enrollment and Disenrollment The State assures that there is a process in place to provide for dissemination of enrollment and disenrollment data between the State and the State Administering Agency. The State assures that it has developed and will implement procedures for the enrollment and disenrollment of participants in the State’s management information system, including procedures for any adjustment to account for the difference between the estimated number of participants on which the prospective monthly payment was based and the actual number of participants in that month.

State: District of Columbia

Supplement 4 to Attachment 3.1-B

Page 1

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

PACE PROGRAM

Name and address of State Administering Agency, if different from the State Medicaid Agency. ____________________________________________________________________________

I. Eligibility

The State determines eligibility for PACE enrollees under rules applying to community groups.

A. X The State determines eligibility for PACE enrollees under rules applying to institutional groups as provided for in section 1902(a)(10)(A)(ii)(VI) of the Act (42 CFR 435.217 in regulations). The State has elected to cover under its State plan the eligibility groups specified under these provisions in the statute and regulations. The applicable groups are:

− Individuals who meet a special income level of 300% of the SSI Federal Benefit Rate (FBR) in accordance with 42 CFR § 435.236. − Note: Spousal impoverishment eligibility rules under Section 1924 of the Social Security Act apply.

(If this option is selected, please identify, by statutory and/or regulatory reference, the institutional eligibility group or groups under which the State determines eligibility for PACE enrollees. Please note that these groups must be covered under the State’s Medicaid plan.)

B. _____The State determines eligibility for PACE enrollees under rules applying to institutional groups, but chooses not to apply post-eligibility treatment of income rules to those individuals. (If this option is selected, skip to II - Compliance and State Monitoring of the PACE Program.

C. X The State determines eligibility for PACE enrollees under rules applying to institutional groups, and applies post-eligibility treatment of income rules to those individuals as specified below. Note that the post-eligibility treatment of income rules specified below are the same as those that apply to the State’s approved HCBS waiver(s).

State: District of Columbia

Supplement 4 to Attachment 3.1-B

Page 2

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

Regular Post Eligibility

1. X SSI State. The State is using the post-eligibility rules at 42 CFR 435.726. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee’s income.

(a). Sec. 435.726--States which do not use more restrictive eligibility

requirements than SSI.

1. Allowances for the needs of the: (A.) Individual (check one) 1. X The following standard included under the State plan (check one): (a) _____SSI (b) _____Medically Needy (c) X The special income level for the institutionalized (d) _____Percent of the Federal Poverty Level: ______% (e) _____Other (specify):________________________ 2._____The following dollar amount: $________ Note: If this amount changes, this item will be revised. 3._____The following formula is used to determine the needs allowance:

Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A in items 2 and 3.

(B.) Spouse only (check one): 1.____ SSI Standard 2.____ Optional State Supplement Standard 3.____ Medically Needy Income Standard 4.____ The following dollar amount: $________ Note: If this amount changes, this item will be revised. 5.____ The following percentage of the following standard that is not greater than the standards above: _____% of ______ standard. 6.____ The amount is determined using the following formula: 7. X Not applicable (N/A)

State: District of Columbia

Supplement 4 to Attachment 3.1-B

Page 3

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

(C.) Family (check one): 1.____ AFDC need standard 2.____ Medically needy income standard

The amount specified below cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State’s approved AFDC plan or the medically needy income standard established under 435.811 for a family of the same size.

3.____ The following dollar amount: $_______ Note: If this amount changes, this item will be revised. 4.____ The following percentage of the following standard that is not greater than the standards above: ______% of______ standard. 5.____ The amount is determined using the following formula: __________________________________________________ __________________________________________________ 6.____ Other 7. X Not applicable (N/A)

(2). Medical and remedial care expenses in 42 CFR 435.726.

Regular Post Eligibility

2. _____ 209(b) State, a State that is using more restrictive eligibility requirements than SSI. The State is using the post-eligibility rules at 42 CFR 435.735. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee’s income.

