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 ftJr MEDICARE & MEDICAID SBMCES Region Ill/Division of Medicaid and Children's Health Operations AUG 8 2011 Rosanne Mahaney, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, Delaware 19720-0906 Dear Ms. Mahaney: We have reviewed State Plan Amendment (SPA) 11-004, in which you propose to update Delaware's State Plan to exempt Medicare cost sharing benefits paid under the Medicare Savings Program from estate recovery. This SPA is acceptable. Therefore, we are approving SPA 11- 004 with an effective date of July 1, 2011 . Enclosed are the approved SPA pages and signed CMS-179 form. If you have further questions about this SPA, please contact Melanie Benning at 215-861-4267. Sincerely, Associate Regional Administrator Enclosures

Revision: HCFA-PM-95-3 (MB) May 1995 53 a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT TN No. SPA #11-004 Supersedes TN No. SPA #06-001 STATE/TERRITORY: DELAWARE (b) Adjustments or Recoveries The State complies with the requirements of section 1917(b) of the Act and regulations at 42 CFR 433.36 (h)-(1). (1) For permanently institutionalized individuals, adjustments or recoveries are made from the individual's estate or upon sale of the property subject to a lien imposed because of medical assistance paid on behalf of the individual for services provided in a nursing facility, ICF/MR, or other medical institution. _Adjustments or recoveries are made for all other medical assistance paid on behalf of the individual. (2) _The State determines "permanent institutional status" of the individuals under the age of 55 other than those with respect to whom it imposes liens on real property under §1917(a)(1)(B) (even if it does not impose those liens. (3) For any individual who received medical assistance at age 55 or older, adjustments or recoveries of payments are made from the individual's estate for nursing facility services, home and community-based services, and related hospital and prescription drug services. _lL In addition to adjustment or recovery of payments for services listed above, payments are adjusted or recovered for all services under the State Plan as listed below: All other medical assistance paid on behalf of the individual. for individuals age 55 and over, except for Medicare cost sharing identified at 4.17(b)(3) (Continued). Approval Date _A_U_G __ 8_2_0_11_ Effective Date July 1, 2011

Revision: HCFA-PM-95-3 (MB) May 1995 53a-1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE 4.17 (b) Adjustments or Recoveries TN No. SPA #11-004 Supersedes TN No. SPA #06-002 (3) (Continued) Limitations on Estate Recovery- Medicare Cost Sharing (i) Medical assistance for Medicare cost sharing is protected from estate recovery for the following categories of dual eligibles: QMB, SLMB, Ql , QDWI, QMB+, SLMB+. This protection extends to medical assistance for four Medicare cost sharing benefits: (Part A and B premiums, deductibles, coinsurance, co-payments) with dates of service on or after January 1, 2010. The date of service for deductibles, coinsurance, and co-payments is the date the request for payment is received by the State Medicaid Agency The date of service for premiums is the date the State Medicaid Agency paid the premium . (ii) In addition to being a qualified dual eligible the individual must also be age 55 or over. The above protection from estate recovery for Medicare cost sharing benefits (premiums, deductibles, coinsurance, co-payments) applies to approved mandatory (i.e., nursing facility, home and community-based services, and related prescription drugs and hospital services) as well as optional Medicaid services identified in the State plan, which are applicable to the categories of duals referenced above. Approval Date -""lA"'""'lJ..u6___,8~.~----Co2.u-01+~-1 Effective Date July 1, 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES IIE/\l.TH CA'RE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL I. TRANSMIIT AL NUMBER: SPA #I 1-004 FORM APPROVED OMB NO. 0938-0193 2. STATE DELAWARE FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE ,July 1.2011 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN XXX AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Medicare Improvements for Patients and Providers Act of2008 a. FFY 2011 $-0- (MIPPA), P.L. I Hl-275, Section I 15; :tnd, Section 1917(h)(l)(B) b. FFY 2012 $-0- 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): General Program Administr:Hion ..t.t7, Liens and Adjustments or l~ccovcrie s, Page 53a General Program Administration 4.17, Liens and Adjustments or Recoveries, Page 53a Cl·ncral Program Administration 4. 17, Liens and Adjustments or Recoveries, Page SJa-1 (NEW) N/A 10. SUBJECT OF AMENDMENT: Eliminating Application of Estate Recovery to Medicare Cost Sharing Benefits, M I PPA Sed ion 115: Exemption of Medicare cost sharing benefits (Parts A & B premiums, deductihles, co-pays, coinsurance) paid urlllt•r MSP for Estate Recovery. Exemption only extends to benefits with chttcs of service on or after .January I. 20 I 0 for qualified dual eligibles age 55 and over. II . GOVERNOR' S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED XXX OTHER, AS SPECIFIED: 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Governor's comments under separate correspondence 12. SIGNATURE OF STATE AGENCY OFFICIAL: //nosanne Maham~y - signature// 16. RETURN TO: ---,--,13:- . -=T,.,...Y'""'P-=E-=-D-N_A_M_E_:----------------~ Rosanne Mahaney Director l~osanne Mahaney, Director, Division of Medicaid and Medical Division of Medicaid and Medical Assistance Assishmcl' ----:-"14.:..::. -::::=T::-:IT='LC....:E~:---:::-D-es....,-ig_t_te-l'-.,. fo_r_R,..--.,.-itl-t -M.,-.-L-,a-n_d_g-ra-::f-, S.,-e-c-re-·t-a r-)-', -D-e- la- ,,- , a-re-~ P.O. Box 906 1-1 It I d S · 1 s· · New Castle, Delaware I 9720-0906 ca · 1 an , octa . ervtces 15. DATE SU BMITTED: July I I , 2011 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEJVED/: ·7 I -z.o J I 118. DATE APPROVED: . 19. EFFECTIVE DA,TE II J 23. REMARKS: FORM HrFA-17Q f07-Q?) PLAN APPROVED- ONE COPY ATTACHED F APPROVED MATERIAL: 20. SIGNA~ OF "2, D I I Ia;:-.( AUG 8 2011

. . ' r 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 Region III/Division of Medicaid and Children's Health Operations SWIFT#: 011820124055 FEB 10 2012 Rosanne Mahaney, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, Delaware 19720-0906 Dear Ms. Mahaney: We have reviewed Delaware State Plan Amendment (SPA) 11-007. This SPA identifies as a plan service concurrent hospice services for children under age 21 years, pursuant to Section 2302 of the Affordable Care Act. This SPA is acceptable. Therefore, we are approving SPA 11-007 with an effective date of September 1, 2011. Enclosed are the approved SPA pages and signed CMS-179 form. If you have further questions about this SPA, please contact Melanie Benning at 215-861-4267 . M I Associate Regional A inistrator Enclosures Do you knol"' someone who has been denied medical insurance because of a pre-existing condition? (f so. they may be eligible for the flew Pre-Existing Condition Insurance Plan. Call tal/free 1-866- 717-5826 (TTY 1- 866-561-160-1) or visit www.pcip.gov and click on "Find Your State·· to leam more

Revision: HCFA-PM-86-20 (BERC) SEPTEMBER 1986 ATTACHMENT 3.1-A Page 7 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State IT erritory: Delaware AMOUNT, DURATION AND SCOPE OF MEDICALAND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 15.a. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined, in accordance with section 1902(a)(31 )(A) of the Act, to be in need of such care. 0 0 Provided: 0 Not provided. No limitations 0 With limitations* b. Including such services in a public institution (or distinct part thereof) for the mentally retarded or persons with related conditions. 0 0 Provided: 0 Not provided. No limitations 0 With limitations* 16. Inpatient psychiatric facility services for individuals under 22 years of age. Provided: 0 No limitations 0 With limitations* *See Attachment 3.1-A, Page 2c Addendum, Item 4.b. - EPSDT. 0 Not provided. 17. Nurse-midwife services. 0 0 Provided: 0 Not provided. No limitations 0 With limitations* 18. Hospice care (in accordance with section 1905(o) of the Act). Provided: 0 No limitations 0 Provided in accordance with section 2302 of the Affordable Care Act 0 With limitations* 0 Not provided. *Description provided on attachment. TN No. SPA #11-007 Approval Date FEB 10 2012 Supersedes TN No. SP - 245 Effective Date September 1, 2011

< • ATIACHMENT 4.19-B Page~ ~3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Delaware METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES- OTHER TYPES OF CARE 18. Hospice Care Reimbursement for Hospice care will be made at one of four predetermined rates for each day in which a beneficiary is under the care of the Hospice. The daily rate (and hourly rate for Continuous Home Care) is applicable to the type and intensity of services furnished to the beneficiary for that day. There are four levels of care into which each day of care is classified: • Routine home care • Continuous home care • Inpatient respite care • General inpatient care The Centers for Medicare and Medicaid Services (CMS) computes a set of prospective Medicaid hospice rates based on the methodology used in setting Medicare hospice rates, which are adjusted to disregard the cost offsets attributable to Medicare coinsurance amounts. Medicaid hospice payment rates are also adjusted for regional differences in wages, using indices published in the Federal Register. In no case may hospice payment amounts be established in amounts lower than the Medicaid hospice amounts computed by CMS. The Medicare reimbursement cap will not be applied to Delaware Medicaid hospice providers. Payment for Room and Board in a NF or ICF/MR- For Medicaid beneficiaries who elect to receive hospice care while residing in a nursing facility or ICF/MR facility, in addition to the payment for routine care or continuous care referenced above, the hospice provider will also be reimbursed a per diem amount to cover room and board services provided by the nursing facility or ICF/MR facility. This reimbursement rate is equal to 95 percent of the base rate that would have been paid to the facility under Delaware Medicaid policy. Payment for Physician Services - The hospice must bill for physician services rendered to a hospice patient for a diagnosis related to the terminal illness when a physician employee of the hospice (including volunteering physicians) is performing direct care services as an attending physician or when the attending physician requests medically necessary services be provided by another doctor. This payment is in addition to the four prospective rates above paid to the hospice. When billing the Delaware Medical Assistance Program (DMAP) for these physician services, the hospice must use the procedure code that reflects what the physician would have billed the DMAP had (s)he been able to bill directly in conjunction with the appropriate revenue code. DMAP will pay the claim based on its physician fee schedule. If the attending physician is not a hospice employee, the physician will bill Delaware Medicaid directly and payment will be made to the physician as per the Delaware Medicaid physician fee schedule. Hospice payment rates can be found on the Delaware Medical Assistance Program website at: http://www.dmap.state.de.us/downloads.html. The fee schedule on the website includes all annual or periodic adjustments. Except as otherwise noted in the plan, the hospice fee schedule is the same for both governmental and private providers. TN No. SPA #11-007 Supersedes TN No. SP - 245 Approval Date Effective Date September 1, 2011

DEPARTMrNT OF H,EALT!-1 AND I-lUMAN SERVICES HEALTH CAR:E FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: STATE PLAN MATERIAL SPA #I 1-007 FORM APPROVED OMB NO. 0938-0193 2. STATE DELAWARE FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE SEPTEIVI BER I, 201 I 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN XXX AMENDMENT COMPLETE BLOCKS 6 THRU I 0 IF THIS IS AN AM ENDMENT (Se arate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: PATIENT PROTECTION AND AFFORDABLE CARE ACT a. FFY 201 I $-0- §2302 b. FFY 20 12 $ -0- 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): ATTACHMENT 3.1 -A, PAGE 7 AHa.eh()UJLf 4.t'16 J Pa.jt ;)..3 ATTACHMENT 3.1-A, PAGE 7 10. SUBJECT OF AMENDMENT: CONCURRENT IIOSPICE FOR CH ILDREN IN ACCORDANCE WITH SECTION 2302 OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT II. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR' S OFFICE ENCLOSED XXX OTHER, AS SPECIFIED: 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Governor's comments under separate correspondence 12. SIGNATURE OF STATE AGENCY OFFICIAL: //Rosanne Mahaney- signature// 16. RETU RN TO: -13-.-T-Y_P_E_D_N_A_M_E_: ----- - --- ------ ----i Rosanne Mahaney l)irector Rosanne Mah~mey, Director, Oivision of Medicaid and Medical Division of Medicaid and Medical Assistance Assistance __:,..:=:::-:=-=:..=....------- --------------1 P.O. Box 906 14. TITLE: Designee for Rita M. Landgraf, Secretary, Oehmare New Castle, Delaware 19720-0906 Health and Social Services 15. DATE SUBM ITTED: 11116/11 17. DATE RECEIVED: 1 I J I J J :l.o l l 23. REMARKS: FORM HCF A-179 (07-92) FOR REGIONAL OFFICE USE ONLY 1 18. DATE APPROVED: FER 10 2012

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 Region Ill/Division of Medicaid and Children's Health Operations SWIFT#: 020920124018 FEB 2 8 2012 Rosanne Mahaney, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, Delaware 19720-0906 Dear Ms. Mahaney: We have reviewed Delaware State Plan Amendment (SPA) 11-0lO. This SPA implements the Program of All-Inclusive Care for the Elderly (PACE) program in Delaware as an optional Medicaid State Plan service. This SPA is acceptable. Therefore, we are approving SPA 11-010 with an effective date of October 1, 2011. Enclosed are the approved SPA pages and signed CMS-179 form. If you have further questions about this SPA, please contact Melanie Benning at 215-861-4267. Enclosures cc: Cindy Proper, CMCS Do you know someone who has been denied medical insurance because of a pre-existing condition? !f so. they may he eligible for the 11ew Pre-Existing Condition Insurance Plan. Call tollfree 1-866-717-5826 (TTY 1- 866-561-160.:1) or visit www.pcip.gov and click on "Find Your State ,. to leam more

Revision: Citation 1905(a)(26) and 1934 HCFA-PM-91-4 AUGUST 1991 (BPD) 19c OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatefTerritory: DELAWARE 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued) X Program of All inclusive Care for the Elderly (PACE) services, as described and limited in Supplement 2 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.) TN No. SPA#11-010 Supersedes Approval Date FEB 2 8 2012 TN No. NEW Effective Date October 1, 2011

Revision: HCFA-PM-91-1 0 (MB) ATTACHMENT 2.2-A Page 11 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Agency* Citation(s) 42 CFR 435.217 TN No. SPA #11-010 Supersedes TN No. NEW State/Territory: DELAWARE Groups Covered B. Optional Groups Other Than the Medically Needy (Continued) X 4. A group or groups of individuals who would be eligible for Medicaid under the plan if they were in a NF or an ICF/MR, who but for the provision of home and community- based services under a waiver granted under 42 CFR Part 441 , Subpart G would require institutionalization, and who will receive home and community-based services under the wa·lver. The group or groups covered are listed in the waiver request. This option is effective on the effective date of the State's section 1915(c) waiver under which this group(s) is covered. In the event and existing 1915(c) is amended to cover this group(s), this option is effective on the effective date of the amendment. X PACE enrollees and will be effective on the effective date of the amendment electing PACE as an optional State plan service. Approval Date FEB 2 8 2012. Effective Date October 1, 2011

Revision: OMB No. CMS ATTACHMENT 3.1-A Page 11 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Staterrerritory: DELAWARE AMOUNT, DURATION, AND SCOPE OF SERVICES OF MEDICAL AND REMEDIAL CARE SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 25. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 2 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. TN No. SPA #11-010 Supersedes TN No. NEW Approval Date FEB 2 8 2012 Effective Date October 1, 2011

Revision: HCFA-PM-87-4 MARCH 1987 (BERC) SUPPLEMENT 2 TO ATTACHMENT 3.1-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Staterrerritory: DELAWARE I. Eligibility The State determines eligibility for PACE enrollees under rules applying to community groups. A._ The State determines eligibility for PACE enrollees under rules applying to institutional groups as provided for in section 1902(a)(1 O)(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. Spousal impoverishment eligibility rules will apply. The applicable groups are: Individuals receiving seiVices under this program are eligible under the following eligibility groups: • A Special Income Level equal to 250% of the SSI Federal Benefit (FBR) (42 CFR 435.236) (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. _x_ 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._ 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). TN No. SPA #11-010 Approval Date FEB 2 8 20·12 Supersedes TN No. NEW Effective Date October 1, 2011

Revision: HCFA-PM-87 -4 MARCH 1987 (BERC) SUPPLEMENT 2 TO ATIACHMENT 3.1-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: DELAWARE Regular Post Eligibility 1. _ 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._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. 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.__ Not applicable (N/A) TN No. SPA #11-010 Approval Date Supersedes _:_.:;::_:;::_ __ _;,_;_=--- TN No. NEW Effective Date October 1, 2011

Revision: HCFA-PM-87-4 MARCH 1987 (BERG) SUPPLEMENT 2 TO ATTACHMENT 3.1-A Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatefTerritory: DELAWARE Regular Post Eligibility Continued (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. 4. 5. __ 6. 7. __ The following dollar amount: $ __ _ Note: If this amount changes, this item will be revised . The following percentage of the following standard that is not greater than the standards above: % of standard. The amount is determined using the following formula: Other: ---.,....,.,..------- -- 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 rema ining 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): ____ _____ _ TN No. SPA #11-010 Approval Date FEB 2 8 2012 Supersedes TN No. NEW Effective Date October 1, 2011

Revision: HCFA-PM-87-4 MARCH 1987 (BERC) SUPPLEMENT 2 TO ATTACHMENT 3.1-A Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Staterrerritory: DELAWARE 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. __ 0ther 7. __ Not applicable (N/A) (b) Medical and remedial care expenses specified in 42 CFR 435.735. TN No. SPA #11-010 Approval Date Supersedes TN No. NEW Effective Date October 1, 2011

Revision: HCFA-PM-87-4 MARCH 1987 (BERC) SUPPLEMENT 2 TO ATTACHMENT 3.1-A Page 5 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: DELAWARE 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 fam ily 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: % 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: TN No. SPA #11..()10 Approval Date FEB 2 8 2012 Supersedes TN No. NEW Effective Date October 1, 2011

Revision: HCFA-PM-87-4 MARCH 1987 (BERC) SUPPLEMENT 2 TO ATTACHMENT 3.1-A Page 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: DELAWARE 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* 2._ 3. 4. Rates are set at a percent of fee-for-service costs Experience-based (contractors/State's cost experience or encounter date) (please describe) Adjusted Community Rate (please describe) Other (please describe) *See Pages 7 and 8 for description of rate setting methodology B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner. Pleas.e list the name, organizational affiliation of any actuary used, and attestation/description for the initial capitation rates. Mercer Government Human Services Consulting 2325 East Camelback Road, Suite 600 Phoenix, Arizona 85016 Attention: Frederick P. Gibison, Jr. 1.602.522.6526 C. The State will submit all capitated rates to the CMS Regional Office for prior approval. TN No. SPA #11-010 Approval Date FEB 2 8 2012 Supersedes TN No. NEW Effective Date October 1, 2011

Revision: HCFA-PM-87 -4 MARCH 1987 (BERG) SUPPLEMENT 2 TO ATTACHMENT 3.1-A Page 7 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: DELAWARE CAPITATED RATE METHODOLOGY Base Data Source and Analysis The PACE rates are based on the Upper Payment Limit (UPL) methodology. The historical fee for service target population data is extracted for claims and eligibility for more than one year. PACE eligible populations used to develop the PACE UPLs are individuals enrolled in home and community based waivers (HCBS) and individuals in nursing facilities. These two populations serve as the basis upon which the PACE UPLs are developed. Claims and eligibility data are gathered for both Medicaid-only individuals receiving the aforementioned services and also those individuals fully dually eligible for Medicaid and Medicare Parts A/B/D. Historical FFS data is compiled by date of service for the applicable year from the State's MMIS and eligibility system. Data for clients in the aforementioned two groups who are not eligible to enroll in PACE (e.g. those under age 55) are excluded from the database. The PACE UPLs include payment for all covered Medicaid services as well as Medicare coinsurance and deductible payments for full dual eligible clients. The final UPLs are developed for two rating groups: Dual Eligible -Age 55+ and Medicaid-only Age 55+. The FFS data used in the analysis is reviewed for reasonableness to be (or as necessary adjusted to be) appropriate for UPL development as described in the most current version of the CMS PACE checklist. • Claims expenditures for the PACE-equivalent population include Medicaid paid amounts increased by applicable patient liability and co-payments paid by recipients. • Data for partial dual eligible populations were specifically excluded from the analysis. as they are not entitled to Medicaid services. • Claims for services that are not covered services under PACE are not included. Adjustments to Develop the UPL The prospective UPL is subject to the following adjustments; ·• Base Data Adjustments: The historical FFS base data are adjusted to comply with the requirements in the PACE UPL checklist and to ensure that the UPLs reflect what otherwise would have been paid under the State plan if participants were not enrolled in PACE (e.g., FFS pharmacy rebates, completion factors, copayments and patient liability). TN No. SPA #11-010 Approval Date FEB 2 8 2012 ~ Supersedes TN No. NEW Effective Date October 1 , 2011

Revision: HCF A-PM-87 -4 MARCH 1987 (BERC) SUPPLEMENT 2 TO ATTACHMENT 3.1-A Page 8 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: DELAWARE CAPITATED RATE METHODOLOGY (cont'd) • Prospective Trend: Trend is an estimate of the change in the overall cost of providing health care benefits over a finite period of time. A trend factor is necessary to estimate the cost of health care services in a defined contract period. As part of the UPL development for the PACE program, annual per-member-per-month (PMPM) trend rates by consolidated COS are developed. The base data is trended forward to the midpoint of the contract period. • Programmatic Changes: Programmatic changes recognize the impact of changes to benefits, eligibility or State reimbursement that take place between the base period and the projection period. • State Administrative Costs: An estimate of the State's FFS administrative costs is included in the UPL development process. PACE Capitation Rates The State will ensure compliance with 42 CFR 460.182(b) by assuring that the PACE capitation rates will be a fixed percentage, of less than 100 percent, of the respective PACE UPL amounts. This percentage will consider differences between the FFS population from which the PACE UPLs were built and the expected enrollment in the PACE plans including relative acuity and the impact of better care management/care coordination. TN No. SPA 1111-010 Approval Date FEB 2 B ·2012 Supersedes TN No. NEW Effective Date October 1, 2011