(a) 42 CFR 435.735--States using more restrictive requirements than SSI.

1. Allowances for the needs of the:

(A.) Individual (check one) 1.___The following standard included under the State plan (check one): (a) _____SSI (b) _____Medically Needy (c) _____The special income level for the institutionalized (d) _____Percent of the Federal Poverty Level: ______% (e) _____Other (specify): ________________________

State: District of Columbia

Supplement 4 to Attachment 3.1-B

Page 4

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

2.___The following dollar amount: $________ Note: If this amount changes, this item will be revised. 3___The following formula is used to determine the needs allowance: ___________________________________________________

Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A in items 2 and 3.

(B.) Spouse only (check one):

1._____The following standard under 42 CFR 435.121: ___________________________________________________

2._____The Medically needy income standard ___________________________________________________

3.____The following dollar amount: $________

Note: If this amount changes, this item will be revised.

4.____The following percentage of the following standard that is not greater than the standards above: ___% of ______ standard.

5._____The amount is determined using the following formula: __________________________________________________

6._____Not applicable (N/A)

(C.) Family (check one):

1.____AFDC need standard

2_____Medically needy income standard

The amount specified below cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State’s approved AFDC plan or the medically needy income standard established under 435.811 for a family of the same size.

3.____The following dollar amount: $_______

Note: If this amount changes, this item will be revised.

4.____The following percentage of the following standard that is not

greater than the standards above: ______% of______ standard.

5.____The amount is determined using the following formula:

6.____ Other

7.____ Not applicable (N/A)

(b) Medical and remedial care expenses specified in 42 CFR 435.735.

State: District of Columbia

Supplement 4 to Attachment 3.1-B

Page 5

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

Spousal Post Eligibility

3.____ State uses the post-eligibility rules of Section 1924 of the Act (spousal impoverishment protection) to determine the individual’s contribution toward the cost of PACE services if it determines the individual’s eligibility under section 1924 of the Act. There shall be deducted from the individual’s monthly income a personal needs allowance (as specified below), and a community spouse’s allowance, a family allowance, and an amount for incurred expenses for medical or remedial care, as specified in the State Medicaid plan.

(a.) Allowances for the needs of the: 1. Individual (check one) (A). ____The following standard included under the State plan (check one): 1. _____SSI 2. _____Medically Needy 3. _____The special income level for the institutionalized 4. _____Percent of the Federal Poverty Level: ______%

State: District of Columbia

Supplement 4 to Attachment 3.1-B

Page 6

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

5. _____Other (specify): ________________________

(B). _____The following dollar amount: $________ Note: If this amount changes, this item will be revised.

(C)_____The following formula is used to determine the needs allowance: ___________________________________________________ ___________________________________________________

If this amount is different than the amount used for the individual’s maintenance allowance under 42 CFR 435.726 or 42 CFR 435.735, explain why you believe that this amount is reasonable to meet the individual’s maintenance needs in the community:

II. Rates and Payments

A. The State assures CMS that the capitated rates will be equal to or less than the cost to the agency of providing those same fee-for-service State plan approved services on a fee- for-service basis, to an equivalent non-enrolled population group based upon the following methodology. Please attach a description of the negotiated rate setting methodology and how the State will ensure that rates are less than the cost in fee-for- service.

1. X Rates are set at a percent of fee-for-service costs 2.___ Experience-based (contractors/State’s cost experience or encounter date) (please describe) 3.___ Adjusted Community Rate (please describe) 4.___ Other (please describe)

B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner. Please list the name, organizational affiliation of any actuary used, and attestation/description for the initial capitation rates.

− The District engaged an actuary to conduct preliminary estimates of Medicaid FFS costs to identify the amount that would otherwise have been paid (AWOP) for PACE. The general methodology developed by the actuary for the Medicaid FFS cost estimates is described in the attachment. The District will use that methodology to ensure the final payment rates remain below the PACE AWOP.