Revision: HCFA-PM-87-4 MARCH 1987 (BERC) SUPPLEMENT 2 TO ATTACHMENT 3.1-A Page 9 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: DELAWARE Ill. 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. TN No. SPA #11-010 Approval Date FEB 2 8 2012 Supersedes TN No. NEW Effective Date October 1, 2011

Revision: OMB No. CMS ATTACHMENT 3.1-A Page 11~ STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: DELAWARE AMOUNT, DURATION, AND SCOPE OF SERVICES OF MEDICAL AND REMEDIAL CARE SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 26. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 2 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. TN No. SPA#11-010 Approval Date FEB 2 8 2012 Supersedes TN No. NEW Effective Date October 1, 2011

DEPARTMENT OF 1-lEALTfl AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MA TERTAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITTAL NUMBER: SPA #11-010 FORM APPROVED OMB NO 0938-0193 2. STATE DELAWARE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE OCTOBER I, 20 II 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN XXX AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate TransmiJJal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR Part 460 a. f'F\' 2011 $-0- b. FFY 2012 $ -U- 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION General Program Administration Page 19c Attachment 2.2-A Page II Attachment 3.1-A Page 11 Supplement 2 to Attachment 3.1-A Pages I through 9 OR ATTACHMENT (f!Applicable): i\cw Athtchment 2.2-A Page 11 New New 10. SUBJECT OF AMENDMENT: This State plan amendment will allow Delaware Medicaid to offe•· Program of All-Inclusive Care (!'ACE) as an optional Medicaid service. II. 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 12. SIGNATURE OF STATE AGENCY OFFICIAL: //Rosanne Mahaney- signature// XXX OTHER, AS SPECIFIED: GoYernor's comments nuder separate correspondence 16. RETURN TO: -=-=u-. =T::-:Yc=-P=E=D-=-N...,..A""'M,-:-:=E-: --- ----- ------ - ---1 Rosanne Mahaney Director Rusannt• Mahaney, Director, Division of Medicaid and Mediclll Assistanct• DiYision of Medicaid and Medical Assistance - 14""".-=T""IT=-L-E_:_D_c_s_ig-,n-e-e-fo_r_R_i_ta_M_ ._L_n_ud_g_r _a_f.-S-.c-cr-c-ta-r-y.- D-e-l-aw-1lr-e--j ~-:~~ ~:~t~e~<~ehtware 19720 _ 0906 Health and Social Services 15. DATE SUBMITTED: December I, 2011 ..... :-:-. .,,"(,.. :.::. F,OR Rl:GJONAL OFFJC,E ~SE ONLY 18. DATEAPPROVED: · FEB -2-8 2012: OFFlCIAL: ··._ '·''· . ~· ;·..:.,._ •J'(.-_v,( L. -,.. .. ·'' · .. FORM HCFA-179 (07-92) . /

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 SEIMCES Region IIJ!Division of Medicaid and Children's Health Operations SVVIFT#:020120124025 FER 0 8 2012 Rosanne Mahaney, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 190 1 N. DuPont Highway New Castle, Delaware 19720-0906 Dear Ms. Mahaney: VVe have reviewed Delaware State Plan Amendment (SPA) 11-011, in which you propose to implement Asset Verification System, a system for verifying the assets of aged, blind or disabled applicants for and recipients of Medicaid. This SPA is acceptable. VV e are approving SPA 11- 011 with an effective date of October 1, 2011. Enclosed are the approved SPA pages and signed CMS-1 79 form. If you have further questions about this SPA, please contact Melanie Benning at 215-861-4267. Enclosures Do you know someone who has /wen denied 111edico/ insur(!nCt' ht'cmls<! <!fu pre-c.risling coll£1i!ion:J ~/so. !heF 111£~V hi! d igihle((Jr !ht' nt!w Prt!-Exisling Condilion insurance Pl£1n. Cull!ull ji·ec I-X{>6-7 1'-58:!6 r7TY 1- 866-561- /60-1) or visit www.pcip.gov aud click on ·'Find Your S!u/e ., to l<'arn 11/0rt'

Revision: SUPPLEMENT 16 TO ATTACHMENT 2.6-A PAGE 1 1940(a) STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory DELAWARE 1. ASSET VERIFICATION SYSTEM The Agency will provide for the verification of assets for purposes of determining or redetermining Medicaid eligibility for aged, blind and disabled Medicaid applicants and recipients using an Asset Verification System (AVS) that meets the following minimum requirements. A. The request and response system must be electronic: (1) Verification inquiries must be sent electronically via the internet or similar means from the Agency to the financial institution (FI). (2) The system cannot be based on mailing paper-based requests. (3) The system must have the capability to accept responses electronically. B. The system must be secure, based on a recognized industry standard of security (e.g., as defined by the U.S. Commerce Department's National Institute of Standards and Technology, or NIST). C. The system must establish and maintain a database of Fls that participate in the Agency's AVS. D. Verification requests also must be sent to Fls other than those identified by applicants and recipients, based on some logic such as geographic proximity to the applicant's home address, or other reasonable factors whenever the Agency determines that such requests are needed to determine or redetermine the individual's eligibility. E. The verification requests must include a request for information on both open and closed accounts, going back up to 5 years. TN No. SPA #11-011 Supersedes Approval Date FER 0 8 2012 TN No. NEW Effective Date October 1, 2011

Revision: SUPPLEMENT 16 TO ATTACHMENT 2.6-A PAGE2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory DELAWARE ASSET VERIFICATION SYSTEM 2. System Development A. __ The Agency itself will build and maintain an AVS. In 3 below, describe how the system will meet the requirements in Section 1. B. _2L The Agency will hire the following contractor to build and maintain an AVS. In 3 below, identify the contractor, if known, and describe how the system will meet the requirements in Section 1. C. __ The Agency will be joining a consortium to develop an AVS. In 3 below, identify the States participating in the consortium. Also identify the contractor, if known, who will build and maintain the consortium's AVS, and how the system will meet the requirements in Section 1. D. __ The Agency already has a system in place that meets the requirements for an acceptable AVS: In 3 below, describe how the system meets the requirements in Section 1. E. Other alternative not included in A. -D. above. In 3 below, describe this alternative approach how it will meet the requirements in Section 1. TN No. SPA #11-011 Supersedes Approval Date_F_£_8_0_ ~ _8_2_01_2_ TN No. NEW Effective Date October 1, 2011 2

Revision: SUPPLEMENT 16 TO ATTACHMENT 2.6-A Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory DELAWARE ASSET VERIFICATION SYSTEM 3. Provide the AVS implementation description and other information requested for the implementation approach checked in Section 2. The contractor is not known at this time. The Agency will select a contractor through the Request for Proposal (RFP) process. The system and entity chosen will be able to comply with the following requirements of Supplement 16 to Attachment 2. 6-A, Page 1: A. An electronic request and response process for asset verification; B. A database of financial institutions (Fis) that provide data to the entity meeting the geographic requirements of the entity; C. A 5-year look-back of the assets on individual applicants, recipients, spouses and partners; D. A secure system based on a recognized industry standard as defined by the United States Commerce Department's National Institute of Standards and Technology, or NIST; E. Verification request will include both open and closed asset account information as determined by the State; F. The acceptable asset verification entity will provide adequate data for the generation of all required reports expected to meet federal reporting requirements such as the number of requests, number of responses and amounts of undisclosed assets found. TN No. SPA #11-011 Supersedes Approval Date --'-F ..::..::E..:::::.B_0_8__:::;c2..;::_01=2--'- TN No. NEW Effective Date October 1, 2011 3

DEPARTME!:-JTOF HEf.LTH AND HUMAN SERVICES HEALTH CARE FfNANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: STATE PLAN MATERIAL SPA#II-011 FORM APPROVED OMB NO 0938-0193 2. STATE DELAWARE FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE OCTOBER I, 2011 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN XXX AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SOCIAL SECURITY ACT §1940 a. FFY 2011 $-0- b. FFY 2012 $-0- 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): SUPPLEMENT 16 TO ATTACHMENT 2.6-A, PAGES I, 2, 3 NEW STATE PLAN PACES 10. SUBJECT OF AMENDMENT: ASSET VERIFICATION SYSTEM (AVS) UNDER THE REQUIREMENTS OF SECTION 1940 OF THE SOCIAL SECURITY ACT II. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED XXX OTHER, AS SPECIFIED: 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Governor's comments under separate correspondence 12. SIGNATURE OF STATE AGENCY OFFICIAL: //Rosanne Mahaney - signature// 16. RETURN TO: -13-. _T_Y_P_ED_N_A_M_E_:-----------------1 Rosanne Mahaney Director Rosanne Mahaney, Director, Division of Medicaid and Medical Division of Medicaid and Medical Assistance Assistance ~~~~~-----~------~------------~ P.O.Box906 14. TITLE: Designee for Rita M. Landgraf, Secretary, Delaware Health and Social Services New Castle, l>elaware 19720-0906 15. DATE SLJBMIH'ED: December 9, 2011 FOR REGIONAL OFFICE USE ONLY 18. DATE APPROVED: FEB 0 8 2012 21. TYPED NAME: 23. REMARl(S: FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Indep~ndence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS IrK MEDICARE a MEDICAID SE/IVICES Region III/Division of Medicaid and Children's Health Operations SWIFT#: 020920124019 MAR 0 5 2012 Rosanne Mahaney, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, Delaware 19720-0906 Dear Ms. Mahaney: We have reviewed Delaware State Plan Amendment (SPA) 11-012, in which you propose to elect to substitute PERM reviews (active and negative) for the State's MEQC traditional reviews during the State's PERM cycle year. This SPA is acceptable. We are approving SPA 11-012 with an effective date of October 1, 2011. Enclosed are the approved SPA pages and signed CMS-1 79 form. If you have further questions about this SPA, please contact Melanie Benning at 215-861-4267. Enclosures Do you knolt' .m meone who has heen denied lllr!dical insurw1cl! b<!causl' <ifu pre-existing condition? ~lso. thc1: may he rdigihlt:f(n· tllr! new Pre-E'Cisting Condition Jn.,·w ·mlce 1'/un. Calltollji·ec I-X66-7 f 7-58:!6 (TTY 1- 866-561-160-/) or 1•isit www.pcip.gov and click on .. Find Your State·· to learn l/J0/"1!

35 Revision: OMB No.: STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Citation 42 CFR 431 Subpart P and Q 50 FR 21839 75 FR 48847 1903(u) of the Act, P.L. 99-509 (Section 9407) P.L. 107-300 P.L. 111-3 State/Territory: 4.4 TN No. SPA #11-012 Supersedes TN No. SP- 250 DELAWARE Medicaid Eligibility Quality Control (MEQC) (a) A system of quality control is implemented in accordance with 42 CFR of Part 431 , Subpart P. (b) In accordance with 431.806(c), the State operates a Medicaid quality control claims processing assessment system that meets the requirements of 431 .830- 431 .836. D Yes. ~ Not applicable. The State has an approved Medicaid Management Information System (MMIS). (c) In accordance with 431 .806(b), Payment Error Rate Measurement (PERM) is implemented in accordance with 42 CFR Part 431 , Subpart Q, in substitution to meet the statutory and regulatory ("traditional") Medicaid Eligibility Quality Control (MEQC) review during the State's PERM cycle. ~ Yes. [2J Effective for FFY 2012. [2] Effective for FFY 2015. D Effective for FFY 2018. Approval Date Effective Date October 1, 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO. 0938-01 93 TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: 2. STATE DELAWARE STATE PLAN MATERIAL SPA #lt-012 FOR: HEALTH CARE FINANCING ADMIN ISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE OCTOBER 1, 2011 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN XXX AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 431 Subpart P and Q, 50 FR 21839, 75 FR 48847, 1903(u) of the Act, P.L. 99-509 (Section 9407), P.L. 107-300, P.L. II 1-3 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: GENERAL PROGRAM ADMINISTRATION PAGE35, 4.4 MEDICAID ELIGIBILITY QUALITY CONTROL (MEQC) 7. FEDERAL BUDGET IMPACT: a. FFY 2.Q(i2.ol3 $-0- b. FFY 2012 $-0- 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (((Applicable): GENERAL PROGRAM ADMINISTRATION PAGE 35. 4.4 MEDICAJl) ELIGIBILITY QUALITY CONTROL (MEQC) 10. SUBJECT OF AMENDMENT: PERM MEQC SUBSTITUTION: Substitute the Payment Error Rate Measurement (PERM) reviews for the Traditional Medicaid Eligibility Quality Control (M EQC) reviews during the State's PERM cycle year. II. 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 12. SIGNATURE OF STATE AGENCY OFFICIAL: //Rosanne Mahaney - signature// XXX OTHER, AS SPECIFIED: Governor's comments under separate correspondence 16. RETURN TO: ---,13-. _T_Y_P-ED_N_A_M_E_:------------------4 Rosanne Mahaney Director Rosanne Mahaney, Director, Division of Medicaid and Medical Assistance Division of Medicaid and Medical Assistance ---'::-"-14::..=. -:::T-:=IT:::=L-=:E'--: --=D=-e-s i::-g-ne-e--:f::-o-r ::-R-,--it-a --=M--=.---,L-a-n--=d-g r-a--=f,.....,s=-· e-c ,-.e-ta_r_y ,-D-e-l a_\\_' ~-.. -.e---4 p · 0 · Box 906 Health and Social Services New Castle, l>elaware 19720-0906 15. DATE SUBMITTED: December 16, 20 II FOR REGIONAL OFFICE USE ONLY 18. DATE APPROVED: PLAN APPROVED- ONE 21. TYPED NAME: f:r~ci'.s Jv\ c Cull o v 1- 23. REMARKS: FORM HCF A-179 (07-92)

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 Region IIIjDivision of Medicaid and Children's Health Operations SWIFT# 031520124063 JUN 072012 Rosanne Mahaney, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, DE 19720-0906 Dear Ms. Mahaney: The Centers for Medicare & Medicaid Services has reviewed Delaware State Plan Amendment (SPA) 12-006, in which you assure compliance with and implementation of Section 6401 of the Affordable Care Act regarding Medicaid Provider Screening and Enrollment. This SPA is acceptable. We are approving SPA 12-006 with an effective date of April 1, 2012. Enclosed are the approved SPA pages and signed CMS-179 form. If you have further questions about this SPA, please contact Michael Cleary at 215-861-4282. Enclosures

79aa STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Citation 1902(a)(77) 1902(a)(39) of of the Act adds 1902(kk); P.L. 111-148 and P.L.111-152 42 CFR 455 Subpart E 42 CFR 455.410 42 CFR 455.412 42 CFR 455.414 StatelTerritory: DELAWARE 4.46 Provider Screening and Enrollment The State Medicaid agency gives the following assurances: PROVIDER SCREENING X Assures that the State Medicaid agency complies with the process for screening providers under section 1902(a)(39), 1902(a)(77) and 1902(kk) of the Act. ENROLLMENT AND SCREENING OF PROVIDERS X Assures enrolled providers will be screened in accordance with 42 CFR 455.400 et seq. X Assures that the State Medicaid agency requires all ordering or referring physicians or other professionals, who are not enrolled in Medicare, to be enrolled under the State plan or under a waiver of the Plan as participating providers. VERIFICATION OF PROVIDER LICENSES X Assures that the State Medicaid agency has a method for verifying providers licensed by a State and that such providers' licenses have not expired or have no current limitations at the time of enrollment or recertification. REVALIDATION OF ENROLLMENT X Assures that providers will be revalidated regardless of provider type at least every 5 years. JUNO 7 2012 TN No. SPA #12-006 Approval Date Supersedes TN No. NEW Effective Date April 1, 2012 1

79ab STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT 42 CFR 455.416 42 CFR 455.420 42 CFR 455.422 42 CFR 455.432 42 CFR 455.434 StatefTerritory: DELAWARE 4.46 Provider Screening and Enrollment Continued TERMINATION OR DENIAL OF ENROLLMENT X Assures that the State Medicaid agency will comply with 1902(a)(39) of the Act and with the requirements outlined in 42 CFR 455.416 for all terminations or denials of provider enrollment. REACTIVATION OF PROVIDER ENROLLMENT X Assures that any reactivation of a provider will include re-screening and payment of application fees as required by 42 CFR 455.460. APPEAL RIGHTS X Assures that all terminated providers and providers denied enrollment as a result of the requirements of 42 CFR 455.416 will have appeal rights available under procedures established by State law or regulation. SITEVtSITS X Assures that pre-enrollment and post enrollment site visits of providers who are in "moderate" or "high risk" categories will occur. CRIMINAL BACKGROUND CHECKS X Assures that providers as a condition of enrollment will be required to consent to criminal background checks including fingerprints if required to do so under State law or by the level of screening based on risk of fraud, waste or abuse for that category of provider. TN No. SPA #12-006 Approval Date 'JUNO 7 2012 Supersedes TN No. NEW Effective Date April 1, 2012 2

79ac STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT 42 CFR 455.436 42 CFR 455.440 42 CFR 455.450 42 CFR 455.470 StateITerritory: DELAWARE 4.46 Provider Screening and Enrollment Continued FEDERAL DATABASE CHECKS X Assures that the State Medicaid agency will perform Federal database checks on all providers or any person with an ownership or controlling interest or who is an agent or managing employee of the provider. NATIONAL PROVIDER IDENTIFIER X Assures that the State Medicaid agency requires the National Provider Identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional. SCREENING LEVELS FOR MEDICAID PROVIDERS X Assures that the State Medicaid agency complies with 1902(a)(77) and 1902(kk) of the Act and with the requirements outlined in 42 CFR 455.450 for screening levels based upon the categorical risk level determined for a provider. TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PROVIDERS OR SUPPLIERS X Assures that the State Medicaid agency complies with any temporary moratorium on the enrollment of new providers or provider types imposed by the Secretary under section 18660)(7) and 1902(kk)(4) of the Act, subject to any determination by the State and written notice to the Secretary that such a temporary moratorium would not adversely impact beneficiaries' access to medical assistance. JUN 0 7 2012­ TN No. SPA #12-006 Approval Date Supersedes TN No. NEW Effective Date April 1! 2012 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938·0193 TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: 2. STATE DELAWARE STATE PLAN MATERIAL SPA #12-006 FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE APRIL 1, 2012 5. TYPE PLAN MATERIAL (Check One): D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS NEW PLAN XXX AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittalfor each amendment) 6. FEDERAL STA TUTEIREGULA TION CITATION: 7. FEDERAL BUDGET IMPACT: AFFORDABLE CARE ACT, SECTION 640) 42 CFR PART 455 SUBPART E 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: a. FFY 2012 $ -0­ b.FFY 2013 $ -0­ ~~~--~~~----------~­ 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): GENERAL PROGRAM ADMll'J1STRATION, 4.46, PAGES 79aa, 79ab and 79ac NEW 10. SUBJECT OF AMENDMENT:MEDICAJI) PROVIDER SCREENING AND ENROLLMENT 11. GOVERNOR'S REVIEW (Check One): D GOVERNOR'S OFFICE REPORTED NO COMMENT XXX OTHER, AS SPECIFIED: D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Governor's comments under separate D NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL correspondence ] 2. SIGNATURE OF STATE AGENCY OFFICIAL: [6. RETURN TO: IIRosanne Mahaney - signaturel/ ~I3:-.-=T=-=Y=P=ED=-=-N-=-A:-::M-:::=E-:-------------------------------1 Rosanne Mahaney Director Rosanne Mahaney, Director, Division of Medicaid and Medical Assistance Division of Medicaid and Medical Assistance ~~~~~----~-=--------------------------~, P.O. Box 906 14. TITLE: Designee for Rita M. Landgraf, Secretary, Delaware New Castle, Delaware 19720-0906 Health and Social Services 15.DA . SUBMITTED: 12 FORM HCFA-179 (07-92)

, . DEPARTMENT OF HEAL 1H & 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 Ill/Division of Medicaid and Children's Health Operations SWIFT# 051620124044 JUL 312012 Rosanne Mahaney, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, DE 19720-0906 Dear Ms. Mahaney: The Centers for Medicare & Medicaid Services has reviewed Delaware State Plan Amendment (SPA) 12-007 to update the income standard used in eligibility determinations for low income families with children. Specifically, this SPA updates the income standard to 75% of the Federal Poverty Level (FPL) used in eligibility determinations for low income families with children under Section 1931 of the Social Security Act, and for children under age 21 under 42 CFR §435.222 for whom public agencies are assuming full or partial financial responsibility (e.g. foster children). This SPA is acceptable. We are approving SPA 12-007 with an effective date ofMay 1, 2012. Enclosed are the approved SPA pages and signed CMS-179 form. If you have further questions about this SPA, please contact Michael Cleary at 215-861-4282. Enclosures Sincerely,

-krancis McCullough Associate Regional Administrator

Revision: HCFA-PM-91-4 AUGUST 1991 (BPD) Supplement 8a to ATTACHMENT 2.6-A Page 1 OMB No.: 0938- STATE PLAN UNDER TITLE OF THE SOCIAL SECURITY ACT State: DELAWARE MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902 (r) (2) OF THE ACT I I Section 1902(f) State IX/ Non-Section 1902 (f) State For children covered under Section 1902 (a) ( 1 0) (A) (I) (Ill) and 1905 (n) of the Social Security Act, the State of Delaware will disregard an equal amount to the difference between 100% of the AFDC payment standard for the same family size and 100% of the Federal Poverty Level for the same family size as updated annually in the Federal Register. Interest and dividend income are excluded for QMB, SLMB, QDWI and Ql-1 cases. A standard deduction will be applied to the gross income from self employment for poverty level pregnant women, infants and children; QMB, SLMB, and Ql-1 cases. The standard deduction for self employment income is considered the cost to produce income. The standard deduction for self employment is a percentage determined annually and announced each October. When the application of the standard deduction results in a finding of ineligibility, the applicant will be given an opportunity to show that actual self employment expenses exceed the standard deduction. If the actual expenses exceed the standard deduction, they will be used to determine net income from self employment. For the TWWIIA Basic Coverage Group, unearned income is excluded up to $956.00 per month for the individual. There is no $956.00 per month unearned income exclusion for a spouse who is not applying for the TWWIIA Basic Coverage Group Medicaid. This unearned income exclusion will be increased annually by the Cost of Living Adjustment (COLA) announced by the Social Security Administration (SSA) in the Federal Register. For individuals whose eligibility is determined under 42 CFR 435.222, income is disregarded in an amount equal to the difference between the State's AFDC payment standard (see Supplement 1 to Attachment 2.6-A Page 1) and 75% of the Federal Poverty Level updated annually in the Federal Register for the same family size. *More liberal methods may not result in exceeding gross income limitations under Section 1903(f) TN No. SPA #12-007 Supersedes TN No. SP 09-005 Approval Date J U L 3 1 2012 Effective Date May 1, 2012 1

Supplement 12 to ATTACHMENT 2.6-A Page 2 · STATE PLAN UNDER TITLE OF THE SOCIAL SECURITY ACT State: DELAWARE ELIGIBILITY CONDITIONS AND REQUIREMENTS ELIGIBILITY UNDER SECTION 1931 OF THE ACT (Cont.) ___ The agency applies higher resource standards than those in effect as of July 16, 1996, increased by no more than the percentage increases in the CPI-U since July 16, 1996, as follows: X The agency uses less restrictive income and/or resource methodologies than those in effect as of July 16, 1996, as follows: 1. The $30 and 1/3 disregard will be applied without regard to prior receipt of Medicaid, if otherwise applicable. The income and/or resource methodologies that the less restrictive methodologies replace are as follows: Prior to 10/1/99, the net income test does not include the $30 and 1/3 disregard for applicant families. 2. For both applicant and recipient families, income is disregarded in an amount equal to the difference between the State's AFDC payment standard (see Supplement 1 to Attachment 2.6-A Page 1) and 75% of the Federal Poverty Level updated annually in the Federal Register for the same family size. All earned income will be disregarded for the second and third months of eligibility. The income and/or resources methodologies that the less restrictive methodologies replace are as follows: Prior to 10/1/99, the net income test for applicant and recipient families includes all countable earned and unearned income. 3. For both applicant and recipient families, all resources are excluded. The income and/or resource methodologies that the less restrictive methodologies replace are as follows: Prior to 10/1/99, available resources cannot exceed $1 ,000 for both applicant and recipient families. TN No. SPA #12-007 Supersedes TN No. SP 09-005 Approval Date _J_U_L_3_1_20-'-1-=2 __ Effective Date May 1, 2012 1

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO 0938-0193 ;J'RANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: 2. STATE DELAWARE STATE PLAN MATERIAL SPA #12-007 FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE MAY 1, 2012 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN XXX AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: SECTION 1931 OF THE SOCIAL SECURITY ACT 42 CFR 435.222 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: SUPPLEMENT 8a to ATTACHMENT 2.6-A, Page I SUPPLEMENT 12 to ATTACHMENT 2.6-A. Page 2 7. FEDERAL BUDGET IMPACT: a. FFY 2012 $-0- b. FFY 2013 $ -0- 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): SUPPLEMENT 8a to ATTACHMENT 2.6-A, Page 1 SUPPLEMENT 12 to ATTACHMENT 2.6-A, Page 2 10. SUBJECT OF AMENDMENT: ELIGIBILITY CONDITIONS AND REQUIREMENTS: ELIGIBILITY UNDER SECTION 1931 OF THE SOCIAL SECURITY ACT -75°/.) FPL II . 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 12. SIGNATURE OF STATE AGENCY OFFICIAL: //Rosanne Mahaney - signature// XXX OTHER, AS SPECIFIED: Governor's comments under separate correspondence 16. RETURN TO: --:-:13~ . -=T""y-=-p-=-ED::::-:-N-:-A-::-M-::-E=-:-----------------l Rosanne Mahaney Director Rosanne Mahaney, Director, Division of Medicaid and Medical Division of Medicaid and Medical Assistance Assistance ----------------------~ P.O.Box906 14. TITLE: Designee for Rita M. Landgraf, Secretary, Delaware Health and Social Services New Castle, Delaware 19720-0906 15. DATE SUBMITTED: May 7, 2012 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: fV\ '7 ?.--o 1 Z 21. TYPED NAME: 22. TITL . flssodc..fe /?e ion~l /ldw~.~',.,,'s,fr<l--- DMCtfo FORM HCFA-179 (07-92)

Table of Contents State Name: Delaware State Plan Amendment (SPA) #13-000SMM 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 ·- -...._ CMS CENTERS FOR MEDICARE & MEDICAID SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFT# 112020134033 'DEC 0 6 20131 Stephen Groff, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, DE 19720-0906 Dear Mr. Groff: The Centers for Medicare & Medicaid Services has reviewed Delaware State Plan Amendment (SPA) 13-000SMM to modify eligibility standards and processes to conform to the requirements under the Affordable Care Act, and to exercise available related state options. The plan pages provide the criteria for coverage under this group, the MAGI-based income standard to be used, and the choice related to presumptive eligibility. The effective date of this SPA is January 1, 2014. Enclosed are the approved SPA pages and CMS-179 form. If you have further questions about this SPA, please contact Michael Cleary at 215-861-4282. Enclosures (b (b) (1) (A), (b) ( b ) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

Page I of2 Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Delaware 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~-~~'!!!_s~if!'!_}'(!_ar, and 0000 = a four digit number with leading zeros. The dashes must also be enteretL DE-13-0005 Propo~t:~ -~f.ft!~!iV{! !late 01/01/2014 (mm/dd/yyyy) Feder.~! ~_tatut.~!R~gu!11tion Ci!1}tio_!l Patient Protection and Affordable Care Act (Public Law 111-148); 42 CFR §§ 431 , 435; and 45 CFR § 155 Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment $ 12237055.00 $27510882.00 Amount State of Delaware Medicaid MAGI-Based Eligibility Groups and AFDC Income Standard State Plan Amendment 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: Governor's Comments Under Separate Correspondence Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Sharon Summers Dec 2, 2013 Sep II, 2013 12/ 11 /2013

c SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0005MM Delaware Pages or sections of pages being superseded by 525, 528, 530, 551, 552, 553, and 514 and related pages or sections of pages being deleted as obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A.2 .b Page 3 Page 2, A.2.c Page 3a Page 2a, A.3 Page 4 Page 5, A.10 Page 4a Page 9c, B.1 remove Attachment 2.2-A Page 12 "Caretaker relativesu Page 13 and "Pregnant womenff Page 13a Page 20, B.14 Page 14 Page 25, C.4 Page 14a Page 21 Page 23 Supplement 1 to Attachment 2.2-A Page 1 Page 3b Page 1, A.2.a(i) and Page 11a (iii) Page 19 Page 6 related to AFDC Page 19a recipients, pregnant Page 19b women, infants, and Attachment 2.6-A Page 21 children. Page 7, 1. a( 1) and ( 2) Page 12, 5.e(2) and ( 3) Page 18, 5.e Page 25, 1l.a(3) Page 1, related to Supplement 1 to Attachment 2.6-A AFDC recipients, pregnant women, infants, and children Supplement 2 to Attachment 2.6-A Pages 1-5 .. 1

Page l, delete for qualified children under l902(a) (10) (A) (i) (III) and for poverty level related pregnant Supplement Sa to Attachment women, infants & 2.6-A children Page 2,delete for qualified pregnant women & children and for poverty level related pregnant women, infants & children Supplement 8b to Attachment Page l, delete for 2.6-A qualified pregnant women & children Supplement 8c to Attachment Page l 2.6-A Supplement 12 to Attachment l-4 2.6-A Pages 2

DE: converted thresholds Date: June 26, 2013 Population/Type Family 1988 Family 1996 Family 1931 Pregnant women & infants Children <1 Pre-CHIP Children 1-5 Children 6-18 Uninsured Children 1-18 Family planning (women age 15-50 not pregnant & not otherwise eligible) Childless 19-64 Parents & Caretakers with income> FPL for 1931 5-CHIP premiums, age 6-18, 101-133% FPL 5-CHIP premiums, age 6-18, 101-133% FPL 5-CHIP premiums, age 1-5, 134-166% FPL 5-CHIP premiums, age 6-18, 134-166% FPL 5-CHIP premiums, age 1-18, 134-166% FPL 5-CHIP premiums, age 1-18, 167-200% FPL 5-CHIP premiums age 1-18 167-200% FPL Citation Unit Size AFDC 5/1/1988 1 2 3 4 5 6 7 addon AFDC 7/16/1996 1 2 3 4 5 6 7 ad don 1931 Mandatory Coverage 1902( a)( 10)(A)(ii)( IX) 1902(a)(10)(A)(i)(VI) 1902( a)( 10)(A)( i )(VI) 1902( a)( 10)(A)( i )(VII) 5-CHIP state plan 1115 demonstration family planning 1115 demonstration 1115 demonstration Lower bound Upper bound Lower bound Lower bound Upper bound Lower bound Upper bound Original Standard Converted Standard $169 $188 $236 $262 $319 $351 $374 $413 $464 $509 $529 $581 $594 $652 $60 $67 $201 $221 $270 $297 $338 $372 $407 $448 $475 $523 $544 $599 $612 $674 $69 $76 75% FPL 87% FPL 200% FPL 209% FPL 185% FPL 194% FPL 133% FPL 142% FP 100% FPL 133% FPL 200% FPL 212% FP 200% FPL 209% FPL 100% FPL 108% FPL 100% FPL 107% FPL 101% FPL 110% FPL 133% FPL 141%fPL 134% FPL 143% FPL 134% FPL 142% FPL 166% FPL 176% FPL 167% FPL 177% FPL 200% FPL 212% FPL

Medicaid Eligibility Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. OMB Control Number 0938-1148 Income Siindard En,try .. 'Dollar, Amount - Au~mati~~~~~- ObttOD:· ~ , '' ~· Sl3a ; . . The standard is as follows: ~- Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way Eiitcr lhe statewid!: standard'' "H '"· .,, '· ""'' 'J;~ ·.~~~·· "· ~·· .,:;- n ,.; ;, M:" ~.,. do Additional incremental amount Household size Standard ($) ~' Yes 0No I lft+ 1 188 X Increment amount $ 167 ( i !+ 2 262 X if i+ 3 ~ 351 X I~ ~+ 4 413 l)ix I+ 5 509 X I ., '""' If,+ 6 581 X I~ ,.+ 7 652 ~~ f?C The dollar amounts increase automatically each year (' Yes r. No TN# 13-0005-MM APPROVED: 12/06/2013 EFFECTIVE: 01/01/2014 Page 1 of 4

Medicaid Eligibility The standard is as follows: (8'; Statewide standard (' Standard varies by region (' Standard varies by living arrangement 0 Standard varies in some other way Eiiter the ~tatewide standard" "' tl 'j·' ; ''4¥i· ~~;r~, .; ' -··. h. ' ·"· ' : Additional incremental amount Household size Standard ($) € Yes 0 No ' t+ 1 201 pc Increment amount ~ V"' 2 270 X ~ -" :x t+ 3 338 f ~& F""" m;.., 4 407 X lfl It;_ 5 475 IX f i I f ' t~ 6 544 If<}( 1r{ = X + 7 612 The dollar amounts increase automatically each year (' Yes r. No The standard is as follows: f: Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No AFDC Need Standard-in Effect As of July 1_6, 19~6 TN# 13-0005-MM APPROVED: 12/06/2013 $169 ~~/ I EFFECTIVE: 01/01/2014 Page 2 of 4

Medicaid Eligibility The standard is as follows: (' Statewide standard (' Standard varies by region C' Standard varies by living arrangement ('Standard varies in some other way The dollar amounts increase automatically each year C Yes C No The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way TN# 13-0005-MM APPROVED: 12/06/2013 S13a EFFECTIVE: 01/01/2014 Page 3 of 4

Medicaid Eligibility The dollar amounts increase automatically each year ('Yes ('No TANF payment standard Inco~e Standard Entry - l)ollar A.mount - 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 The dollar amounts increase automatically each year (' Yes ('No MAGI-equivalent TANF payment standard .: Income Standard Entry - Dollar Amount - Automatic lncf'e!lSe Option The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year ('Yes ('No PRA Disclosure Statement S13a S13a 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# 13-0005-MM APPROVED: 12/06/2013 EFFECTIVE: 01/01/2014 Page 4 of 4

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Cover~ Parents and Other Caretaker-Rebitives 42 CFR 435.110 1902(a)(10)(A)(i)(I) 193l(b) and (d) ~ Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or • below a standard established by the state. 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 arc also included. The state elects the following options: This eligibility group includes individuals who arc parents or other caretakers of children who are 18 years old, cgj provided the children arc full-time students in a secondary school or the equivalent level of vocational or technical training. cgj Options relating to the definition of caretaker relative (select any that apply): cgj 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: Unmarried partner whether of the same or different gender D 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: cgj 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. cgj Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or {. care by reason of the death. physical or mental incapacity, or absence from the home or unemployment of at least one parent. (' The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 1 of 3

Medicaid Eligibility ~ 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 SJO MAGI- Based Income Methodologies, completed by the state. ~ Income standard used for this group ~ Minimum income standard The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. 0 The state certifies that it has submitted and received approval for its converted May 1. 1988 AFDC payment standard. An attachment is submitted. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for parents and 0 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. The state's maximum income standard for this eligibility group is: (' The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. (e The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 (' demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 (' demonstration as of December 31. 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 2 of 3

Medicaid Eligibility (i' A percentage of the federal poverty level: D % (' The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. (' The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in Sl4 AFDC Income Standards. (' Other dollar amount ~ Income standard chosen: Indicate the state's income standard used for this eligibility group: (' The minimum income standard (i' The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. (' Another income standard in-between the minimum and maximum standards allowed ~ 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 Pregnm.lt Women (42 CFR 435.116) and/or Infants and Children under Age 19 ( 42 CFR 435.118) eligibility groups when determined presumptively eligible. ('Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01101/2014 Page 3 of 3

Medicaid Eligibility Eligibility Groups - Mandatory Coverage 828 Pregnant Women 42 CFR 435.116 1902(a)(10)(A)(i)(Ill) and (IV) 1902(a)(10)(A)(ii)(I). (IV) and (IX) 1931(b) and (d) 1920 [!] Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. 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. (' Yes (e 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. (' Yes r. No The minimum income standard for this eligibility group is 133% 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: 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), i902(a)(lO)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(l0) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01101/2014 Page 1 of 2

Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a}(lO)(A)(i)(III) (qualified pregnant women), 1902(a}(lO)(A)(i)(IV) (mandatory poverty Ievel- l-' related pregnant women}, 1902(a}(lO}(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)(lO)(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 Medicaidl115 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 Medicaid1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of 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 le' 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: le' All pregnant women eligible under this group receive full Medicaid coverage under this state plan. (' Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. ~ Presumptive Eligibility The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. (' Yes 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 No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 2 of 2

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age< 1~ · 42 CFR 435.118 1902(a)(10){A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) 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. 0 The state attests that it operates this eligibility group in accordance with the following provisions: [!] Children qualifying under this eligibility group must meet the following criteria: [!] Are under age 19 [!] Have household income at or below the standard established by the state. [!] MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI- Based Income Methodologies, completed by the state. [!] Income standard used for infants under age one [!] Minimum income standard The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. { Yes (8 No The minimum income standard for infants under age one is 133% FPL. [!] Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for infants 0 under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. r-~~~===-~~~====~========~~~~~~~-, 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 (' 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 No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 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)(Ill) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related (e' infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. C The state's effective income level for any population of infants under age one under a Medicaid 11 J 5 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 1 115 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: (e' 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)(III) (qualified children), 1902(a)(IO) (' (A)(i)(IV) (mandatory poverty level-related infants), l902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants (' under age one under sections 1931 (low-income families), 1902(a)(lO)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(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 r 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 r if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. ~ Income standard for children age one through age five, inclusive ~ Minimum income standard TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 2 of 5

Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for children [Z] 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- r income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- le income families), 1902(a)(lO)(A)(i)(III) (qualitied 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 December 31 , 2013, converted to a MAGI-equivalent percent of FPL. r The state's effective income level for any population of children age one through five under a Medicaid 111.5 demonstration as of March 23, 2010. converted to a MAGI-equivalent percent of FPL. r The state's effective income level for any population of children age one through five under a Medicaiclll15 demonstration as of December 31. 2013. converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: ~ % FPL ~ lncomc 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). r 1902(a)(lO)(A)(i)(Vl) (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 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 r 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)(lO)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid stale plan as of December 31, 2013, converted to a . MAGI-equivalent percent of FPL. TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 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 r 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 r 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. C: Ahnotfl.1 1 ~r i~1come standard 1 in-dbeftwehe~ the minim~m ahnd maxim! um stafnMdardsha 7 11 3 ow 2 e 0 d 1 , 0 provided it is higher than t e e · ecttve mcome stanc ar or t IS age group m t e state p an as o arc _ , . . ~ 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 agt:: 0 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. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (' (low-income families), 1902(a)(lO)(A)(i)(III) (qualified children), 1902(a)(lO)(A)(i)(Vli) (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), l902(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)(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 Medicaicllll5 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent o(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 {. 13YYc· FPL ~ Income standard chosen The state's income standard used for children age six through eighteen is: TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 4 of 5

Medicaid Eligibility (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 six through eighteen under sections 1931 (low-income families), 1902(a)(lO)(A)(i)(III) (qualified children), (' 1902(a)(JO)(A)(i)(Vll) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children (' age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(Ill) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and (' if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and (' if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. ~ There is no resource test for this eligibility group. ~ Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity. (' Yes (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 No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 5 of 5

Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 ~,.,..,..,...,,....,....,..,..--,-- state covers the Adult Group as described at 42 CFR 435.119. (e' Yes (' No ~Adult Group- Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. [ZJ The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Have attained age 19 but not age 65. ~ Are not pregnant. ~ Are not entitled to or enrolled for Part A or B Medicare benefits. ~ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan .in accordance • with 42 CFR 435. subpart B. Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. ~ Have household income at or below 133% FPL. ~MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ~ There is no resource test for this eligibility group. Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is ~ receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrollee! in minimum essential coverage, as defined in 42 CFR 435.4. (e' Under age 19, or C A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: ~ 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. C Yes (e' No PRA Disclosure Statement TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 1 of 2

Medicaid Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 2 of 2

42 CFR 435.150. 1902(a)(10)(A)(i)(IX) Medicaid Eligibility OMB Control Number 0938-1148 ~ ~o~mer Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and m foster care when they turned age 18 or aged out of foster care. [{] The state attests that it operates this eligibility group under the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are under age 26. ~ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state ~plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. The state elects to cover children who were in foster care and on Medicaid in~ state at the time they turned 18 or aged out of the foster care system. ('Yes le' No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 ( 42 CFR 435.118) eligibility groups when determined presumptively eligible. ('Yes (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 No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01101/2014 Page 1 of I

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10!}1 /2014 .. Eligibility Groups- Options for Coverage S50 Individuals above 133% FPL ·. ~ ,_ 1902(a)( 1 O)(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 (e' No - J~RA Qisclosu_re Stal~.ment 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 write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore, l'vlaryland 2 1244-1850. TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page I of I

Medicaid Eligibility Eligibility Groups - Options for Coverage ·- .;J; Optional Coverage of Parents and Other Caretak,er Relatives 42 CFR 435.220 1902(a)( 1 0)( A)( ii)(I) OMB Control Number 0938-1148 OMB Expiration date: 10i31/2014 S51 Optional Coverage of Parents and Other Caretaker Relatives- The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. ("Yes {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 No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page I of I

Medicaid Eligibility Eligibility Groups - Options for Cover .. ge Reasoaable Classification of Individuals under Age l l 42 CFR 435.222 1902(a)(lO)(A)(ii)(I) 1902(a)(lO)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 -The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. (' Yes (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 No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01101/2014 Page 1 of l

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups· Options for Cover&lse, · ·.,. ChUdren with Non IV -E Adoption Assistahee 42 CFR 435.227 1902(a)(lO)(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. (a' Yes (' No 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: ~ ~ 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): (a' Under age 21 (' Under age 20 (' Under age 19 (' Under age 18 MAGI-based income methodologies arc used in calculating household income. Please refer as necessary to SlO MAGI- Based Income Methodologies, completed by the state. The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23,2010 or December 31, 2013. (a' Yes (' No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. (a' Yes (' No ~ Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to • the execution of the adoption agreement. The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. (e' 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, J 996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. ~ Maximum income standard TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 1 of 2