State: District of Columbia

Supplement 4 to Attachment 3.1-B

Page 7

TN #: 19-005

Approval Date: February 3, 2020

Effective Date: February 1, 2020 Supersedes TN#: NEW

C. The State will submit all capitated rates to the CMS Regional Office for prior approval.

III. Enrollment and Disenrollment The State assures that there is a process in place to provide for dissemination of enrollment and disenrollment data between the State and the State Administering Agency. The State assures that it has developed and will implement procedures for the enrollment and disenrollment of participants in the State’s management information system, including procedures for any adjustment to account for the difference between the estimated number of participants on which the prospective monthly payment was based and the actual number of participants in that month.

State: DISTRICT OF COLUMBIA

Supplement 5 to Attachment 4.19-B 1

TN# 19-005 Approval Date: February 3, 2020 Effective Date: February 1, 2020 Supersedes TN# NEW Medicaid Reimbursement Methodology for Programs of All-Inclusive Care for the Elderly (PACE)

This Section applies to reimbursement for Program of All-Inclusive Care for the Elderly (PACE) services described in Supplement 7 to Attachment 3.1-A, Page 6-7 and Supplement 4 to Attachment 3.1-B, Page 6- 7.

Federal regulation requires that states pay PACE organizations a monthly capitated payment that: • Is less than the amount Medicaid would otherwise have paid for PACE eligible individuals under the state plan (commonly referred to as the “amount that would otherwise have been paid” (AWOP) for PACE); • Takes into account the comparative frailty of the PACE population; and • Is a fixed amount regardless of participant’s health status. The District will utilize a payment methodology that fulfills the requirements set forth above. A general description of the methodology follows: The District will obtain the most recent Medicaid claims available and calculate Medicaid costs incurred for two categories of beneficiaries: individuals residing in nursing facilities and individuals enrolled in home-and-community-based services (HCBS). To better capture the frailty of the PACE eligible population, the nursing facility population will be limited to long-term users, such as those with stays of at least three months, and the HCBS population will be limited to those in the District’s 1915(c) Elderly and Physically Disabled (EPD) waiver, as these individuals must meet a nursing facility level-of-care standard to qualify. Medicaid costs for those two populations will be blended in proportions that reflect their expected enrollment in PACE. In its analysis, the District may make the following exclusions or adjustments: • Those enrolled in managed care plans will be excluded. Most beneficiaries who qualify as elderly or due to disability are exempted from the managed care program. • Sub-categories of beneficiaries who are not relevant to PACE, such as Qualified Medicare Beneficiaries (QMBs), will be excluded. • Costs that do not reflect services covered under PACE, such as patient liability or spend- down amounts, will be excluded. • The District will account for any other factors as necessary, including, but not limited to, claims processing time lag; pharmacy rebates; programmatic changes; health care cost inflation; any irrelevant payments, such as DSH, GME, and IME; third party liability; and copayments. The District will calculate a per-member-per-month (pmpm) payment rate based on a percentage of the PACE AWOP. Depending on cost patterns observed in the analysis above, the District may implement separate capitated rates for dual eligible and Medicaid-only PACE enrollees or other sub-groups. The final rate(s) will never be equal to or more than the PACE AWOP.