Medicaid Eligibility E~ibilitji Group$ • Options for Cover~, · ; Optional Targeted Low Income Ch118M. · 1902(a)(l O)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905( u )(2)(B) Optional Targeted Low Income Children- The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. (' Yes r. 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 cstimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01101/2014 Page 1 of I

Medicaid Eligibility Eligibility Groups • Options for Coverage Individuals with Tuberculosis 1902(a)(10)(A)(ii)(XII) 1902(z) OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 '855 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 for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 1 of 1

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups- Options for Coverage Inde ndent Foster Care Adolescents 42 CFR 435.226 1902( a )(1 O)(A)(ii )(XVII) Independent Fosfer Care Adolescents -The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. (' Yes (a No PRA Disclosure Statement .. 857 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page 1 of l

1902( a)( lO)(A )(ii)(XXI) 42 CFR 435.214 Medicaid Eligibility OMB Control Number 0938-1148 . S59 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. (' Yes (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 No. 13-0005 MM Approval Date: 12/06/2013 Effective Date: 01/01/2014 Page I of l

Table of Contents State Name: Delaware State Plan Amendment (SPA) #13-0006MM 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 .. ----- CMS CENTERS FOR MEDICARE & MEDICAID SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFT# 112020134036 DEC 0 9 2013 Stephen Groff, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, DE 19720-0906 Dear Mr. Groff: Enclosed is an approved copy of Delaware state plan amendment (SPA) 13-0006-MM, which was submitted to CMS on September 11 , 2013. SPA 13-0006-MM incorporates the MAGI- based eligibility process requirements, including the single streamlined application, into Delaware's Medicaid state plan in accordance with the Affordable Care Act. The effective date ofthis SPA is October 1, 2013. Until March 1, 2014, the state is using interim alternative single streamlined paper applications for individuals and families and an interim alternative paper application used to apply for multiple human service programs. Until October 1, 2014, the state is using an interim alternative single streamlinea online application. The state will implement revised applications that will address CMS concerns outlined in the companion letter issued with this SPA approval. Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Delaware's approved state plan: • S94, pages S94-1 and S94-2 • Attachment 1- Statement of use with respect to the alternative single streamlined online application • Attachment 2 - Statement of use with respect to the alternative single streamlined paper applications CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Michael Cleary at 215-861-4282. Enclosures (b) (1) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A) (b) (b) (1) (A), (b) /S/

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Delaware Transmittal Number: Page I of I 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. DE-13-0006 ProposedJi:f!ective Date 10/01/2013 (mm/ dd/ yyyy) Federal Statute/~egulation Citation Patient Protection and Affordable Care Act (Public Law 111-148); 42 CFR §§ 431 , 435; and 45 CFR § 155 Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment $ 12237055.00 $27510882.00 Amount State of Delaware Medicaid MAGI Eligibility Process State Plan Amendment 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 •(i) Other, as specified Describe: Governor's Comments Under Separate Correspondence Signature of State Agency Official Submitted By: Sharon Summers Last Revision Date: Dec 9, 2013 Submit Date: Sep II, 2013 12/11/2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0006 MM Delaware PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): S94 General Eligibility Requirements - Eligibility Process General Program Administration, Page I 0, Item 2.1 (a), TN SP- 300, effective January I, 1992, approved May 27, 1992 General Program Administration, Page Ita, Item 2.1(d), TN SP- 309, effective July I, 1992, approved December 21, 1992

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION lRl Online A lication TRANSMITTAL NUMBER: STATE: DE 13-0006-MM Delaware Through October 31, 2014, the state is using an interim alternative single streamlined application. After October 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state's application. The revised application will be incorporated by reference into the state plan.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATIONS [8]Paper Applications DOnline Ap lication TRANSMITTAL NUMBER: STATE: DE 13-0006-MM Delaware Through March 1, 2014, the state is using interim alternative single streamlined paper applications for individuals and families and an interim paper application used to apply for multiple human service programs. After March 1, 2014, the state will use revised alternative single streamlined paper applications. The revised applications will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state's applications. The revised applications will be incorporated by reference into the state plan.

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General EUgibility Requirements Eligibility Process 42 CFR 435, Subpart J and Subpart M Eligibility Process 894 [Z] The state meets all the requirements of 42 CFR 435. Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. D The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(l)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(l)(B) of the ~ Affordable Care Act and approved by the Secretary. which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the ~ agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. .I Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and [g] approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. \. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which D minimizes the burden on applicants. submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: l- Yes (" No TN No. 13-0006 MM Approval Date: 12/09/2013 Effective Date: 10/01/2013 Page 1 of 2

Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + Fax Machine application accepted by facsimile transmission X f + Email application accepted by email attachment The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility 0 groups listed below at locations other than those used for the receipt and processing of applications for the title IV -A program, including Federally-qualified health centers and disproportionate share hospitals. Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing 0 Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ~Once every 12 months ~Without requiring information_from th~ indivi~ual if able to do so based on reliable information contained in the individual's account or other more current mformat10n avatlable to the agency If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional ~ information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ~ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): IZJ Once every 12 months 0 Once every 6 months 0 Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between 0 Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMI3 control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 13-0006 MM Approval Date: 12/09/2013 Effective Date: 10/01/2013 Page 2 of 2

Table of Contents State/Territory Name: Delaware State Plan Amendment (SPA) #: 13-0007-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 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 I“ % Philadelphia, Pennsylvania 19106-3499 f{

CENTERS FOR MEDICARE & MEDICAID SERVICES

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

SWIFT #110520134017

NOV 15 2079

Stephen Groff, Director

Division of Medicaid & Medical Assistance Department of Health & Social Services 1901 DuPont Highway

New Castle, DE 19720

Dear Mr. Groff:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of Delaware’s State Plan Amendment (SPA) 13-0007MM, which was submitted to CMS on September 11, 2013. SPA13-0007MM incorporates the MAGI-based income methodologies and designates the income options the State is electing in 2014, 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 Delaware’s approved State Plan:

. S10, Pages S10-1 through $10-2

Notwithstanding any other provisions of the Delaware Medicaid State Plan, the financial eligibility methodologies described in SPA 13-0007MM apply to all MAGI-based eligibility groups covered under Delaware’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.

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 concerning this letter, please contact Kia Banton at 215-861-4252.

Sincerely,

wil Regional Adnfinistrator

Enclosures

State/Territory name: Delaware Submitted By: Sharon Summers Last Revision Date: Oct 21, 2013 Submit Date: Sep 11, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. DE-13-0007 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Patient Protection and Affordable Care Act (Public Law 111-148); 42 CFR §§ 431, 435; and 45 CFR § 155 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 12237055.00 Second Year 2015 $ 27510882.00 Subject of Amendment State of Delaware Medicaid MAGI Income Methodologies State Plan Amendment 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: Governor's Comments Under Separate Correspondence Signature of State Agency Official

ccms Medicaid Eligibility

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

IMAGI-Based Income Methodologies

$10

1902(e)(14) 42 CFR 435.603

Cy

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:

C The pregnant woman is counted just as herself. C The pregnant woman is counted as herself, plus one.

(@ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions:

When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size.

When determining eligibility for current beneficiaries, financial eligibility is based on:

@ Current monthly household income and family size

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:

Include a prorated portion of a reasonably predictable increase in future income and/or family size. P Pp Y Pi Ly Account for a reasonab! ictable decrease in future income and/or family size. Kl 'y

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.

C Yes @No

TN# DE 13-0007MM Approved: 10/25/2014 Effective: 01/01/204

Page 1 of 2

ccms Medicaid Eligibility

[M) The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is:

@ Age 19

C 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# DE 13-0007MM Approved: 10/25/2014 Effective: 01/01/204

Page 2 of 2

Table of Contents State Name: Delaware State Plan Amendment (SPA) #13-0009MM 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 Medicue &. Medicaid Services ISO S. lndq>endence Mall West Suite 2l6, The Public Ledger Building Philadelphia. Pennsylvania 19106-3499 ..... - ...... , .. __ t"C~s <:ENTERS fOR MEOICARE & MEDICAID SERVICE.~ Region m/Division of Mcdic~tid and Children's Health Opcr.ltions S\V!FT # 112520134038 NOV 2 6 2013 Stephen Groff, Director Division of Medicaid & Medical Assistance Department of I Iealth & Social Services 1901 DuPont Highway Ne"v Castle. DE 19720 Dear Mr. Groff: The Centers for Medicare & Medicaid Services (CMS) has completed its review of Delaware's State Plan Amendment (SPA) 13-0009MM, which was submitted to CMS on September 11, 2013. SPA 13-0009MM incorporates the MAGI-based residency requirements into Delaware's State Plan, in accordance with the Affordable Care Act. Enclosed is a copy of the new State Plan pages and attachments to be incorporated within a separate section at the end of Delaware's approveJ State Plan: • SS8 (Residency) This SPA was approved November 26, 2013, with an effective date of January l, 2014. t\lso enclosed for your records is a copy of the CMS 1 79 form. lf you have any questions concerning this letter. please contact Kia Banton at 215-861-4252. Sincerely, /S/ ~u~ Associate Regional Ac(p:lihistrator Enclosures

111 (l~i!b. ll fl(j 00 · 1"!1 IJ I. 201 ~ -------------------------------------------- 'IMicfl cniltJry name: D~hH\:Irt' Transmirt:1l :'iumhcr: Plrasr enter the Trausmittnl i\umht!r (Ti\') in fhe format. ST-Y\' -0000 where ST= the stat<' ahl.Jn•viation. Y V"' the last two 1ligih of the submission ·'car. anu OUUO = n four digit number with lt•ading zeros. The dashf's must also be cntt•rcd. II )J .. I 1-l)(i()'} I l'rnrto't'r! Effective Onfc Ill! Ol · ~0 I .J Frdcral Statuh:/f{cgulatinn Citation l l'i!licnt !'r,,ll'(liPn a:1u . \i'f(Jrdabk t'nr.; ,\.;! ( l'ul•lil' I .a\\ I II-! -IX 1: -12 l T R ~~ .JJ I . .:135: und -I:' CF!{ ~ 155 Fe-deral Budget lmp:tct Fl•clcral Fisl'al Yl·nr .-\10011111 hr>t Year !201-1 \IIJ.()Il ~crond Y car j2111 :' Suhjn·t uf Ami'Hthncnt State of D~lawarc tvkdicaid i\IA(Il State Residi.:'llC) Statt: Plan Amendment Governor\ orn~·c Rl'YiC\1 0 Go,•crnur's oflh-c rcpurf~d no \'ommcnt 0 Lnmm~·nt~ of GoH!nwr's uflin reccil·cd lk,uit'>t•: 0 No •·<•pi) n:ccintl within -15 days ofsnhmillal 0 Other. a~ spl·cilied I k".:r: IJL·: Gm ern or\ c\)TillllefllS Under Separate ( 'orrcspll11tktu:c :',ign>~turc of Statt· AJ!~nr~ Offid:1l ~uhmi!lcd ~~~: "haron Surnllll'r~ La~l Rt•, i~i on 11:Hr: i\0\· 20, lOU :-.uhmil Hale Scp 11.201J TN#: 13-0009MM Approved: 111261201 J IS/ A=cv>~ ~LAim 1~"- Effective: 01i0112014

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: 13-0009 MM j PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: S88 Non-Financial Eligibility- State Residency STATE: Delaware PAGE NUMBER OF THE SUPERSEDED PLAN SECTJOl' OR ATTACHMENT (If Applicable): General Program Administration, Page 13, Item 2.3, TN SP-250 effective July I, 1987,approvedDecember23, 1987 Attachment 2.6-A: Page 3, Item 4 TN I 3-00 I 0 MM

Medicaid Eligibility OMB Control Number0938-1148 OMB Expiration date· 10/3li2014 Non-Financial Eligibility State Residency 42 CFR 435.403 State Residency z· [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: OO 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: 00 Intends to reside in the state, including without a fixed address, or 00 Entered the state with a job commitment or seeking employment, whether or not currently employed. OO Individuals age 21 and over, not living in an institution, who arc not capable of indicating intent, are residents of the state in which they live. 00 Non-institutionalized individuals under 21 not described above and non TV-E beneficiary children: 00 Residing in the state, with or without a fixed address, or OO The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)( I), with whom the individual resides. OO Individuals living in institutions, as defined in 42 CFR 435.10 I 0, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: 888 OO 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 OO 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 ofthe 00 institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. OO 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. 00 Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. OO 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. 00 IV-E eligible children living in the state, or Page I of 4

Medicaid Eligibility Meet the criteria specified in an interstate agreement. (.' Yes (' No ~ The state has interstate agreements with the following selected stales: [8J Alabama IZJ Illinois cgj Montana IZI Rhode Island IZI Alaska cgJ Indiana [8J Nebraska IZI South Carolina [8J Arizona IZI Iowa t8J Nevada IZI South Dakota [8J Arkansas IZI Kansas [gJ New Hampshire IZl Tennessee [gJ California [gJ Kentucky IZI New Jersey IZl Texas IZI Colorado IZl Louisiana [8J New Mexico IZl Utah IZl Connecticut 181 Maine 0 NewYork IZl Vermont 0 Delaware IZJ Maryland 181 North Carolina 181 Virginia IZl District of Columbia IZJ Massachusetts fZj North Dakota IZJ Washington IZl Florida IZl Michigan IZl Ohio [gJ West Virginia IZl Georgia IZJ Minnesota IZl Oklahoma fZl Wisconsin I2J Hawaii [8] Mississippi IZl Oregon 0 Wyoming [8] ldaho 1Zl Missouri IZl 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): 181 Are lV-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 IZJ Other type of individual Name of Type Description Children with Special Needs Children with Special Needs under a state funded Adoption + Subsidy Agreement: These Children with Special Needs for X whom there is a signed state-funded Adoption Subsidy Agreement are included under our ICAMA agreement. + X The state has a policy related to individuals in the state only to attend school. Page 3 o 4

Medicaid Eligibility (' Yes (i No I!] Otherwise meet the criteria of resident, but who may be temporarily absent fi·om the state. The state has a definition of temporary absence, including treatment of individuals who attend school in another state. (i Yes (' No Provide a description of the definition: Temporary Absences Out of State An individual may be found eligible and remain eligible during a temporary absence if the individual intends to return when the purpose of the absence has been accomplished unless another state has determined that the person is a resident there for purposes of Medicaid. PRA Disclosure Statement According to the Paperwork Reduction Act of I 995, 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. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this fom1, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Page 4 o' 4

Table of Contents State Name: Delaware State Plan Amendment (SPA) #13-0010MM 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 --- CMS CENTERS FOR MEDICARE & MEDICAID SERVICES Region III/Division of Medicaid and Children's Health Operations SWIFT# 112520134039 DEC 0 6 2013' Stephen Groff, Director Division of Medicaid & Medical Assistance Delaware Health and Social Services 1901 N. DuPont Highway New Castle, DE 19720-0906 Dear Mr. Groff: The Centers for Medicare & Medicaid Services has reviewed Delaware State Plan Amendment (SPA) 13-0010MM to modify eligibility standards and processes to conform to the requirements under the Affordable Care Act, and to exercise available related state options. In particular, this SPA describes the rules concerning Medicaid requirements related to U.S. citizenship and non- citizen eligibility in accordance with regulations at 42 CFR 435.406, Section 1137(d)(4) of the Social Security Act and Section 211 of the Children's Health Insurance Program Reauthorization Act (CHIPRA) The effective date of this SPA is January 1, 2014. Enclosed are the approved SPA pages and CMS-179 form. If you have further questions about this SPA, please contact Michael Cleary at 215-861-4282. Enclosures (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

DE.0307.ROO.OO- Jan 01, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) State{ferritory name: Delaware 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. DE-13-0010 Pro~?.~~-~!!~~tive -~~~~---- -· 01/01/2014 (mm / dd/ yyyy ) Federal Statute/Regulation Citation Patient Protection and Affordable Care Act (Public Law 111-148); 42 CFR §§ 431, 435; and 45 CFR § 155 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $0.00 Subject of Amendment State of Delaware Medicaid MAGI Citizenship and Immigration Status State Plan Amendment Governor's Office Review 0 Governor's office reported no comment 0 Comments of Governor's office received Describe: 0 No reply received within 45 days of submittal ~ Other, as specified Describe: Governor's Comments Under Separate Correspondence Signature of State Agency Official Submitted By: Sharon Summers Last Revision Date: Nov 20,2013 Submit Date: Sep 11, 2013 file://G:\DMCH\Medicaid\DE\SPAs\MAGI SPAs\DE-13-0010 MM\DE-13-0010MM 17 ... 12/10/2013

SUPERSEDING PAGES OF STATE PIAN MATERIAL TRANSMITIAL NUMBER: 13-0010 MM PAGE NUMBER OF THE PLAN SECTION OR A IT ACHMENT: S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility STATE: Delaware PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 2.6-A: Page 2a, Entire page, TN 10-003 Attachment 2.6-A: Page 2b, Entire page, TN 10-003 Attachment 2.6-A: Page 2c, Entire page, TN 10-003 Attachment 2.6-A: Page 2d, Entire page, TN 10-003

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and ( 4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility ; 889 ' The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 [Z] CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ~ The state provides Medicaid eligibility to otherwise eligible individuals: ~ Who are citizens or nationals of the United States; and Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity ~ Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or ~ satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956. The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. (i' 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. (i' Yes ('No The date benefits arc furnished is: (i' The date of application containing the declaration of citizenship or immigration status. ('The elate the reasonable opportunity notice is sent. (' Other date. as described: TN NO 13-0010 MM APPROVED DATE 12/06/2013 EFFECTIVE DATE 01/1/2014 Page 1 of 3

Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). (;Yes ('No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)( 4) of the Act. (;Yes ('No r:gj Pregnant women r:gJ Individuals under age 21: (; Individuals under age ?1 ('-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: l. Is a qualified non-citizen as defined in 8 U.S.C. 164l(b) and (c): 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. ll0l(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 110 I (a)(17)); 3. Is a non-citizen who has been paroled into the United Slates in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: ~ Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ~ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ~ Granted employment authorization under 8 CFR 274a.l2(c); ~ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ~ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ~ Granted Deferred Action status; [!] Granted an administrative stay of removal under 8 CFR 241; [!] Beneiiciary of approved visa petition who has a pending application for adjustment of status; 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.l231, or under the Convention Against Torture who- [!] Has been granted employment authorization; or TN N~3-00IO<i4li1the age of 14 and has had ~1Uidlli'{T®41it'®f.ro13t least 180 days; EFFECTIVE DATE 01/1/2014 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. ll!H(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa: or 9. Is a victim of severe trafficking in persons. in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. D Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition. not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following [{] individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ~ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ~ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). PRA Disclosure Statement A~.:cording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO 13-0010 MM APPROVED DATE 12/06/2013 EFFECTIVE DATE 01/1/2014 Page 3 of3

Table of Contents State Name: Delaware State Plan Amendment (SPA) #: 14-0006-MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

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 2

SWIFT# 061820144007 JUN 26 2014

Stephen Groff, Director

Division of Medicaid & Medical Assistance Delaware Health and Social Services

1901 N. DuPont Highway

New Castle, DE 19720-0906

Dear Mr. Groff:

Enclosed is an approved copy of Delaware state plan amendment (SPA) 14-0006-MM7, which was submitted to CMS on March 28, 2014. SPA 14-0006-MM7 allows hospitals in the state to determine eligibility presumptively under the option in 42 CFR 435.1110, and the state to provide Medicaid coverage for individuals determined presumptively eligible under this provision. The effective date of this SPA is January 1, 2014.

The CMS recognizes that no hospitals in Delaware are currently performing presumptive eligibility determinations. This approved SPA serves as record that the state is prepared, with approved state policies and materials, to assist any qualified hospital in implementing the hospital presumptive eligibility program should a hospital decide to conduct presumptive eligibility determinations. If the situation in Delaware changes, the state will work with CMS to incorporate any policy or programmatic changes in the state plan as necessary.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Michael Cleary at 215-861-4282.

ancis McCu Associate Regional A

Enclosures

Aedicaid State |

State/Territory

name:

Delaware Transmittal Number:

Page | of |

Please enter the Transmittal Number (TN) in the format ST-Y Y-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. DE-14-0006

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 $ 0.00 Second Year 2015 $ 0.00

Subject of Amendment Hospital Presumptive Eligibility

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal Other, as specified

Describe:

Governor's comments under separate correspondence.

Signature of State Agency Official Submitted By: Sharon Summers Last Revision Date: Mar 28, 2014 Submit Date: Mar 28, 2014

pha

06/26/2014

Medicaid Eligibility

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

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: Pp p [i] 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 [i] 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. CyYes (No [i] The eligibility groups or populations for which hospitals determine eligibility presumptively are: [i] Pregnant Women [i] Infants and Children under Age 19 [i] Parents and Other Caretaker Relatives [i] Adult Group, if covered by the state [i] Individuals above 133% FPL under Age 65, if covered by the state [Mi] Individuals Eligible for Family Planning Services, if covered by the state [®] Former Foster Care Children [| Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state (C) Other Family/Adult groups: (7 Eligibility groups for individuals age 65 and over (7 Eligibility groups for individuals who are blind (7) Eligibility groups for individuals with disabilities (7) Other Medicaid state plan eligibility groups (J Demonstration populations covered under section 1115

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

TN No. 14-0006-MM7 Approval Date: 06/26/2014 Effective Date: 01/01/2014 Delaware $21-1 Page | of 3

Medicaid Eligibility

CYes @No [i] The presumptive period begins on the date the determination is made.