___________________________________________________________________________________ Table of Contents State/Territory Name: District of Columbia State Plan Amendment (SPA) #: 19-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 701 5th Avenue, Suite 1600, MS/RX-200 Seattle, Washington 98104 Medicaid and CHIP Operations Group 0DUFK Melisa Byrd Medicaid Director Department of Health Care Finance 441 4th Street, N.W., 9th floor, South Washington, D.C. 20001 Dear Director Byrd: 7KH&HQWHUVIRU0HGLFDUH 0HGLFDLG6HUYLFHV &06 LVapproving WKH'LVWULFWRI&ROXPELD V 1915(i) +ome and &ommunity-%ased 6ervices (HCBS) state plan amendment (SPA), transmittal number TN # 19-007. The purpose of this amendment is to renew the District of Columbia’s 1915(i) State Plan HCBS benefit. The effective date for this renewal is April 1, 2020. Enclosed is a copy of the approved SPA. Since the state has elected to target the population who can receive these §1915(i) State Plan HCBS, CMS approves this SPA for a five-year period, in accordance with §1915(i)(7) of the Social Security Act. To renew the §1915(i) State Plan HCBS benefit for an additional five-year period, the state must submit a renewal application 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 the §1915(i) State Plan HCBS in the previous year. Additionally, at least 21 months prior to the end of the five-year approval period, the state must submit evidence of the state’s quality monitoring in accordance with the Quality Improvement Strategy in their approved SPA. The evidence must include data analysis, findings, remediation, and describe any system improvement for each of the §1915(i) requirements. It is important to note that CMS’ approval of this 1915(i) HCBS state plan benefit solely addresses the state’s compliance with the applicable Medicaid authorities. CMS’ approval does not address the state’s independent and separate obligations under federal laws including, but not limited to, the Americans with Disabilities Act, Section 504 of the Rehabilitation Act, or the Supreme Court’s Olmstead decision. Guidance from the Department of Justice concerning

compliance with the Americans with Disabilities Act and the Olmstead decision is available at http://www.ada.gov/olmstead/q&a_olmstead.htm. If you have any questions regarding this SPAplease PHDW  RU\RXUVWDIIPD\ contact Chuck Steinmetz at HLWKHU 215 861-4169RU Charles.Steinmetz@cms.hhs.gov. Sincerely, David Meacham, Division Director Division of HCBS Operations and Oversight cc: Alice Weiss, DCHF Eugene Simms, DCHF Wendy Hill-Petras, CMS Digitally signed by David L. Meacham -S DN: c=US, o=U.S. Government, ou=HHS, ou=CMS, ou=People, 0.9.2342.19200300.100.1.1=2000041858, cn=David L. Meacham -S Date: 2020.03.18 11:39:21 -07'00'

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED 0MB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: 19-007 2. STATE: FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: Regional Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services 5. TYPE OF PLAN MATERIAL (Check One): District of Columbia 3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act 4. PROPOSED EFFECTIVE DATE: April 1, 2020 0 NEW ST ATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN iZI 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: 1915(i) of the Social Security Act (42 U.S.C. 1396(n)) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.1 (i) pp 1-39 Attachment 4.19B Part 1 pp 29- 33 State Plan Attachment 2.2-A pp 28-29 10. SUBJECT OF AMENDMENT: 1915(i) Adult Day Health Program Renewal 11. GOVERNOR'S REVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL FFY20: $ 4,481,029.00 FFY21: $ 4,615,460.00 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable}: Attachment 3.1(i) pp 1-34 Attachment 4.19B Part 1 pp 29-35 iZI OTHER, AS SPECIFIED: D.C. Act: 22-434 16. RETURN TO Melisa Byrd ------, Senior Deputy Director/Medicaid Director Department of Health Care Finance Melisa Byrd 441 4th Street, NW, 9th Floor, South ------------------ - - -------, Washington, DC 20001 14. TITLE Senior Deputy Director/Medicaid Director 15. DATE SUBMITTED {2/1/) FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 118. DATE APPROVED PLAN APPROVED-ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE David Meacham Director, Division of Home and Community Based Services December 3, 2019 March 18, 2020 April 1, 2020

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 1 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 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 Program (ADHP) Services 2. Concurrent Operation with Other Programs. (Indicate whether this benefit will operate concurrently with another Medicaid authority): Select one: 9 Not applicable { Applicable Check the applicable authority or authorities:

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 waiver 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; (c) the specific 1915(i) State plan HCBS furnished 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.

Waiver(s) authorized under §1915(b) of the Act. Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved: Specify the §1915(b) authorities under which this program operates (check each that applies):

§1915(b)(1) (mandated enrollment to managed care)

§1915(b)(3) (employ cost savings to furnish additional services)

§1915(b)(2) (central broker)

§1915(b)(4) (selective contracting/limit number of providers)

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 2 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004

A program operated under §1932(a) of the Act. Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:

A program authorized under §1115 of the Act. Specify the program: 3. State Medicaid Agency (SMA) Line of Authority for Operating the State plan HCBS Benefit. (Select one): 9 The State plan HCBS benefit is operated by the SMA. Specify the SMA division/unit that has line authority for the operation of the program (select one): { The Medical Assistance Unit (name of unit): 9 Another division/unit within the SMA that is separate from the Medical Assistance Unit (name of division/unit) This includes administrations/divisions under the umbrella agency that have been identified as the Single State Medicaid Agency. Long Term Care Administration { The State plan HCBS benefit is operated by (name of agency) a separate agency of the state that is not a division/unit of the Medicaid agency. In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the State plan HCBS benefit and issues policies, rules and regulations related to the State plan HCBS benefit. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this delegation of authority is available through the Medicaid agency to CMS upon request.

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 3 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 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): Function Medicaid Agency Other State Operating Agency Contracted Entity Local Non- State Entity 1 Individual State plan HCBS enrollment ;

2 Eligibility evaluation ; ;

3 Review of participant service plans ;

;

4 Prior authorization of State plan HCBS ;

;

5 Utilization management ;

;

6 Qualified provider enrollment ;

7 Execution of Medicaid provider agreement ;

8 Establishment of a consistent rate methodology for each State plan HCBS ;

9 Rules, policies, procedures, and information development governing the State plan HCBS benefit ;

10 Quality assurance and quality improvement activities ;

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

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 4 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 Function (2) eligibility evaluation is a multi-step process. Once the Department of Health Care Finance’s (DHCF’s) Long Term Care Services and Supports (LTCSS) Contractor has completed the face-to-face assessment, the findings are released in DC Care Connect to the DC Aging and Disability Resource Center (ADRC), which performs its responsibilities in accordance with its interagency agreement with DHCF. ADRC is a governmental agency within the District of Columbia Department of Aging and Community Living. ADRC is not a provider 1915(i) services. Function (3), review of person-centered service plan/authorization, is performed by the Quality Improvement Organization (QIO). The QIO reviews the PCSP to ensure that the goals and services are appropriate, approves the PCSP, and generates authorizations to ensure that the providers of the included services are able to submit claims for reimbursement. Functions (4) and (5), prior authorization and utilization management for State Plan HCBS services, are performed by DHCF’s LTCSS Contractor.

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 5 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 (By checking the following boxes the State assures that): 5. ; 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: x related by blood or marriage to the individual, or any paid caregiver of the individual x financially responsible for the individual x empowered to make financial or health-related decisions on behalf of the individual x 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. (If the 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. ; 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.

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 6 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 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 1 April 1, 2020 March 31, 2021 177 Year 2 April 1, 2021 March 31, 2022 Year 3 April 1, 2022 March 31, 2023 Year 4 April 1, 2023 March 31, 2024 Year 5 April 1, 2024 March 31, 2025 2. ; 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)(XXII) of the Social Security Act. States that want to adopt the §1902(a)(10)(A)(ii)(XXII) eligibility category make the election in Attachment 2.2-A of the state Medicaid plan.) 2. Medically Needy (Select one): † The State does not provide State plan HCBS to the medically needy. ; The State provides State plan HCBS to the medically needy. (Select one): † The state elects to disregard the requirements section of 1902(a)(10)(C)(i)(III) 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. ; The state does not elect to disregard the requirements at section 1902(a)(10)(C)(i)(III) of the Social Security Act. Evaluation/Reevaluation of Eligibility