[lil 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: (No more than one period within a calendar year. C No more than one period within two calendar years.

> No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

(© Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes (© 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.

[ 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 (¢.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 [X| 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.

PRA Disclosure Statement

TN No. 14-0006-MM7 Approval Date: 06/26/2014 Effective Date: 01/01/2014 Delaware $21-2 Page 2 of 3

Medicaid Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No. 14-0006-MM7 Approval Date: 06/26/2014 Effective Date: 01/01/2014 Delaware $21-3 Page 3 of 3

DMMA PE App (Rev. 6/2014)

DELAWARE HEALTH AND SOCIAL SERVICES (DHSS)

Application for Hospital Presumptive Eligibility for Medicaid

You can use this form to apply if you are a patient of the hospital, a patient’s family member, or a community member.

Use this form to find out quickly if you qualify for presumptive eligibility for Medicaid. Presumptive eligibility is a temporary determination that gives you immediate access to health care while you wait for a regular Medicaid determination. You can apply for regular Medicaid on line at www.assist.dhss.delaware.gov, by telephone, in-person in your area, or by mail.

Who can qualify for presumptive eligibility for Medicaid? You can qualify for presumptive eligibility for Medicaid if you meet all of these rules:  Your income is below the monthly limit  You are a U.S. citizen, U.S. national, or eligible immigrant  You do not already have Medicaid  You have not had presumptive eligibility for Medicaid in the past 12 months. Or, if you are pregnant, you have not had presumptive eligibility for Medicaid during this pregnancy.  You are in one of the groups that qualifies for presumptive eligibility for Medicaid: • Children under age 19 • Parents and caretaker relatives • Pregnant women • Other adults age 19-64 • People under age 26 who were in foster care at age 18 (no income limit) • Women in treatment for breast and cervical cancer

Need help with your application for regular Medicaid?  Phone: Call our Customer Relations Unit at 1-800-372-2022.  In person: There may be social workers/case managers in your area who can help.  En Español: Llame a nuestro centro de ayuda gratis al 1-866-843-7212.  In a language other than English: Call 1-866-843-7212.  TTY users: Call 711 or 1-800-232-5460.

1 TN No. 14-0006-MM7 Delaware Approval Date: 06/26/2014 Application for Hospital Presumptive Eligibility for Medicaid-1 Effective Date: 1/1/2014

1 Tell us about yourself We ask for this information so that we can contact you about this application.

Name (first, middle, last)

Home address (leave blank if you don’t have one)

City State ZIP code

Mailing address (if different from home address)

Primary Phone Number (if you have one) Secondary Phone Number (if you have one)

Preferred Methods of Contact I want to receive information about this application and future communication by: ☐ Email Address ☐ U.S. Mail Email Address:

Preferred Spoken or written Language (if not English)

2 Tell us about your family List yourself and the members of your immediate family who live with you. Include your spouse and your children under 19 if they live with you. Do not list other relatives or friends even if they live with you. Name (first, middle, last) Date of birth (XX/XX/ XXXX) Relationship to you Applying for presumptive eligibility for Medicaid? (Yes or No) Already has Medicaid? (Yes or No) U.S. Citizen, U.S. National, or eligible immigrant? (Yes or No) Resident of Delaware? (Yes or No) 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) TN No. 14-0006-MM7 Delaware Approval Date: 06/26/2014 Application for Hospital Presumptive Eligibility for Medicaid-2 Effective Date: 1/1/2014

3 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. Is anyone pregnant, even if she is not applying for presumptive eligibility for Medicaid?  Yes  No If yes, who? How many babies does she expect?

Is anyone who is applying for presumptive eligibility for Medicaid receiving Medicare?  Yes  No If yes, who?

Is anyone who is applying for presumptive eligibility for Medicaid a parent or caretaker relative?  Yes  No For example, a grandparent who is the main person taking care of a child. If yes, who?

Was anyone who is applying for presumptive eligibility for Medicaid in foster care at age 18 or older and received Delaware Medicaid?  Yes  No If yes, who?

Is anyone who is applying for presumptive eligibility for Medicaid being treated for breast or cervical cancer?  Yes  No If yes, who?

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.  Job income For example, wages, salaries, and self-employment income.

Amount $

How often? (check one)  Weekly  Biweekly  Monthly  Yearly

 Other income For example, unemployment checks, alimony, or disability payments from the Social Security Administration (“SSDI”). Do not include Supplemental Security Income (“SSI payments”) or any child support you receive.

Amount $

How often? (check one)  Weekly  Biweekly  Monthly  Yearly

5 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. Your signature: Date: Signature of Authorized Representative: Date: TN No. 14-0006-MM7 Delaware Approval Date: 06/26/2014 Application for Hospital Presumptive Eligibility for Medicaid-3 Effective Date: 1/1/2014

6 7 If you qualify for presumptive eligibility for Medicaid, what happens next?

▪ You will get a letter from the hospital saying you were approved.

▪ 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 saying you are approved. Use the letter to get services until you get a card in the mail. If you lose the letter, you can call 1-800-372-2022. • 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. 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 application for medical assistance to see if you qualify for regular 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 regular Medicaid or other health coverage,

• The hospital will give you an application for regular Medicaid. • Phone: Call our Customer Relations unit at 1-800-372-2022. • In person: There may be social workers/case managers in your area who can help. • En Español: Llame a nuestro centro de ayuda gratis al 1-866-843-7212 • In a language other than English: Call 1-866-843-7212 • TTY users: Call 711 or 1-800-232-5460.

If you do not qualify for presumptive eligibility for 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 regular Medicaid or other health coverage using the application for medical assistance.

TN No. 14-0006-MM7 Delaware Approval Date: 06/26/2014 Application for Hospital Presumptive Eligibility for Medicaid-4 Effective Date: 1/1/2014

Wai

‘yall

que

bLoz/9z/9 :a}eq jeaoiddy ZW W 9000-1 “ON NL

PLoz/t/L :93eq AAIDANA

* In this training, the following will be covered:

*

*

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date:

Overview of the Hospital Presumptive Program Terms and Definitions

Eligibility Requirements

Household Composition

Income

Process of completing a Presumptive Eligibility Determination.

Finalizing the Presumptive Eligibility Process.

* What is Hospital Based Presumptive Eligibility?

* With new Medicaid regulations taking effect 1-1-2014, hospitals will have the option to participate in the Hospital Based Presumptive Eligibility Program. This program allows qualified hospitals to provide presumptive Medicaid eligibility to individuals based on preliminary declared information (income, citizenship/immigration status, and residence).

* Individuals approved will be eligible for Medicaid services during a temporary presumptive time period.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Frequency Limitations:

* Presumptive eligibility determinations are limited to no more than one period within a 12-month period starting

with the effective date of the initial PE period. * A pregnant woman may be authorized for presumptive eligibility once per pregnancy.

TN No. 14-0006 MM7 Approval Date: 6/26/2014

* Qualified Entity Responsibilities: ~~ —— * Notify the appropriate individual at the time a determination

regarding presumptive eligibility is made, in writing or orally if

appropriate, of such determination, that —

* If a Medicaid application on behalf of the eligible individual is not filed by the last day of the following month, the individual’s presumptive eligibility will end on that last day.

If a Medicaid application on behalf of the eligible individual is filed by the last day of the following month, the individual’s

presumptive eligibility will end on the day that a decision is made on the Medicaid application, and

If the individual is not determined presumptively eligible, the qualified entity shall notify the appropriate individual of the reason for the determination and that he or she may file an application for Medicaid with the Medicaid agency.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Qualified Entity Responsibilities (cont.)

*

TN No. 14-0006 MM7 Approval Date: 6/26/2014

Provide the individual with the Delaware Health and Social Services Application for Presumptive Eligibility for Medicaid;

Within five working days after the date that the determination is made, notify the agency that the individual is presumptively eligible; and

Shall not delegate the authority to determine presumptive eligibility to another entity.

* Qualified Hospital Criteria: * Participate as a Medicaid Provider;

* Notify Delaware Health and Social Services of its decision to make presumptive determinations;

* Agree to make determinations consistent with federal

and state policy and procedures; and

* Shall not be disqualified by Delaware Health and Social

Services (DHSS).

TN No. 14-0006 MM7

Approval Date: 6/26/2014

Effective Date: 1/1

* Performance Standard:

* All Hospital Presumptive Eligibility determinations will be subject to review by DHSS Quality Assurance staff. The participating hospitals will be expected to maintain a level of accuracy.

* Hospitals not meeting this requirement will complete additional training in order to improve their accuracy. If the standards are not met after additional training, the hospital will be subject to disqualification from the presumptive eligibility program.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

All PE providers must be qualified Medicaid pro\

The provider will notify DHSS of its decision to make pres mptive determinations.

All staff members employed by the provider who intend to make PE determinations must successfully complete PE training and sign the Confirmation of Training form. All PE training materials must be ina DHSS approved format.

The provider must agree to make PE determinations consistent with Delaware policy and procedure.

In order for a hospital to be accepted as a PE provider, the provider’s CEO or executive director must acknowledge all staff members accepted as PE providers have successfully completed training by signing a Confirmation of Participation form.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Application Signature: The application must be signed by an adult household member (age 18 or over) or by an emancipated minor (under age 18). An application may also be signed by an authorized representative.

* Application Submission: Applications for regular Medicaid may be submitted in person, by mail, or by fax.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Dependent Child: A child from birtht ‘who is age and a full-time student in secondary schoel vor UES vocational or technical training), if before attaining age 19 the child may be reasonably expected to complete such school or training.

Eligibility Determination: An approval or denial of eligibility.

Family Size Using Modified Adjusted Gross Income (MAGI) Methodology: Means the number of persons counted as members of an individual’s household. When determining the family size of individuals who have a pregnant woman in their household, the family size is counted as the pregnant woman plus the number of children she is expected to deliver.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Modified Adjusted Gross Income (MAGI): The methodology used to determine financial eligibility.

* Non-Applicant: An individual who is not seeking an eligibility determination for himself or herself and is included in an applicant’s or client’s household to determine eligibility for such applicant or client.

* Non-Filer: Individuals who do not intend either to file taxes or to be claimed as a tax dependent.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Parent/Caretaker Relative: A relative of ad

adoption, or marriage with whom the anita is ne who assumes

primary responsibility for the child’s care, and who is one of the

following:

* The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece.

* The spouse of such parent or relative including same sex marriage, even after the marriage is terminated by death or divorce.

* Another relative of the child based on blood, adoption, or marriage; the domestic partner of the parent or caretaker relative; or an adult with whom the child is living and who assumes primary responsibility for the dependent child’s care.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Tax Dependent: An individual for whom another individual claims a deduction for a personal exemption for a taxable year.

* Tax Filer: Individuals who intend to file a federal tax return for the coverage year and who do not intend to be claimed as a tax dependent by another taxpayer.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Qualified providers will make eligibility determinations for

Presumptive Eligibility based on the following preliminary information as declared by the client:

@* The individual has gross income at or below the income standard established for the applicable group;

* The individual has attested to being a citizen or national of the United States or is in satisfactory immigration status; and

* The individual is a resident of Delaware.

* No verifications are required.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Income:

* In order to be determined presumptively eligible for Medicaid, an individual must declare monthly gross income at or below the income standard for their eligibility group and household size (See the attached Income Chart).

* This calculation is made using the income included when calculating MAGI-based income.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

* Eligibility Groups: An Individual mu

following eligibility groups in order to be found presumptively eligible for Medicaid.

*

* *+ KF

Pregnant Women

Infants and Children under age 19

Parent and Other Caretaker Relatives Adults ages 19-64 who do not have Medicare

Former Foster Care Children — under age 26 and in Delaware Foster Care upon aging out of care

Individuals needing treatment for Breast or Cervical Cancer - screened under Centers for Disease Control Early Detection Program

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

Apply these three steps to determine an applicant’s MAGI- based income eligibility for Medicaid or CHIP:

* Identify members of the individual’s family who are considered part of his/her household and determine family size.

* Add the income of all the relevant members of the individual’s household.

* Compare total household income to the federal poverty level for the individual’s family size.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

The household composition rules under AG tax filing unit. Delaware has taken the State option to use

non-filer rules.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014 PP.

For adults, the household must include:

* The adult applying for coverage: AND

* The adult’s married spouse if living with the individual; AND

* The adult’s natural, adopted, and step-children under age 19 if living with the adult.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

*

*

*

*

Household for children under age 19 must include:

The child applying for coverage: AND

The child’s parents (including biological, adopted, and step- parents) if living with the child; AND

Any of the child’s siblings (including biological, adopted and step-siblings) who are under age 19.

If the child is married, the spouse (if the spouse is living with the child); and if the child has their own child, the children and step-children (if living with the married child).

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

Once the household is determined, if the individual is a pregnant woman the family size must be adjusted based on the number of children she expects to deliver.

Example

Analysis

Pregnant woman expecting a single child

Family size increased by 1

+

Pregnant woman expecting twins

Family size increased by 2

TN No. 14-0006 MM7

Approval Date: 6/26/2014

Effective Date: 1/1/2014

| Taxable wages/salary (before taxes are taken out)

Self-employment (profit once business expenses are paid)

Countable eae ee ocial Security benefits Income y Unemployment benefits a ere I Note: Pre-tax I Alimony received I contributionsto I dependent care I | Most retirement benefits ! accounts, health | | I insurance I Interest (including tax-exempt interest) ' premiums, flexible 1 | Spending accounts, I i i i i i retirement | Net capital gains (profit after subtracting capital losses) | po ae : | Most investment income, such as interest and dividends oe l expenses are NOT I | included as income |

Rental or royalty income (profit after subtracting costs)

[Se

| Other taxable income, such as canceled debts, court awards, jury duty pay not given to an employer, cash | support, and gambling, prizes, or awards

| Foreign earned income : TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

Non-Countable Income

TN No. 14-0006 MM7

Temporary Assistance to Needy Families (TANF)

and other government cash assistance

Supplemental Security Income (SSI)

Child support received

Veterans benefits

| Worker’s compensation payments

Proceeds from life insurance, accident insurance, or health insurance

Federal tax credits and Federal income tax refunds

Gifts and Loans

| Inheritances

Approval Date: 6/26/2014 Effective Date: 1/1/2014

Individual arrives for care at a qua t medical insurance. Sire: es Provider verifies that the individual is not currently active in Delaware Medicaid.

A Presumptive Eligibility Certified staff person completes the Application for Hospital Presumptive Eligibility with the individual. The individual signs the presumptive form, attesting to the included citizenship, pregnancy, and income information.

Qualified staff person determines the household size for the individual.

Qualified staff person compares the household income with the FPL for the individual’s Medicaid category and household size in order to determine if the individual is presumptively eligible for Medicaid (See attached income chart).

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

Notify the applicant of the presump ive copy of the application to the individual, and if the applicant is roar’

eligible, provide the Proof of Temporary Coverage Letter. Explain to the applicant that a Notice of Decision confirming presumptive eligibility will be provided within approximately 10 days.

Explain to the individual that a regular application must be completed and provide the following contact information:

Phone: Call our Customer Relations Unit 1-800-372-2022

In person: There may be social workers/case managers in your area who can help.

En Espanol: Llame a nuestro centro de ayuda gratis al 1-866-843-7212.

In a language other than English: Call 1-866-843-7212.

TTY users: Call 711 or 1-800-232-5460. Within 5 working days of the presumptive eligibility determination, submit the Application for Hospital Presumptive Eligibility for Medicaid to the Delaware Health and Social Services (DHSS) via fax 1-866-843-7212. Keep the fax verification sheet as proof in case DHSS does not receive it.

A copy of the agency’s Notice of Decision to the applicant will be provided to the hospital within approximately 10 days.

TN No. 14-0006 MM7 Approval Date: 6/26/2014 Effective Date: 1/1/2014

Annual Income | Monthly Income | Monthly Income | Monthly Income} Monthly Income Family 100% FPL 92% FPL 138% FPL 147% FPL 217% FPL Size Parents/Caretaker | Age 6 through 18 Age 1 through 5|/Pregnant Women Relatives Adults Infants 1 11,670 896 1,392 1,479 2,160 Z 15,730 1,207 1,875 1,993 2,911 3 19,790 1,518 2,359 2,508 3,662 4 23,850 1,830 2,843 3,022 4,413 5 27,910 2,141 3,327 3,536 5,165 6 31,970 2,452 3,811 4,051 5,916 7 36,030 2,764 4,295 4,565 6,667 8 40,090 3,075 4,779 5,080 7,418 i) 44,150 3,385 5,262 5,593 8,168 10 48,210 3,697 5,746 6,107 8,919

* Note: There is no income test for Former Foster Care Children and Breast

and Cervical Cancer Groups. A 5% FPL disregard has been added.

Effective Date: 1/1/2014

TN No. 14-0006 MM7

Approval Date: 6/26/2014

DELAWARE HEALTH AND SOCIAL SERVICES DIVISION OF MEDICAID & MEDICAL ASSISTANCE

Proof of Temporary Coverage for Presumptive Eligibility

Dear Provider:

The person(s) listed below has temporary health coverage through Presumptive Eligibility (PE). Temporary coverage may last between 30 and 60 days depending on the effective date of coverage shown (below). To ensure payment, providers must verify eligibility prior to providing services and submitting claims. If you have questions concerning Presumptive Eligibility, please call the DHSS Customer Relations Unit at 1-800-372-2022.

Verify Presumptive eligibility via: • Delaware Medical Assistance Program Website www.dmap.state.de.us Click on the Interactive Services tab and enter your web user ID and password. If a provider has not registered to use the interactive services tab, they can register at https://www.dmap.state.de.us/secure/emailIntro.do • Provider Relations 1-800-999-3371 Option 0, then # 2

Services included under temporary coverage are the same as those available under regular program coverage. NOTE: Social Security Numbers are requested but are not required. Name (First - Middle Initial - Last) Social Security Number AND Date of Birth mm/dd/yyyy Effective Date of Coverage mm/dd/yyyy Check the appropriate coverage group Parent/ Caretaker Relative Pregnant Women Infants and Children under age 19 Adults Former Foster Children

Name of Qualified Entity Determining Presumptive Eligibility (Please Print)

Date

Signature of Qualified Entity

Qualified Entity: Within 5 days of Determination FAX PE Application and Proof of Temporary Coverage form to: DHSS at 1-866-843-7212.

Delaware Health and Social Services (DHSS), PO BOX 906, New Castle, DE 19720 TN No. 14-0006-MM7 Delaware Approval Date: 6/26/2014 Proof of Temporary Coverage for Presumptive Eligibility for Medicaid Effective Date: 1/1/2014

Table of Contents State Name: Delaware State Plan Amendment (SPA) #: 14-0007 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 150 S. Independence Mall West Suite 216, The Public Ledger Building CENTERS FOR MEDICARE & MEDICAID SERVICES

Philadelphia, Pennsylvania 19106-3499

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

SWIFT 4060420144026 JUN 06 2014

Mr. Stephen M. Groff, Director

Division of Medicaid and Medical Assistance P.O. Box 906

New Castle, DE 19720-0906

Dear Mr. Groff:

We are pleased to inform you of the approval of Delaware State Plan Amendment (SPA) 14-0007. In accordance with Section 4106 of the Affordable Care Act (ACA), this amendment covers and reimburses all United States Preventive Services Task Force (USPSTF) grade A and B clinical preventive services and approved adult vaccines and their administration recommended by the Advisory Committee on Immunization Practices (ACIP), without cost- sharing; and establishes a one percentage point increase in federal medical assistance percentage (FMAP) for these service expenditures whether they are provided in fee-for-service (FFS), managed care or under an alternate benefit plan.

Enclosed is a copy of the approved SPA pages and the signed CMS-179 form. The effective date of this amendment is April 1, 2014.

If you have any questions, you may contact Michael Cleary at (215) 861-4282.

Associate Regional

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

2. STATE DELAWARE

1. TRANSMITTAL NUMBER: SPA #14-0007

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

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE April 1, 2014

5. TYPE OF PLAN MATERIAL (Check One):

(J) NEW STATE PLAN

[] AMENDMENT TO BE CONSIDERED AS NEW PLAN

XXX AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Section 1905(a)(13) of the Social Security Act (42 U.S.C. 1396d(a)(13))

7, FEDERAL BUDGET IMPACT: As section 4106 of the ACA establishes a one percentage point increase in the Federal Medical Assistance Percentage applied to a specified preventive services and adult vaccines, the State expects to realize savings of one percent (1%) for these services State Fiscal Years 2014 and 2015.

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 3.1-A Page 6 Attachment 3.1-A Page 6 Addendum

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable):

Attachment 3.1-A Page 6 NEW State Plan Page

10. SUBJECT OF AMENDMENT: Preventive Services Affordable Care Act Section 4106: To cover clinical preventive services and adult vaccines in accordance with the United States Preventive Services Task Force (USPSTF) recommendations and the Advisory Committee

on Immunization Practices (ACIP) recommendations

11. GOVERNOR’S REVIEW (Check One): (.] GOVERNOR’S OFFICE REPORTED NO COMMENT [_] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED [J NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

XXX OTHER, AS SPECIFIED: Governor’s comments under separate correspondence

12. SIGNATURE OF STATE AGENCY OFFICIAL: //Stephen M. Groff - signature//

13. TYPED NAME: Stephen M. Groff, Director, Division of Medicaid and Medical Assistance

14. TITLE: Designee for Rita M. Landgraf, Secretary, Delaware Health and Social Services

15. DATE SUBMITTED: May 6, 2014

16. RETURN TO:

Stephen M. Groff

Director

Division of Medicaid and Medical Assistance P.O. Box 906

New Castle, Delaware 19720-0906

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED: JU) 06 2014

May t dol 5) PLAN APPROVED — ONE CQPATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: BAG Apail 1, 20/4

21. TYPED NAME:

FRancis Me Collovgh

FORM HCFA-179 (07-92)

Revision: HCFA-PM-85-3 (BERC) ATTACHMENT 3.1-A MAY 1985 Page 6 OMB No.: 0938-0193

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Delaware

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

b. Screening services. _. Provided: ____ No limitations ___ With limitations* _X_ Not provided.