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 7 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 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): { Directly by the Medicaid agency 9 By Other (specify State agency or entity under contract with the State Medicaid agency): The DC Aging and Disability Resource Center (ADRC) performs evaluations/ reevaluations of eligibility for State Plan HCBS in accordance with its interagency agreement with DHCF. 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): Initial assessments /reassessments of needs-based eligibility criteria are conducted by a registered nurse (RN) or licensed independent clinical social worker (LICSW) employed by DHCF’s LTCSS Contractor. The assessment/reassessment determinations are then released to the ADRC for evaluations/revaluations of eligibility. The ADRC staff responsible for the evaluations/reevaluations are licensed social workers. 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: The beneficiary first must get a LTCSS Prescription Order Form (POF) signed by an enrolled Medicaid provider (MD or APRN), which identifies the age of the individual as well as any diagnosed chronic medical conditions. To initiate the LTCSS face-to-face assessment process, the signed POF is sent directly to DHCF’s LTCSS Contractor or uploaded into DC CareConnect. Upon receipt of the POF, DHCF’s LTCSS Contractor schedules and then conducts the face-to-face assessment of the beneficiary’s need for LTCSS using a standardized assessment tool that has been designed and validated for all long-term care populations. The needs-based criteria for the State Plan HCBS benefit, including ADHP services, is developed and determined by DHCF. As noted above, assessments and reassessments will be conducted in-person by a RN or LICSW employed/contracted by DHCF’s LTCSS Contractor. The assessment tool identifies a beneficiary’s needs across multiple domains, including functional, clinical, and behavioral; the resulting numerical score indicates whether the individual meets the needs-based eligibility criteria for the 1915(i) HCBS benefit. Once DHCF’s LTCSS Contractor has completed the assessment, the findings are immediately available to ADRC in DC CareConnect. ADRC then evaluates information/documentation in DC Care Connect and determines whether the individual is eligible for the 1915(i) State Plan HCBS benefit. If any individual is found not to meet the eligibility criteria, the individual has the right to request a reconsideration and/or fair hearing. The reevaluation process does not differ from the initial evaluation process.

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 8 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 4. ; Reevaluation Schedule. (By checking this box the state assures that): Needs-based eligibility reevaluations are conducted at least every twelve months. 5. ; 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): To be eligible for 1915(i) ADHP services, an individual has to obtain a minimum score of four (4) on the assessment tool. The needs-based criteria are determined by a standardized assessment tool which evaluates the individual’s care and support needs across three domains: (1) functional; (2) skilled care; and (3) cognitive/behavioral. 1) Functional - Type and frequency of assistance required with activities of daily living such as bathing, dressing, eating/feeding, eating/feeding, transferring, mobility, and toileting. 2) Skilled Care – Occurrence and frequency of certain treatments/procedures, skilled care (e.g. wound care, infusions), medical visits, and other types of formal care. 3) Cognitive/Behavioral – Presence of and frequency with which certain conditions and behaviors occur (e.g., communications impairments, hallucinations or delusions, physical/verbal behavioral symptoms, eloping or wandering). Completion of the assessment will yield a final total score determined by adding up the individual scores from the three domains. 6. ; Needs-based Institutional and Waiver Criteria. (By checking this box the state assures that): There are needs-based criteria for receipt of institutional services and participation in certain waivers 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 waivers 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 needs-based eligibility criteria NF (& NF LOC** waivers) ICF/IID (& ICF/IID LOC waivers) Applicable Hospital* (& Hospital LOC waivers)