G: Preventive services. _X_ Provided: _____No limitations _X__With limitations* _. Not provided.

d. Rehabilitative services. _X_ Provided: ___ No limitations _X_ With limitations*

__ Not provided.

14. Services for individuals age 65 or older in institutions for mental diseases. a. Inpatient hospital services. X_ Provided: _X_Nolimitations _ With limitations*

Not provided. b. Skilled nursing facility services. ___. Provided: __ No limitations _ With limitations* _X_ Not provided. CG Intermediate care facility services. _X_ Provided: _X_Nolimitations _ — With limitations*

Not provided. *Description provided on attachment.

TN No. SPA #14-0007 Approval Date JUN 06 AN

Supersedes TN No. SP-270 Effective Date April_1, 2014

Attachment 3.1-A Page 6 Addendum

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: Delaware

LIMITATIONS ON AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES

13:¢:

PROVIDED TO THE CATEGORICALLY NEEDY Preventive Services

In accordance with section 4106 of the Affordable Care Act, Delaware Medicaid covers and reimburses all preventive services assigned a grade of A or B by the United States Preventive Services Task Force (USPSTF) and all approved vaccines and their administration, recommended by the Advisory Committee on Immunization Practices (ACIP), without cost-sharing.

Preventive Services are any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts acting within the scope of their practice under State law and are reimbursed according to the methodologies for services described in Attachment 4.19-B, Methods and Standards for Establishing Payment Rates — Other Types of Care, of the state plan.

The State assures the availability of documentation to support the claiming of federal reimbursement for these preventive services.

The State assures that the benefit package will be updated as changes are made to USPSTF and ACIP recommendations, and that the State will update the coverage and billings codes to comply with these revisions.

TN No. SPA #14-0007 Approval Date_ JUN 0 6 2U14

Supersedes TN No. NEW Effective Date April 1, 2014

Table of Contents State Name: Delaware State Plan Amendment (SPA) #18-004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS-179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 801 N Market Street, Suite 9400 Philadelphia, Pennsylvania 19107-3134 Region III/Division of Medicaid and Children’s Health Operations SWIFT #100120184019 Mr. Stephen M. Groff, Director Division of Medicaid and Medical Assistance P.O. Box 906 New Castle, DE 19720-0906 Dear Mr. Groff: We are pleased to inform you of the approval of Delaware State Plan Amendment (SPA) 18-004. This amendment modifies the State Plan to grant Delaware an exception to the Recovery Audit Contracting (RAC) requirements for a 2-year period ending June 30, 2020. If Delaware decides to request an extension beyond this 2-year approval period, a SPA will need to be submitted at that time that demonstrates the RAC requirements continue to be impractical and not cost effective. Enclosed is a copy of the approved SPA pages and the signed CMS-179 form. The effective date of this amendment is July 1, 2018. If you have any questions, you may contact Michael Cleary at (215) 861-4282. Sincerely, Francis McCullough Associate Regional Administrator Enclosures 'HFHPEHU

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: SPA #18-004 2. STATE DELAWARE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE July 1, 2018 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN XXX AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: x The Patient Protection and Affordable Care Act, Public Law 111-148, Section 6411, Expansion of the Recovery Audit Contractor (RAC) program x Section 1902(a)(42)(b) of the Social Security Act, requires States to establish programs to contract with RACs to audit payments to Medicaid providers by December 31, 2010 x 42 CFR 455 Subpart A, Medicaid Agency Fraud Detection and Investigation Program x 42 CFR 455 Subpart F, Medicaid Recovery Audit Contractors Program 7. FEDERAL BUDGET IMPACT: a. FFY 2018 $ 0 b. FFY 2019 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Section 4.5 General Program Administration Pages 36, 36a, and 36b 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Section 4.5 General Program Administration Pages 36, 36a, and 36b 10. SUBJECT OF AMENDMENT: Medicaid Recovery Audit Contractors Program 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT XXX OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Governor’s comments under separate NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL correspondence 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Stephen M. Groff Director Division of Medicaid and Medical Assistance P.O. Box 906 New Castle, Delaware 19720-0906 13. TYPED NAME: Stephen M. Groff, Director, Division of Medicaid and Medical Assistance 14. TITLE: Designee for Kara Odom Walker, MD, MPH, MSHS, Secretary, Delaware Health and Social Services 15. DATE SUBMITTED: 9/28/18 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED September 28, 2018 18. DATE APPROVED: ĞĐĞŵďĞƌϮϲ͕ϮϬϭϴ PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: July 1, 2018 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: Fran McCullough 22. TITLE: Associate Regional Administrator 23. REMARKS:

Revision: HCFA-PM-88-10 (BERC) OMB No: 0938-0193 September 1988 36 HCFA ID: 1010P/0012P TN No. SPA# 18-00ϰ Supersedes TN No. SP# 268 Approval Date ĞĐĞŵďĞƌϮϲ͕ϮϬϭϴ Effective Date July 1, 2018 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE Citation §1902(a)(42)(B) P.L. 111-148 §42 CFR 455 Subpart A §42 CFR 455 Subpart F 4.5 Medicaid Agency Fraud Detection and Investigation Program The Medicaid agency has established and will maintain methods, criteria, and procedures for prevention and control of program fraud and abuse, including methods for identification, investigation, and referral of suspected fraud cases.

36a TN No. SPA# 18-00ϰ Supersedes TN No. 10-005 Approval Date ĞĐĞŵďĞƌϮϲ͕ϮϬϭϴ Effective Date July 1, 2018 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE 4.5 Medicaid Recovery Audit Contractor Program Citation Section 1902(a)(42)(B)(i) of the Social Security Act Section 1902(a)(42)(B)(ii)(I) of the Act Section 1902 (a)(42)(B)(ii)(ll)(aa) of the Act The State has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State plan and under any waiver of the State plan. The State is seeking an exception to establishing such program for the following reasons: Although the Delaware Division of Medicaid and Medical Assistance (DMMA) previously had a Recovery Audit Contract (RAC) vendor, that contract is no longer in place. DMMA posted a Request for Proposals (RFPs) in an attempt to attract a new RAC vendor, but received no bids. The majority of Delaware’s Medicaid population is enrolled in managed care and the providers treating them are not subject to audit recovery contracting. There is not sufficient revenue generation to fund an adequate contingency fee The State/Medicaid agency has contracts of the type(s) listed in section 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute. Delaware RFP for RACs is completed. Place a check mark to provide assurance of the following: The State will make payments to the RAC(s) only from amounts recovered. The State will make payments to the RAC(s) on a contingent basis for collecting overpayments. The following payment methodology shall be used to determine State payments to Medicaid RACs for identification and recovery of overpayments (e.g., the percentage of the contingency fee): The State attests that the contingency fee rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare RACs, as published in the Federal Register

36b TN No. SPA# 18-00ϰ Supersedes TN No. 10-005 Approval Date ĞĐĞŵďĞƌϮϲ͕ϮϬϭϴ Effective Date July 1, 2018 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE 4.5 Medicaid Recovery Audit Contractor Program Citation Section 1902 (a)(42)(B)(ii)(ll)(bb) of the Act Section 1902 (a)(42)(B)(ii)(III) of the Act Section 1902(a)(42)(B)(ii) (IV)(aa) of the Act Section1902(a)(42)(B)(ii)(IV)(bb) of the Act Section 1902 (a)(42)(B)(ii)(IV)(cc) of the Act The State attests that the contingency fee rate paid to the Medicaid RAC will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will only submit for FFP up to the amount equivalent to that published rate. The contingency fee rate paid to the Medicaid RAC that will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will submit a justification for that rate and will submit for FFP for the full amount of the contingency fee. The following payment methodology shall be used to determine State payments to Medicaid RACs for the identification of underpayments (e.g., amount of flat fee, the percentage of the contingency fee): The State has adequate appeal process in place for entitles to appeal any adverse determination made by Medicaid RAC(s). The State assures that the amounts expended by the State to carry out the program will be amounts expended as necessary for the proper and efficient administration of the State plan or waiver of the plan. The State assures that the recovered amounts will be subject to a State's quarterly expenditure estimates and funding of the State's share. Efforts of the Medicaid RAC(s) will be coordinated with other contactors or entitles performing audits of entitles receiving payments under the State plan or waiver in the State, and/or State and Federal law enforcement entitles and the CMS Medicaid Integrity Program.

Table of Contents State Name: Delaware State Plan Amendment (SPA) #19-006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS-179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850

Center for Medicaid and CHIP Services Disabled and Elderly Health Programs Group

February 6, 2020

Stephen M. Groff, Director Division of Medicaid and Medical Assistance Delaware Health and Social Services P.O. Box 906 New Castle, DE 19720-0906

Dear Mr. Stephen Groff:

We have reviewed Delaware’s State Plan Amendment (SPA) 19-0006, Drug utilization Review, received in the Philadelphia Regional Operations Group on December 20, 2019. This SPA proposes to amend the Title XIX Medicaid State Plan regarding DUR provisions included in section 1004 of the SUPPORT for Patients and Communities Act with the effective date of October 1, 2019.

Based on the information provided and consistent with the regulations at 42 CFR 430.20, we are pleased to inform you that DE SPA 19-0006 is approved with an effective date of October 1, 2019. If changes are subsequently made to the DUR pages, a new SPA and any required documents should be submitted to CMS for review and authorization.

A copy of the signed CMS-179 form, as well as the pages approved for incorporation into Delaware’s state plan will be forwarded by the Philadelphia Regional Operations Group.

If you have any questions regarding this amendment, please contact Whitney Swears at (410) 786-6543 or Whitney.Swears@cms.hhs.gov.

Sincerely, John M. Coster, Ph.D., R.Ph. Director, Division of Pharmacy

cc: Nicole Cunningham, State Plan Coordinator

Kimberly Xavier, State Senior Policy Administrator Glyne Williams, State Chief Policy, Planning and Quality Christiana Ogunremi, State Pharmacy Director Frances McCullough, CMS, Director, Philadelphia Regional Operations Group Michael Cleary, CMS, Philadelphia Regional Operations Group

  !!  !  !  !  !

 !! 

!
! 

 !  ! 


  


 


 

 
 

 



  
     zg7°uLQUgb9Z°9I\UbUxzu9zgu° FLbzLux°Ogu°\LIUF9uL°°\LIUF9UI°xLuUFLx° ILn9uz\Lbz°gO°TL9ZzT°9bI°T\9b°xLuUFLx° ) z‡nL°gO°nZ9b°\9zLuU9Z°


    zu9bx\Uzz9Z°b\CLu 2° ‰° °  *°

 

  
 !°xz9zL H“›Š¬Š¤“ % mvfPv:]°UILczUNUE:{Ufc6°{UzZL° U °fN°{SL°xfEU:Z xLFuUz‡°9Fz°\LIUF9UI ' nugngxLI°LOOLFzUL°I9zL h¨¡“¤° ° "2
bL„°xz9zL°nZ9b
9\LbI\Lbz°zg°CL°FgbxUILuLI°9x°bL„°nZ9b

9\LbI\Lbz° Fg\nZLzL°CZgFXx°+°zTu°°UO°zTUx°Ux°9b°9\LbI\Lbz°
  

   

      + OLILu9Z°xz9zzLuLQZ9zUgb°FUz9zUgb - OLILu9Z°CIQLz°U\n9Fz |˜©œ”°†V†°^”‘˜Œ™’°y©Œ©”°oŒž 0 n9QL°b\CLu°gO°zTL°nZ9b°xLFzUgb°gu°;~z9FT\Lbz y”©™ ž°(#,°  xCWLFz°gO°9\LbI\Lbz H¤ª–°€¨š›š¯Š¨š¡Ÿ°w“«š“¬°H€w °  QgLubgux°uLUL„°


  
QgLubgux°gOOUFL°uLnguzLI°bg°Fg\\Lbz
Fg\\Lbzx°gO°QgLubgux°gOOUFL°LbFZgxLI
bg°uLnZ‡°uLFLULI°„UzTUb°')°I9‡x°gO°xC\Uzz9Z ! xUQb9zuL°gO°xz9zL°9QLbF‡°gOOUFU9Z y©”£—”ž°^°R¥ •° '°zUzZL° J˜¥”© ¦ ) I9zL°xC\UzzLI 'HFHPEHU

‹ OO‡° ##
°
 Ž OO‡° ##

° i° 3 n9QL°b\CLu°gO°zTL°xnLuxLILI°nZ9b°xLFzUgb° gu°;~z9FT\Lbz°
 

  y”©˜ ž°(#,° ˆ¢zTLu °9x°xnLFUOULI8° + uLzub°zg y©”£—”ž°^°R¥ • °J™¥”© ¥ °J^^< °pj°D ®°4,°d”­°GŒ§©œ”°JM 4.#° / K=zL°uLFLU‚LI 'HFHPEHU

! 
!

 !  ! !

1 I>zL°?qrugƒLI

)HEUXDU\ !  ! ! !
 ! ! 5 LOOLFzUL°I9zL°kO°@snugLI°_9zLuU9Z 2FWREHU

$ z‡tLI°eA`L -DPHV*6FRWW !! }Uz[L 'LUHFWRU'LYLVLRQRI3URJUDP2SHUDWLRQV !& uLaBuYx !  !  ! 

 




Revision: HCFA-PM-93-3 (MB) 74 TN No. SPA# 19-006 Supersedes TN No. 345 Approval Date February 6, 2020 Effective Date October 1, 2019 Distinction STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation 4.26 Drug Utilization Review Program 1927(g) 42 CFR 456.700 A. (1) The Medicaid agency meets the requirements of Section 1927(g) of the Act for a drug use review (DUR) program for outpatient drug claims. 1927(g)(1)(A) 1927(g)(1)(a) 42 CFR 456.705 (b) and 456.709(b) (2) The DUR program assures that prescriptions for outpatient drugs are: x Appropriate x Medically necessary x Are not likely to result in adverse medical results. B. The DUR program is designed to educate physicians and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, and patients or associated with specific drugs as well as: x Potential and actual adverse drug reactions x Therapeutic appropriateness x Overutilization and underutilization x Appropriate use of generic products x Therapeutic duplication x Drug disease contraindications x Drug-drug interactions x Incorrect drug dosage or duration of drug treatment x Drug-allergy interactions x Clinical abuse/misuse 1927(g)(1)(B) 42 CFR 456.703 (d) and (f) C. The DUR program shall assess data use against predetermined standards whose source materials for their development are consistent with peer- reviewed medical literature which has been critically reviewed by unbiased independent experts and the following compendia: x American Hospital Formulary Service Drug Information x United States Pharmacopeia-Drug Information x American Medical Association Drug Evaluations

Revision: HCFA-PM-93-3 (MB) 74a TN No. SPA # 19-006 Supersedes TN No. SPA 345 Approval Date February 6, 2020 Effective Date October 1, 2019 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation 4.26 Drug Utilization Review Program 1927(g)(1)(D) 42 CFR 456.703(b) D. DUR is not required for drugs dispensed to residents of nursing facilities that are in compliance with drug regimen review procedures set forth in 42 CFR 483.60. The State has never-the-less chosen to include nursing home drugs in: Prospective DUR Retrospective DUR. 1927(g)(2)(A) 42 CFR 456.705(b) E. 1. The DUR program includes prospective review of drug therapy at the point of sale or point of distribution before each prescription is filled or delivered to the Medicaid recipient. 1927(g)(2)(A)(i) 42 CFR 456.705 (b), (1)-(7)) 2. Prospective DUR includes screening each prescription filled or delivered to an individual receiving benefits for potential drug therapy problems due to: x Therapeutic duplication x Drug-disease contraindications x Drug-drug interactions x Drug-interactions with non-prescription or over-the-counter drugs x Incorrect drug dosage or duration of drug treatment x Drug allergy interactions x Clinical abuse/misuse 1927(g)(2)(A) (ii) 42 CFR 456.705 (c) and (d) 3. Prospective DUR includes counseling for Medicaid recipients based on standards established by State law and maintenance of patient profiles. 1927(g)(2)(B) 42 CFR 456.709 (a) F. 1. The DUR program includes retrospective DUR through its mechanized drug claims processing and information retrieval system or otherwise which undertakes ongoing periodic examination of claims data and other records to identify: x Patterns of fraud and abuse x Gross overuse x Inappropriate or medically unnecessary care among physicians, pharmacists, Medicaid recipients, or associated with specific drugs or groups of drugs.

Revision: HCFA-PM-93-3 (MB)

74b

TN No. SPA# 19-006 Supersedes TN No. 345 Approval Date February 6, 2020

Effective Date October 1, 2019

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation 4.26

Drug Utilization Review Program

927(g)(2)(C) 42 CFR 456.709 (b) F. 2. The DUR program assesses data on drug use against explicit predetermined standards including but not limited to monitoring for: x Therapeutic appropriateness x overutilization and underutilization x Appropriate use of generic products x Therapeutic duplication x Drug-disease contraindications x Drug-drug interactions x Incorrect drug dosage/duration of drug treatment x Clinical abuse/misuse

1927(g)(2)(D) 42 CFR 456.711 3. The DUR program through its State DUR Board, using data provided by the Board, provides for active and ongoing educational outreach programs to educate practitioners on common drug therapy problems to improve prescribing and dispensing practices.

1927(g)(3)(A) 42 CFR 456.716(a) G. 1. The DUR program has established a state DUR Board either:

Directly,

or Under contract with a private organization 1927(g)(3)(B) 42 CFR 456.716 (A) and (B) 2. The DUR Board membership includes health professionals (one-third licensed actively practicing pharmacists and one"', third but no more than 51 percent licensed and actively practicing physicians) with knowledge and experience in one or more of the following: x Clinically appropriate prescribing of covered outpatient drugs. x Clinically appropriate dispensing and monitoring of covered outpatient drugs . x Drug use review, evaluation and intervention. x Medical quality assurance. 927(g)(3)(c) 42 CFR 456.716 (d)

3. The activities of the DUR Board include: x Retrospective DUR, x Application of Standards as defined in section 1927(g)(2)(C), and x Ongoing interventions for physicians and pharmacists targeted toward therapy problems or individuals identified in the course of retrospective DUR.

Revision: HCFA-PM-93-3 (MB)

74c

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation 4.26

Drug Utilization Review Program

TN No. SPA# 19-006 Supersedes TN No. 345 Approval Date February 6, 2020

Effective Date October 1, 2019

1927(g)(3)(C) 42 CFR 456.711 (a)-(d) G. 4. The interventions include in appropriate instances: x Information dissemination x Written , oral, and electronic reminders x Face-to-Face discussions x Intensified monitoring/review of prescribers/dispensers 1927(g)(3)(D) CFR 456.712 (A) and (B) H. The State assures that it will prepare and submit an annual report to the Secretary, which incorporates a report from the State DUR Board, and that the State will adhere to plans, steps, procedures as described in the report. 1927 (h)(1) 42 CFR 456.722

I. 1. The State establishes, as its principal means of processing claims for covered outpatient drugs under this title, a point-of-sale electronic claims management system to perform on-line:

• real time eligibility verification • claims data capture • adjudication of claims • assistance to pharmacists, etc. applying for and receiving payment. 1927(g)(2)(A)(i) 42 CFR 456.705(b)

2. Prospective DUR is performed using an electronic point-of-sale drug claims processing system. 1927 (j)(2)

J. Hospitals which dispense covered outpatient drugs are exempted from the drug utilization review requirements of this section when facilities use drug formulary systems and bill the Medicaid program no more than the hospital's purchasing cost for such covered outpatient drugs.

Revision: HCFA-PM-93-3 (MB)

74d

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation 4.26

Drug Utilization Review Program

TN No. SPA# 19-006 Supersedes TN No. 345 Approval Date February 6, 2020

Effective Date October 1, 2019

1902(a)(85) K. Section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) a. Claim Review Limitations i. Prospective Safety Edits on opioids including days’ supply, early refills, duplicate fills, and quantity limits for clinical appropriateness. ii. Maximum Daily Morphine Milligram Equivalents (MME) Safety Edits: A maximum dosing limit on opioids limits the daily morphine milliequivalent (as recommended by clinical guidelines) and regularly reviewed by the state. iii. Concurrent Utilization Alerts: Prospective drug-to-drug interaction alerts require a response from the pharmacy if an opioid and benzodiazepine or opioid and antipsychotic are being dispensed within an overlapping period. Retrospective reviews are performed on an ongoing periodic basis to alert prescribers of these alerts. iv. Comprehensive Retrospective DUR is performed on opioid prescriptions on an ongoing periodic basis.

b. Programs to monitor antipsychotic medications to children i. Antipsychotic agents are reviewed for age appropriateness, duplicate therapy, and adverse effects in children based on the FDA product approval and clinical guidelines.

c. Fraud and abuse identification i. DMMA receives monthly data of recipient prescriptions from the Prescription Monitoring Program for review, analysis and investigation for additional steps to be taken, such as audits or client lock-in to a specific pharmacy, when clinical concerns are established.