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 9 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 To be eligible for reimbursement of 1915(i) ADHP services, an individual has to obtain a minimum score of four (4) on the assessment tool. The needs-based criteria are determined by a standardized assessment tool which will include an assessment of the individual’s support needs across three domains including: (1) functional; (2) skilled care; and (3) cognitive/behavioral. 1) Functional - Type and frequency of assistance required with activities of daily living such as bathing, dressing, eating/feeding, eating/feeding, transferring, mobility, and toileting. 2) Skilled Care – Occurrence and frequency of certain treatments/procedures, skilled care (e.g. wound care, infusions), medical visits, and other types of formal care. 3) Cognitive/Behavioral – Presence of and frequency with which certain conditions and behaviors occur (e.g., communications impairments, hallucinations or delusions, physical/verbal An individual who is a new admission shall be eligible for nursing facility services if they obtain a total score of nine (9) or more on the assessment tool. Nursing facility level of care is determined using the same standardized assessment tool that is used to determine state plan HCBS 1915(i) eligibility. Individuals who qualify for ICF/MR services will not be assessed via DHCF’s LTCSS assessment tool. To determine if an individual requires services furnished by an ICF/MR, assessments are conducted by DHCF’s Quality Improvement Organization (QIO) via the DC Level of Need (LON) which is a comprehensive assessment tool to determine the level of care criteria for ICF/MR services. A person shall meet a level of care determination if one of the following criteria has been met: (a) The person’s primary disability is an intellectual disability (ID) with an intelligence quotient (IQ) of fifty-nine (59) or less; (b) The person’s primary disability is an ID with an IQ of sixty (60) to sixty nine Individuals who are admitted to the hospital are considered acute care patients. There is no applicable waiver for individuals who meet a hospital LOC. The State Medicaid Agency (SMA) contracts with a Quality Improvement Organization (QIO), Qualis Health, to prior authorize hospital admissions for Medicaid beneficiaries who are in need of inpatient hospital services based on medical necessity criteria. There no applicable LOC or corresponding admission criteria for long term care or chronic care hospitalizations

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 10 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 behavioral symptoms, eloping or wandering). Completion of the assessment will yield a final total score determined by adding up the individual scores from the three domains. (69) and the person has at least one (1) of the following medical conditions: (1) Mobility deficits; (2) Sensory deficits; (3) Chronic health problems; (4) Behavior problems; (5) Autism; (6) Cerebral Palsy; (7) Epilepsy; or (8) Spina Bifida. (c) The person’s primary disability is an ID with an IQ of sixty (60) to sixty- nine (69) and the person has severe functional limitations in at least three of the following major life activities: (1) Self-care; (2) Understanding and use of language; (3) Functional academics; (4) Social Skills; (5) Mobility; (6) Self-direction; (7) Capacity for independent living; or

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 11 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 (8) Health and Safety. (d) The person has an ID, has severe functional limitations in at least three (3) of the major life activities set forth in (c) (1) through (c)(8) (see above); and has one (1) of the following diagnoses: (1) Autism; (2) Cerebral Palsy; (3) Prader Willi; or (4) Spina Bifida *Long Term Care/Chronic Care Hospital **LOC= level of care 7. ; Target Group(s). The state elects to target this 1915(i) State plan HCBS benefit to a specific 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)): Individuals enrolled in the 1915(i) program shall: (1) Be age 55 or older; and (2) Have one or more chronic conditions or progressive illnesses as diagnosed by a physician † 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):

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 12 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 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: 1 ii. Frequency of services. The state requires (select one): ~ The provision of 1915(i) services at least monthly { 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): 1. ; Home and Community-Based Settings. The State plan HCBS benefit will be furnished to individuals who reside and receive HCBS in their home or in the community, not in an institution. (Explain how residential and non-residential settings in this SPA comply with Federal home and community-based settings requirements at 42 CFR 441.710(a)(1)-(2) and associated CMS guidance. Include a description of the settings where individuals will reside and where individuals will receive HCBS, and how these settings meet the Federal home and community-based settings requirements, at the time of submission and in the future): (Note: In the Quality Improvement Strategy (QIS) portion of this SPA, the state will be prompted to include how the state Medicaid agency will monitor to ensure that all settings meet federal home and community-based settings requirements, at the time of this submission and ongoing.)