Table of Contents

State/Territory Name: Delaware State Plan Amendment (SPA) #: 19-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 3) Approved SPA Pages

Records / Submission Packages - View All DE - Submission Package - DE2019MS0001O - (DE-19-0008) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID DE2019MS0001O Program Name N/A SPA ID DE-19-0008 Version Number 4 Submitted By Nicole Cunningham Package Disposition Priority Code P2 Submission Type OŰcial State DE Region Philadelphia, PA Package Status Approved Submission Date 12/23/2019 Approval Date 3/19/2020 2:09 PM EDT Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Philadelphia Regional OŰce 150 S. Independence Mall West Suite 216 The Public Ledger Building Philadelphia, PA 9106-34991 Division of Medicaid and Children's Health Operations March 19, 2020 Stephen Groſ Director, DMMA Division of Medicaid and Medical Assistance 1901 N. DuPont Highway P.O. Box 906 New Castle, DE 19720 Re: Approval of State Plan Amendment DE-19-0008 Dear Stephen Groſ: On December 23, 2019, the Centers for Medicare and Medicaid Services (CMS) received Delaware State Plan Amendment (SPA) DE-19-0008 to exempt temporary census worker income for certain optional eligibility groups which include: Individuals Eligible for Cash Except for Institutionalization, Individuals in Institutions Eligible under a Special Income Level and Ticket to Work Basic.. We approve Delaware State Plan Amendment (SPA) DE-19-0008 on March 19, 2020 with an eſective date(s) of October 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact michael cleary at michael.cleary@cms.hhs.gov. Sincerely, James Scott Director Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID N/A SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date N/A State Information State/Territory Name: Delaware Medicaid Agency Name: Division of Medicaid and Medical Assistance Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID N/A SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date N/A SPA ID and Eſective Date SPA ID DE-19-0008 Reviewable Unit Proposed Eſective Date Superseded SPA ID Non-MAGI Methodologies 10/1/2019 New Mandatory Eligibility Groups 10/1/2019 DE-17-0010 Optional Eligibility Groups 10/1/2019 DE-17-0010 Individuals Eligible for Cash Except for Institutionalization 10/1/2019 DE-92-0300 Individuals in Institutions Eligible under a Special Income Level 10/1/2019 DE-92-0300 Ticket to Work Basic 10/1/2019 DE-09-005 Page Number of the Superseded Plan Section or Attachment (If Applicable): Supplement 8A to Attachment 2.6 A Page 2

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID N/A SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives The Centers for Medicare and Medicaid Services (CMS) allows states to exclude the earned income of temporary census workers for purposes of eligibility. The Delaware state plan currently excluded earnings of temporary census workers to ensure that individuals (and their families), who are temporarily hired by the Census Bureau to assist in Census activities, do not lose eligibility for Medicaid because of the income they receive from employment with the Census Bureau. The purpose of this amendment is to add additional eligibility groups to that exclusion. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2021 $0 Second 2022 $0 Federal Statute / Regulation Citation CMS, Informational Bulletin dated July 3, 2019, Temporary Census Income and Medicaid and CHIP Eligibility

Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID N/A SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date N/A Governor's OŰce Review No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID N/A SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: Upload copies of public notices and other documents used Name Date Created Public Notice 12/9/2019 8:05 AM EST Upload with this application a written summary of public comments received (optional) Name Date Created No items available Indicate the key issues raised during the public comment period (optional) Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Public Hearing or Meeting Other method Access Quality Cost Payment methodology Eligibility Beneţts Service delivery Other issue

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID N/A SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID New User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831.

A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the ţnancial methodologies of either the SSI program or the AFDC program in eſect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group.

Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID New User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 C. Financial Responsibility of Relatives 1. In determining ţnancial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in eſect as of July 16, 1996. (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID New User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identiţed below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state deţnes family size for one or more of the following FPL eligibility groups to include others beyond those identiţed in D.1. and D.2. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID New User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 E. Use of MAGI-like Methodologies 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in eſect as of July 16, 1996. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID New User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that would be deducted in determining eligibility under SSI. 2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID New User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 G. Additional Information (optional)

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-17-0010 System-Derived SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneţciaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualiţed Medicare Beneţciaries NEW Qualiţed Disabled and Working Individuals NEW Speciţed Low Income Medicare Beneţciaries NEW Qualifying Individuals NEW

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-17-0010 System-Derived SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Yes No

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-17-0010 System-Derived SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 NEW Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children NEW Individuals above 133% FPL under Age 65 APPROVED Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Yes No

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for Cash Except for Institutionalization APPROVED Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneţciaries NEW Individuals in Institutions Eligible under a Special Income Level APPROVED PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic APPROVED Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-17-0010 System-Derived SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. Yes No

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-17-0010 System-Derived SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Individuals who would be eligible for federal cash assistance or an optional state supplement, except for institutionalization. Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 The state covers the optional Individuals Eligible for Cash Except for Institutionalization eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria:

1. Are in a medical institution.

2. Would meet the eligibility requirements for at least one of the following cash assistance programs, but for the lower income standards used to determine eligibility for institutionalized individuals: a. SSI b. Optional State Supplement c. AFDC

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. In calculating household income and resources for populations for which AFDC is the most closely related program, the following methodology(ies) are used: 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Exclude the earned income of temporary census workers for purposes of eligibility 4. Less restrictive methodologies are used in calculating countable resources. a. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No Census Bureau wages are disregarded. Yes No

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 D. Income Standard Used The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Individuals who are in medical institutions for at least 30 consecutive days who are eligible under a special income level. Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 The state covers Individuals in Institutions Eligible under a Special Income Level in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Have been in a medical institution for at least 30 consecutive days. 2. Have income at or below a standard described in section D.

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 B.Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 C. Financial Methodologies 1. In calculating household income, the methodologies of the most closely related cash assistance program are used, except that disregards are not applied. 2. In calculating household resources, the methodologies of the most closely related cash assistance program are used Please refer as necessary to Non- MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Yes No A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 D. Income Standard Used The income standard for this group is: 250.00% 1. 300% of the SSI Federal Beneţt Rate (FBR) for an individual 2. Other lower income level a. Percent of the SSI FBR: b. Dollar amount:

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 E.Resource Standard Used The resource standard for this group is the one used for the most closely-related cash assistance program.

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-92-0300 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 F.Additional Information (optional) Earned income of temporary census workers for purposes of eligibility will be excluded.

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Individuals between ages 16 and 64 with a disability, who have earned income. Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-09-005 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 The state covers the optional Ticket to Work basic eligibility group in accordance with the following provisions:

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-09-005 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are at least age 16 but less than 65 years of age. 2. Have earned income. 3. But for earned income, meet the SSI deţnition of disability. 4. Have income and resources that do not exceed the standards established by the state.

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-09-005 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income and resources. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Exclude the earned income of temporary census workers for purposes of eligibility Name of methodology: Description: Unearned income disregard For individuals in the TWWIIA Basic eligibility group, the unearned income disregard increases each year and is it solely based on the annual COLA. The disregard amount for 2020 $1,110. 3. Less restrictive methodologies are used in calculating countable resources. Yes No Census Bureau wages are disregarded. The following less restrictive methodologies are used: Yes No

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-09-005 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 C. Income Standard Used The income standard for this group is: FPL 275.00% 1. No income standard 2. A percentage of the federal poverty level: 3. A percentage of the SSI Federal Beneţt Rate: 4. A dollar amount 5. Other

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-09-005 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 D. Resource Standard Used The resource standard for this group is: 1. No resource standard 2. SSI resource standard 4. A dollar amount higher than the SSI resource standard

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-09-005 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 E. Premiums and Cost Sharing Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan.

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | DE2019MS0001O | DE-19-0008 Package Header Package ID DE2019MS0001O Submission Type OŰcial Approval Date 3/19/2020 Superseded SPA ID DE-09-005 User-Entered SPA ID DE-19-0008 Initial Submission Date 12/23/2019 Eſective Date 10/1/2019 F. Additional Information (optional) Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections as well as page 12o of Attachment 2.6 of the eligibility section of the state plan.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 4/6/2020 1:19 PM EDT

Table of Contents State/Territory Name: Delaware State Plan Amendment (SPA) #: 20-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group Sincerely, James G. Scott, Director Division of Program Operations cc: Nicole Cunningham, State Plan Coordinator Kimberly Xavier, State Senior Policy Administrator Glyne Williams, State Chief Policy, Planning and Quality James G. Scott, Director Division of Program Operations Nicole McKnight, CMCS, Branch Manager, Division of Program Operations Talbatha Myatt, CMCS, State Lead, Division of Program Operations 6HSWHPEHU Mr. Stephen M. Groff, Director Division of Medicaid and Medical Assistance P.O. Box 906 New Castle, DE 19720-0906 Dear Mr. Groff: We are pleased to inform you of the approval of Delaware State Plan Amendment (SPA) 20-0001. This amendment amends Title XIX Medicaid State Plan to add adult dental services. Enclosed is a copy of the approved SPA pages and the signed CMS-179 form. The effective date of this amendment is October 1, 2020. If you have any questions regarding this SPA, please contact Talbatha Myatt at (215) 861-4259. She can also be reached at Talbatha.Myatt@cms.hhs.gov.

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED

COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 2 0 0 0 1 Delaware October 1, 2020 ✔ Title XIX Medicaid State Plan 2021 7,559,702 2022 7,937,687 3.1-A Page 4, 3.1-A Page 4b Addendum, 4.19-B Page 19 3.1-A Page 4, 3.1-A Page 4b Addendum, 4.19-B Page 19 Adult Dental Services ✔ Stephen M. Groff Director Stephen M. Groff, Director, DMMA, P.O. Box 906 New Castle, DE19720 8/27/20  
 

          2FWREHU -DPHV*6FRWW 'LUHFWRU'LYLVLRQRI3URJUDP2SHUDWLRQV  $XJXVW

Attachment 3.1-A Page 4 TN No. SPA #ϮϬͲϬϬϬϭ Supersedes TN No. SPA #402 Approval Date Effective Date͗KĐƚŽďĞƌϭ͕ϮϬϮϬ STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 9. Clinic Services Provided: No limitations With limitations* Not provided. 10. Dental Services Provided: No limitations With limitations* Not provided. 11. Physical Therapy and related services a. Physical therapy Provided: No limitations With limitations* Not provided. b. Occupational therapy Provided: No limitations With limitations* Not provided. c. Services for individuals with speech, hearing, and language disorders (provider by or under the supervision of a speech pathologist or audiologist). Provided: No limitations With limitations* Not provided. ƵŐƵƐƚϮϴ͕ϮϬϮϬ

Attachment 3.1-A Page 4b Addendum TN No. SPA #20-0Ϭ01 Supersedes TN No. SPA #14-001 Approval Date Effective Date October1, 2020 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Health care professionals that provide the above services at the SBWCs include: physicians, nurse practitioners, licensed clinical social workers, certified and licensed drug and alcohol counselors, certified sexual assault counselors and registered dieticians. Licensure requirements for each practitioner type are specified in the Title 24 of the Delaware Code, Professions and Occupations and in the Delaware Administrative Code. 10. Dental Clinic Services for individuals younger than age 21 are only available as ESPDT services. Dental services for individuals 21 and older are limited to: x Diagnostics x Preventive x Restorative (Basic) x Periodontics x Prosthodontics Repairs x Oral and maxillofacial Surgery Limitations on dental services for individuals 21 and older: x Payments for dental care treatments are subject to a $3 recipient copay x Annual maximum Adult Dental benefit may not exceed $1,000 per year; except that an additional $1,500 may be authorized on an emergency basis ƵŐƵƐƚϮϴ͕ϮϬϮϬ

Attachment 4.19-B Page 19 TN No. SPA #20-00Ϭ1 Supersedes TN No. SPA #17-009 Approval Date ___________ Effective Date KĐƚŽďĞƌ1, 2020 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES- OTHER TYPES OF CARE Dental Services Dental Services are reimbursed as follows. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both government and private providers. Dental Services - Effective for dates of service on or after July 1, 2017, Delaware pays for dental services at the lower of: x the provider's billed amount that represents their usual and customary charge; or x the Delaware Medicaid maximum allowed amount per unit per covered dental procedure code according to a published fee schedule. The Delaware Medicaid dental fee schedule will be developed based on the National Dental Advisory Service (NDAS) annual Comprehensive Fee Report. For each covered dental procedure code, Delaware's maximum allowable amount will be computed as a percentage of the NDAS published national fee. Delaware will rebase its dental fee schedule rates each time the NDAS publishes a new survey. Preventive General Dental Services shall be paid at 61.00% of the NDAS 70th percentile amounts Restorative General Dental Services shall be paid at 84.60% of the NDAS 70th percentile amounts Adjunctive General Dental Services shall be paid at 72.24% of the NDAS 70th percentile amounts Specialty Dental Services shall be paid at 68.80% of the NDAS 80th percentile amounts Access-Based Fees for certain specialty procedure codes may be established to account for deficiencies in rates that are based on the NDAS fee schedule percentages above relating to the adequacy of access to health care services for Medicaid clients. The maximum allowed amounts for procedure codes not included in the NDAS fee schedule or for new procedure codes established after the annual NDAS fee schedule is published will be based on the existing rates for similar existing services. If there are no similar services the maximum allowed amount is set at 80% of the estimated average charge until a rate can be established based on the NDAS fee schedule. The dental fee schedule is available on the Delaware Medical Assistance Portal https://medicaid.dhss.delaware.gov ƵŐƵƐƚϮϴ͕ϮϬϮϬ

Table of Contents State/Territory Name: Delaware State Plan Amendment (SPA) #: 20-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 2, 2020 Stephen Groff Director Division of Medicaid Medical Assistance P.O. Box 906 New Castle, DE 19720 Re: Delaware State Plan Amendment (SPA) 20-0002 Dear Mr. Groff: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0002. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.

Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of Delaware requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. These waivers or modifications of the requirements related to SPA submission timelines, DQG public notice apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Delaware’s Medicaid SPA Transmittal Number 20-0002 is approved effective March 1, 2020. 3OHDVH QRWH WKDW WKH HIIHFWLYH GDWHV IRU FHUWDLQ SUHPLXP DQG FRVW VKDULQJ SURYLVLRQV DV VSHFLILHG LQ 6HFWLRQ & RI WKLV DPHQGPHQW DUH HLWKHU 0DUFK   RU $SULO   Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Talbatha Myatt at 215-861-4259 or by email at Talbatha.Myatt@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Delaware and the health care community. Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures 6LQFHUHO\ Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020 05.27 09:04:09 -04'00'

DocuSign Envelope ID: 0E77934A 5754 4315 ASED 3A79949194C9

DEEPA TMIEN! Ur MEAL MAND NUMAN OCHVILES

CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB No. 0938-0193

1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 20 002 — Delaware STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 03/1/2020 5. TYPE OF PLAN MATERIAL (Check One) [_]new sTATE PLAN [[] AMENDMENT To BE CONSIDERED AS NEW PLAN AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION Section 1135 SSA, Title 19 of the Social Security Act

7. FEDERAL BUDGET IMPACT a. FFY_2020 $0 b. FFY_2021 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7.4

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

New

10. SUBJECT OF AMENDMENT

Medicaid Disaster Relief

11. GOVERNOR'S REVIEW (Check One)

] GOVERNOR’S OFFICE REPORTED NO COMMENT H COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

[VJoTHER, AS SPECIFIED:

NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL

13. TYPED NAME Stephen M. Groff

14. TITLE Director

15. DATE SUBMITTED4/20/2020

16. RETURN TO

Stephen M. Groff, Director, DMMA, P.O. Box 906 New Castle, DE19720

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED April 20, 2020

18. DATE APPROVED May 27, 2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL March 1, 2020

20. SIGNATURE OF REGIONAL OFFICIAL

Anne M. Costello -S geialy Sone by hoe M. Cosi

21. TYPED NAME

Anne Marie Costello

Date: 2020.05.27 00-04-40 0400 22. TITLE Deputy Director Center for Medicaid & CHIP Services

23. REMARKS

DE requested pen and ink change to update proposed effective date to March 1, 2020 in Box #4 and update to Box #15 Date Submitted to reflect state's initial submission date of April 20, 2020

FORM CMS-179 (07/92)

Instructions on Back

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW Approval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 _X____ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X___ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X___ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates).

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW ƉƉƌŽǀĂů ĂƚĞ͗ DĂLJ Ϯϳ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ c. _____ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of state] Medicaid state plan, as described below: Please describe the modifications to the timeline. Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies:

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW pproval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 Less restrictive resource methodologies: 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods.

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW Approval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: DHSS suspends all copayments for all beneficiaries effective March 26, 2020. 2. _X____ The agency suspends enrollment fees, premiums and similar charges for: a. _X____ All beneficiaries b. _____ The following eligibility groups or categorical populations:

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW Approval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 DHSS suspends all premiums for all beneficiaries effective April 1, 2020. 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _____ The agency makes the following adjustments to benefits currently covered in the state plan: 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe.

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW Approval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 Telehealth: 5. __X___ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Telehealth services may be delivered in any of the following manners: Interactive Communication (as described in the approved state plan) is the preferred method of telehealth services. Telephonic Services, Store and Forward, and Remote Patient Monitoring are acceptable modes to deliver telehealth only if the mode of delivery is medically appropriate for the underlying covered service and the provision of the telehealth services can appropriately reduce the need for on-site or in-office visits. Drug Benefit: 6. __X___ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. - Amend prior authorization policy to increase the emergency fill policy from 72 hours to 14 days for an emergency fill. - Remove quantity limits on Nebulizer solutions and inhalers. 7. __X___ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. __X___ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available.

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW Approval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology: a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): b. _____ Other: Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: Please list all that apply. a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: Please describe. ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules –

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW Approval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. Payment for services delivered via telehealth: 3. __X___ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. __X___ Differ from current state plan provisions governing reimbursement for telehealth; Payment will be made for Telephonic Services, Store and Forward, and Remote Patient Monitoring, in addition to already reimbursable interactive telecommunication services. DMMA will reimburse providers for the provision of telehealth in the same manner that providers are reimbursed for face-to-face services. The State has added a COVID-19 Virtual Healthcare Expansion Fee Schedule for DMAP Fee-for-Service providers. Payment for these will sunset and end at the end of the public health emergency (PHE). d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes: Please describe.

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW Approval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information 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 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. 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. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection

State/Territory: Delaware TN: 20-0002 Supersedes TN: NEW Approval Date: May 2ϳ, 2020 Effective Date: March 1, 2020 burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870.

__________________________________________________________________________________ Table of Contents State/Territory Name: Delaware State Plan Amendment (SPA) #: 21-0009 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 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group December 2 , 2021 Mr. Stephen Groff, Director Division of Medicaid and Medical Assistance P.O. Box 906 New Castle, DE 19720-0906 RE: 21-0009 Pathways to Employment (MAT) Delaware’s §1915(i) home and community-based services (HCBS) state plan amendment (SPA) Dear Mr. Groff: The Centers for Medicare & Medicaid Services (CMS) is approving the state’s request to amend its 1915(i) state plan home and community-based services (HCBS) benefit, transmittal number 21-0009. The effective date for this amendment is January 1, 2022. With this amendment, the state is modifying the targeting criteria, by maintaining the minimum age as fourteen (14) and removing the maximum age of twenty-five (25). Enclosed are the following approved SPA pages that should be incorporated into your approved state plan: • Attachement 3.1-I, Pages 1-58 The state has identified its intent to use money realized from section 9817 of the American Approval of this action does not constitute approval of the state’s spending The state must have an approved spending plan to use the money realized from section 9817 of the ARP. It is important to note that CMS’ approval of this change to the state’s 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.

Mr. Groff– Page 2 Sincerely, George P. Failla, Jr., Director Division of HCBS Operations and Oversight Enclosure cc: Deanna Clark, CMCS Jerica Bennett, CMCS Tabaltha Myatt, CMCS

DocuSign Envelope ID: 678E53E2-25EB-4204-96E4-CC02359E0DEE

DEPAHTIMEN! UF MEALIN ANU NUMAN SEHVILES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED. OMB No. 0938-0193

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

1. TRANSMITTAL NUMBER 2. STATE

21 0 —o0d 0 9

Delaware

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

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

4. PROPOSED EFFECTIVE DATE

January 1, 2022

5. TYPE OF PLAN MATERIAL (Check One) [_]new stare PLAN

[_JamenpMeNT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION Title XIX Medicaid State Plan

7. FEDERAL BUDGET IMPACT a. FFY_2022 $ 284,105

b. FFY_2023 $ 1,395,330

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

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

10. SUBJECT OF AMENDMENT

1915(i) HCBS State Plan Option Amendment Pathways

11. GOVERNOR’S REVIEW (Check One)

[—]GoveRNor’s OFFICE REPORTED NO COMMENT [_] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED [_]NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED:

a OF STATE AGENCY OFFICIAL

13. TYPED NAME Lisa Zimmerman, Deputy Director, for Stephen M. Groff, Director

14. TITLE Director

1% PATREY EMITTER pm et

16. RETURN TO

Stephen M. Groff, Director, DMMA, P.O. Box 906 New Castle, DE 19720

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED 10/1/2021

18. DATE APPROVED 12/23/2021

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL 1/1/2022

21. TYPED NAME

George P. Failla, Jr.