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 13 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 The District assures that this SPA renewal will be subject to any provisions or requirements included in the District’s most recent and/or approved home and community-based settings Statewide Transition Plan. The District will implement any CMCS required changes by the end of the transition period as outlined in the home and community-based settings Statewide Transition Plan.

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 14 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 Person-Centered Planning & Service Delivery (By checking the following boxes the state assures that): 1. ; 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. 2. ; 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 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). 3. ; 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. 4. 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): DHCF’s LTCSS Contractor will perform face-to-face assessments to determine eligibility for all LTCSS programs. In particular, the initial face-to-face assessment will assess the participant’s level of need for all LTCSS including State Plan HCBS benefit by using a standardized assessment tool. The LTCSS contractor will also perform reassessments at least once every twelve (12) month period, or whenever there is a significant change to the person’s health or service needs. The face-to-face assessment will be performed by an RN or LICSW employed by DHCF’s LTCSS Contractor. The staff performing the assessment will be licensed health care professionals trained in assessment of individuals with physical, cognitive, or mental conditions that trigger a potential for HCBS services and supports. Each RN and LICSW will be licensed or authorized to practice pursuant to qualifications prescribed by the District of Columbia Department of Health, Health Occupation and Regulations Act. 5. 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 individualized, person-centered service plan. (Specify qualifications): The Aging, Disability, and Resource Center (ADRC), through an MOU with DHCF, will be responsible for developing the person-centered service plan. The person-centered service plans will be developed in consultation with the beneficiary, the beneficiary’s guardian or representative, and any other person(s) chosen by the individual. Staff and agents performing person-centered service plans (PCSPs) are licensed social workers employed by ADRC. The ADRC staff/agents performing the PCSPs also must have intake assessment and options counseling experience, have completed person-centered thinking (PCT) trainings, have current knowledge of available resources, services options and providers, and be knowledgeable regarding best practices to improve health and quality of life outcomes.

State: District of Columbia §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-007 Page 15 Effective: April 1, 2020 Approved: March 18, 2020 Supersedes: 14-004 6. 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): The person-centered service plan shall be based on a person-centered planning approach. The person-centered planning process shall be directed by the individual with long-term support needs and may include a representative whom the individual has freely chosen and others chosen by the individual to contribute to the process. The minimum requirements of the person-centered planning process are that the process results in a person-centered service plan with individually identified goals and preferences, including those related to community participation, health care and wellness, education, and others. The plan will reflect the services and supports to be received, and who provides them. The planning process, and the resulting person-centered service plan, will assist the individual in achieving personally defined outcomes in the most integrated community setting, ensure delivery of services in a manner that reflects personal preferences and choices, and contribute to the assurance of health and welfare. During the person-centered planning process, each person and their representative shall receive information regarding all services and supports for which they are eligible based upon the results of the face-to-face assessment. Once they have made a choice of service type, they will receive information regarding qualified providers. Trained staff, who are experienced in providing “options” counseling will assist persons to make an informed choice based upon his/her needs and preferences. All information will be presented in simple and easily understood English and individuals with limited English proficiency will receive services that are culturally and linguistically appropriate. Additionally, persons with disabilities will be provided with alternative formats and other assistance to ensure equal access. 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): At the ADRC, each beneficiary is given a choice of 1915(i) ADHP providers from which to select. This information is provided by a licensed social worker staff person at the ADRC during the intake and assessment process, PCSP development process, and as well as via informational materials on the 1915(i) benefit /program—includes both general and ADHP-specific materials. Additional information on the 1915(i) benefit and a District ADHP provider directory are both available on DHCF’s Long Term Care Administration website. . Once the beneficiary has selected an ADHP provider, based on the information and guidance provided by the ADRC, and has a completed PCSP, they will work with a designated staff person at the ADHP provider site to develop a written plan of care. The designated staff at the ADHP provider will have primary responsibility for developing a written plan of care to implement each person’s PCSP. In doing so, the staff person will play an essential role in assisting persons to learn about the various professionals offering