22. TITLE

Director, Division of HCBS Operations and Oversight

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 1 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

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):

Employment Navigation

Financial Coaching Plus

Benefits Counseling

Non-Medical Transportation

Orientation, Mobility, and Assistive Technology

Career Exploration and Assessment

Small Group Supported Employment

Individual Supported Employment

Personal Care (including option for self-direction)

2. Concurrent Operation with Other Programs. (Indicate whether this benefit will operate concurrently with another Medicaid authority): Select one: Not applicable X 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.

X 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:

This 1915(i) SPA will run concurrently with the State’s approved 1915(b)(4)

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 2 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Pathways waiver for the purposes of limiting providers for Employment Navigation and Transportation Services.

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

This 1915(i) SPA will run concurrently with the State’s approved 1915(b)(4) Pathways waiver for the purposes of limiting providers for Employment Navigation and Transportation Services.

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:

X A program authorized under §1115 of the Act. Specify the program:

This 1915(i) SPA will run concurrently with the State’s approved 1115 waiver, the Diamond State Health Plan/Diamond State Health Plan Plus.

3. State Medicaid Agency (SMA) Line of Authority for Operating the State plan HCBS Benefit. (Select one): 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): X 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. The benefit will be administered by the following Division within the Delaware Department of Health and Social Services, the Single State Medicaid Agency. Developmental Disabilities Services The State plan HCBS benefit is operated by (name of agency)

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 3 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

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: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 4 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

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

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 5 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

(Specify, as numbered above, the agencies/entities (other than the SMA) that perform each function): For items 7 and 8 above, Delaware contracts with a provider relations agent to perform specific administrative functions. Specific functions performed by this contractor include the ongoing enrollment of service providers, execution of the Medicaid provider agreement, and the verification of provider licensure, where applicable, on an annual basis.

Provider relations functions include:

enrolling service providers

executing provider agreements

For participant directed services, the contracted Fiscal Management entity will execute and hold provider agreements for providers employed by the individual receiving services.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 6 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

(By checking the following boxes the State assures that): 5. X 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:

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

financially responsible for the individual

empowered to make financial or health-related decisions on behalf of the individual

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. X 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. X 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. X 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: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 7 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

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 Year 1 January 1, 2020 December 31, 2020 575 Year 2 January 1, 2021 December 31, 2021 650 Year 3 January 1, 2022 December 31, 2022 725 Year 4 January 1, 2023 December 31, 2023 800 Year 5 January 1, 2024 December 31, 2024 875 2. X 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. X 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): X The State does not provide State plan HCBS to the medically needy. The State provides State plan HCBS to the medically needy. (Select one):

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 8 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

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 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): X Directly by the Medicaid agency By Other (specify State agency or entity under contract with the State Medicaid agency):

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): For all target groups, the minimum qualifications for independent individuals performing initial evaluations for eligibility are as follows:

State classification of Senior Social Worker/Case Manager or equivalent standards for education and experience, with additional disability-specific training provided as needed to effectively perform evaluation. Minimally, this additional training will include training in assessment of individuals whose physical, cognitive, or mental conditions trigger a potential need for home and community-based services and supports, and current knowledge of available resources, service options, providers, and best practices to improve health and quality of life outcomes. For all target groups, reevaluations are conducted by individuals holding an associate’s degree or higher in a behavioral, social sciences, or a related field OR experience in health or human services support which includes interviewing individuals and assessing personal, health, employment, social or financial needs in accordance with program requirements.

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

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 9 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

this determination. If the reevaluation process differs from the evaluation process, describe the differences: To facilitate access to the benefit, Delaware will be utilizing the Aging and Disability Resource Center (ADRC) as an initial no wrong door entry point for individuals new to the delivery system. Individuals already enrolled or identified as eligible for Pathways through an operating division do not need to go through the ADRC before the process initiates. The ADRC will do a preliminary screening to determine interest in work and likely target group eligibility. This screen will collect information on employment interest, available service history information, and a preliminary review of target group. The ADRC will not actually perform an evaluation against the needs-based criteria but will facilitate the performance of the evaluation by the appropriate state entity by gathering information. The ADRC will perform a referral, conveying all applicable information to the Assessment manager within the division responsible for conducting evaluation. Referrals will occur on an ongoing basis, as individuals contact the ADRC. Protocols for referrals will be developed and overseen by the administering division and DMMA, with the aim being a seamless experience for individuals accessing the Pathways program. The Assessment Manager, who may also serve as the conflict-free Employment Navigator conducting evaluations, assessment and plan of care development activities, will ensure the completion of the formal initial evaluation of whether the individual meets the targeting and needs-based criteria. This evaluation will include a thorough review of documentation such as the individual’s medical history, visual acuity documented in accordance with state requirements, functional support needs related to activities of daily living (ADL), and cognitive and adaptive functioning, as applicable to the needs-based criteria for the appropriate target group. The single state Medicaid agency will make final determinations regarding program eligibility. Reevaluations will be conducted by a qualified professional as described in Item #2 above and will include a review to verify that individuals continue to meet the applicable needs-based criteria.

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

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 10 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

5. X 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): Individuals who have a desire to work in a competitive work environment and for which the services provided herein are not otherwise available to the individual under either special education and related services as defined in section 602(16) and (17) of the Education of the Handicapped Act (20 U.S.C. 1401(16) and (17)) or vocational rehabilitation services available to the individual through a program funded under section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730). Group A Group B Group C Individuals who are Visually Impaired Individuals with Physical Disabilities

Individuals with Intellectual Disabilities, Autism Spectrum Disorders or Asperger’s Syndrome Individuals who need ongoing physical or verbal assistance with performing one ADL and who are at risk of being unable to obtain or sustain competitive employment without this assistance. Individuals whose physical condition affects their ability to live independently, who need ongoing assistance with at least one ADL and who are at risk of being unable to sustain competitive employment without supports. Individuals with significant limitations in adaptive function and/or who need assistance with at least one area of ADL, and/or who have difficulty understanding and interpreting social situations and who are unlikely to be able to obtain or sustain competitive employment without supports.

6. X 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: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 11 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

State plan HCBS needs- based eligibility criteria NF (& NF LOC** waivers) ICF/IID (& ICF/IID LOC waivers) Applicable Hospital* (& Hospital LOC waivers) Group A Individuals who are Visually Impaired Individuals who need ongoing physical or verbal assistance with performing one ADL and who are at risk of being unable to obtain or sustain competitive employment without this assistance.

Group B Individuals with Physical Disabilities

Individuals whose physical condition affects their ability to live independently, who need ongoing assistance with at least one ADL and who are at risk of being unable to sustain competitive employment without supports.

Group C Individuals with Intellectual Disabilities, Autism Spectrum The individual must have deficits in at least two ADLs. Individual: 1) Has a diagnosis of intellectual or developmental disability and has been deemed eligible for services through the Division of Developmental Disabilities Services (DDDS). 2) Has been determined to meet ICF/IID level of care based on an assessment completed by a Qualified Intellectual Disability Professional that indicates the individual requires assistance in at least two of the following domains: ADLs, safety, household activities, community access, maintaining relationships, health maintenance, communication, psychological and active treatment services for maximum independence. The diagnosis of Intellectual or Developmental Disability is determined An Acute Hospital LOC is assigned to individuals that require the highest intensity of medical and nursing services provided within a structured environment providing 24-hour skilled nursing and medical care

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 12 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Disorders or Asperger’s Syndrome. Individuals with significant limitations in adaptive function and/or who need assistance with at least one area of ADL, and/or who have difficulty understanding and interpreting social situations and who are unlikely to be able to obtain or sustain competitive employment without supports.

based on: 1) The administration of the Adaptive Behavior Assessment System (ABAS) or Vineland Adaptive Behavior Scale (VABS) by a licensed psychologist, certified school psychologist or a licensed physician who practices psychiatry who certifies that the individual/applicant has significantly sub-average intellectual functioning or otherwise meets the following criteria: b. An adaptive behavior composite standard score of two or more standard deviations below the mean; or a standard score of two or more standard deviations below the mean in one or more component functioning areas (ABAS: Conceptual, Social; Practical: VABS: Communication; Daily living Skills, Social). *Long Term Care/Chronic Care Hospital

**LOC= level of care

7. X 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)): Delaware defines the following target groups: Group A Group B Group C

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 13 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Individuals who are Visually Impaired Individuals with Physical Disabilities Individuals with Intellectual Disabilities, Autism Spectrum Disorders or Asperger’s Syndrome Individuals age 14 and above determined by a doctor of optometry or ophthalmology to be: totally blind (no light perception), legally blind (20/200 in the better eye with correction, or a field restriction of 20 degrees or less) or severely visually impaired (20/70 to 20/200 in the better eye with correction). Individuals age 14 and above with a physical disability; whose physical condition is anticipated to last 12 months or more. Individuals age 14 and above with intellectual developmental disorder attributed to one or more of the following: IQ scores of two standard deviations below the mean, autism spectrum disorder, Asperger’s disorder, Prader-Willi Syndrome, as defined in the APA Diagnostic and Statistical Manual, brain injury or neurological condition related to IDD that originates before age 22.

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

(By checking the following box the State assures that): 8. X 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):

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 14 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

X 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. X 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: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 15 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Settings in which Pathways participants live and where they receive 1915(i) HCBS meet the HCB settings requirements at 441.710(a)-(b). Pathways participants typically live in their own home, the home of a family member (owned or leased by the participant/participant’s family for personal use) or a provider managed residential setting. Individuals living in a Medicaid-funded provider managed setting can only be enrolled in Pathways if the setting meets the requirements for HCBS residential settings, as articulated in the HCBS Settings Rule. As part of the evaluation process for entry into the program, Employment Navigators will determine where applicants reside and will not enroll any applicant that lives in a setting that does not comply with the requirements of the HCBS Settings Rule. Pathways participants will receive HCBS in a variety of settings, including but not limited to their homes or home of a family member, community settings (such as libraries), provider offices, and worksites. We have concluded that participant homes and community settings are compliant with HCB settings requirements as a result of the following: Homes are owned or leased by the participant/participant’s family for personal use Participant rights are respected Participant has access to the community We have determined that provider offices and worksites are compliant with HCB settings requirements as a result of the following: The setting facilitates access to the community The setting facilitates interaction with non-disabled, non-Medicaid individuals The provider meets all qualifications prior to service delivery, including training that emphasizes participant rights, privacy, dignity and respect Provider offices and worksites will be inspected as part of the provider approval process By its very nature, Supported Employment and Group Supported Employment will be considered to be compliant with HCB setting requirements because that service is delivered in the member’s place of work. As applicable, Delaware will use the criteria above to monitor continued compliance with HCB settings requirements for both residences and settings where participants receive HCBS on an ongoing basis. As part of their routine monitoring, Employment Navigators will ask questions to ensure participants continue to reside in HCBS settings and also receive Pathways services in settings that are compliant with HCB settings requirements. This monitoring may include participant and provider surveys as well as site reviews. Participants found to reside in non-compliant settings will be dis-enrolled from Pathways. Non-compliant HCB settings where HCBS are provided will no longer be allowed as service sites. When this applies to a provider setting or worksite, the provider will be instructed that it cannot provide the service in that site and must either provide services in a compliant setting or be removed as a qualified provider of HCBS.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 16 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Person-Centered Planning & Service Delivery (By checking the following boxes the state assures that): 1. X 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. X Based on the independent assessment, there is a person-centered service plan for each individual determined to be eligible for the State plan HCBS benefit. The person-centered service plan is developed using a person-centered service planning process in accordance with 42 CFR §441.725(a), and the written person-centered service plan meets federal requirements at 42 CFR §441.725(b). 3. X 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): Face-to-Face Assessments are conducted by Employment Navigators employed by the State (see Provider Qualifications for the Employment Navigator service under “Services”). These individuals must have a minimum of an associate’s degree or higher in a behavioral, social sciences or a related field OR experience in health or human services support, which includes interviewing individuals and assessing personal, health, employment, social or financial needs in accordance with program requirements. Individuals performing Face-to- Face Assessments will also receive training in assessment of individuals whose physical, cognitive, or mental conditions trigger a potential need for home and community-based services and supports, and current knowledge of available resources, service options, providers, and best practices to improve health and quality of life outcomes. 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 person-centered service plan required as per 42 CFR 441.725 may hereafter be referred to in the SPA as the “person-centered employment plan” or simply the “employment plan”. Person- centered employment plan development will be conducted by Employment Navigators employed by the State (see Provider Qualifications for the Employment Navigator service under “Services”. These individuals must have a minimum of an associate’s degree or higher in a behavioral, social sciences or a related field OR having experience in health or human services support, which includes interviewing individuals and assessing personal, health, employment, social or financial needs in accordance with program requirements. Individuals who develop the person-centered employment plan will also receive training in assessment of individuals whose physical, cognitive, or mental conditions trigger a potential need for home and community-based services and supports, and current knowledge of available resources, service options, providers, and best practices to improve health and quality of life outcomes.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 17 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

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 Employment Navigator will actively support the participant in the development of their person-centered employment plan. The process will: 1. Include people chosen by the participant. 2. Provide necessary information, in a manner understandable to the participant, and support for the participant to ensure that he/she directs the process to the maximum extent possible and is empowered to make informed choices and decisions. 3. Be timely and be scheduled at times and locations of convenience to the participant. 4. Reflect cultural considerations of the participant. 5. Include strategies for solving conflict or disagreement within the process, including clear conflict-of-interest guidelines for all planning participants. 6. Offer the full array of choices to the participant regarding the services and supports they receive and from whom. 7. Include a method for the participant to request updates to the plan. Participants will receive information about the employment planning process and available supports and information from the Employment Navigator in writing, verbally and via the Pathways website. Information will be made available initially prior to the employment planning meeting and ongoing during employment planning meeting updates, upon request by the participant or family member or at any time the Employment Navigator feels the participant needs to be reminded about available resources. Information made available to the participant shall include, at a minimum, the purpose of the employment planning meeting, background information on person-centered planning and the participant’s role in the person-centered planning process, information about the participant’s ability to invite the individuals they want to participate in the employment planning process. Additionally, the Employment Navigator may make available additional resources to help facilitate the person-centered planning process such as, but not limited to an interpreter and information in braille and large print, as necessary.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 18 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

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): 8. Process for Making Person-Centered Service Plan Subject to the Approval of the Medicaid Agency. (Describe the process by which the person-centered service plan is made subject to the approval of the Medicaid agency): All person-centered employment plans are subject to review by an approving entity within the Single State Medicaid agency. In addition, in the performance of oversight functions, a representative sample of all person-centered employment plans will be reviewed to ensure compliance with all requirements. 9. Maintenance of Person-Centered Service Plan Forms. Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR §74.53. Service plans are maintained by the following (check each that applies): X Medicaid agency X Operating agency Case manager Other (specify):

Services 1. State plan HCBS. (Complete the following table for each service. Copy table as needed): Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Employment Navigation (Case Management) Service Definition (Scope): Employment Navigation service will assist participants in gaining access to needed employment and related supports. This service ensures coordination between employment and related supports and other State plan services, as well as medical, social, educational, and other services, regardless of the funding source for the services to which access is gained. Employment Navigators are limited to employees of the State of Delaware as per an approved 1915(b)(4) selective contracting waiver. The Employment Navigator will inform participants about all willing and qualified providers available from which to choose as part of the person-centered planning process. The Employment Navigator will also make the individual aware of available online resources that contain provider information sorted geographically.

Prior to the development of the person-centered plan, participants and/or their legal guardians or representatives are provided with information about the freedom to choose among a set of qualified providers. Participants are also given a list of providers and can choose among these service providers. The information is provided to participants at least annually. In addition, provider lists will be available to participants at any time during their enrollment in the Pathways program.

Information will be provided to participants in an accessible manner, taking into consideration the participant’s unique communication needs. Accommodations will be provided as necessary.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 19 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Employment Navigators are responsible for collecting information for evaluating and/or re-evaluating the participant’s needs-based eligibility and for performing assessments to inform the development of the person-centered employment plan. In the function of delivering Employment Navigation services the Employment Navigator will: In the performance of providing information to individuals served through Pathways; • Informs participants about the Pathways HCBS services, required needs assessments, the person-centered planning process, service alternatives, service delivery options (opportunities for participant-direction), roles, rights, risks, and responsibilities. • Informs participants on fair hearing rights and assist with fair hearing requests when needed and upon request. In the performance of facilitating access to needed services and supports; • Collects additional necessary information including, at a minimum, preferences, strengths, and goals to inform the development of the participant’s person-centered employment plan. • Assists the participant and his/her service planning team in identifying and choosing willing and qualified providers. • Coordinates efforts and prompts the participant to ensure the completion of activities necessary to maintain Pathways program eligibility. In the performance of the coordinating function; • Coordinates efforts and prompts the participant to engage in the completion of a needs assessment to identify appropriate levels of need and to serve as the foundation for the development of and updates to the employment service plan. • Uses a person-centered planning approach and a team process to develop the participant’s employment Plan to meet their needs in the least restrictive manner possible. • Develops and updates the person-centered employment plan based upon the needs assessment and person-centered planning process annually, or more frequently as needed. • Explores coverage of services to address participants’ identified needs through other sources, including services provided under the State Plan, Medicare, and/or private insurance or other community resources. • Coordinates, as needed, with other individuals and/or entities essential in the delivery of services for the participant, including MCO care coordinators, as well as vocational rehabilitation and education coordinators to ensure seamless coordination among needed support services and to ensure that the participant is receiving services as appropriate from such other sources. • Coordinates with providers and potential providers of services to ensure seamless service access and delivery.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 20 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

• Coordinates with the participant’s family, friends, and other community members to cultivate natural supports. In the performance of the monitoring function; • Monitors the health, welfare, and safety of the participant and the person-centered employment plan implementation through regular contacts at a minimum frequency as required by the department. • Responds to and assesses emergency situations and incidents and ensure that appropriate actions are taken to protect the health, welfare, and safety of the participant. • Reviews provider documentation of service provision and monitors participant progress on employment outcomes and initiate meetings when services are not achieving desired outcomes. •Through the service plan monitoring process, solicits input from the participant and/or family, as appropriate, related to satisfaction with services. Competitive and integrated employment, including self-employment, shall be considered the first option when serving persons with disabilities who are of working age. Documentation is maintained that the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.) or other sources. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits): Federal Financial Participation (FFP) is not claimed for incentive payments, subsidies, or unrelated vocational training expenses. Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify):

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 21 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Employment Navigation Provider The providers of this service will be limited per concurrent operation with the Pathways 1915(b)(4) waiver granting waiver of free choice of providers for this service, necessary to ensure conflict free status, access, and quality.

Comply with Department standards, including regulations, policies, and procedures relating to provider qualifications.

Individuals providing this service must be employed by the State of Delaware and must: Have an associate’s degree or higher in a behavioral, social sciences, or a related field OR experience in health or human services support, which includes interviewing individuals and assessing personal, health, employment, social, or financial needs in accordance with program requirements. Complete Department-required training, including training on the participant’s service plan and the participant’s unique and/or disability-specific needs, which may include, but is not limited to, communication, mobility, and behavioral needs. Comport with other requirements as determined by the Department.

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Employment Navigation Department or Designee Initially and annually or more based on service monitoring concerns. Service Delivery Method. (Check each that applies): Participant-directed X Provider managed

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 22 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Career Exploration and Assessment Service Definition (Scope): Career Exploration and Assessment is a person centered, comprehensive employment planning and support service that provides assistance for program participants to obtain, maintain, or advance in competitive employment or self-employment. It is a focused, time limited service engaging a participant in identifying a career direction and developing a plan for achieving competitive, integrated employment at or above the State’s minimum wage. The outcome of this service is documentation of the participant’s stated career objective and a career plan, including any necessary education and training, used to guide individual employment support. This service may include conducting community-based career assessment. The assessment may include: • conducting a review of the participant’s work history, interests and skills; • identifying types of jobs in the community that match the participant’s interests, abilities, and skills; • identifying situational assessments (including job shadowing or job tryouts) to assess the participant’s interest and aptitude in a particular type of job; and/or • developing a report that specifies recommendations regarding the participant’s individual needs, preferences, abilities, and characteristics of an optimal work environment. The report must also specify if education, training, or skill development is necessary to achieve the participant’s employment or career goals, with an indication of whether those elements may be addressed by other related services in the participant’s service plan or other sources. Services must be delivered in a setting that complies with HCBS standards and in a manner that supports the participant’s communication needs including, but not limited to, age appropriate communication, translation services for participants who are of limited English proficiency or who have other communication needs requiring translation. An integral component of Career Assessment and Exploration is transportation which allows the participant to engage in opportunities such as job shadowing and community-based assessments. Competitive and integrated employment, including self-employment, shall be considered the first option when serving persons with disabilities who are of working age. Documentation is maintained that the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 23 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits): Career Exploration and Assessment may be authorized for up to 6 months in a benefit year, with multi-year service utilization and reauthorization only with explicit written Department approval.

This service is not available to individuals who are eligible for or are receiving this benefit through vocational rehabilitation programs offered by the Division for the Visually Impaired (DVI).

Federal Financial Participation (FFP) is not claimed for incentive payments, subsidies, or unrelated vocational training expenses.

Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Career Exploration Agency State Business License or 501 (c)(3) status Pathways Certified Provider (utilizing DDDS Criteria) Comply with all Department standards, including regulations, contract requirements, policies, and procedures relating to provider qualifications.

Ensure employees complete Department-required training, including training on the participant’s service plan and the participant’s unique and/or disability-specific needs, which may include, but is not limited to, communication, mobility, and behavioral needs.

Individuals employed by providers must:

Have criminal background investigations in accordance with state requirements.

Have a screening against the

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 24 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

child abuse and adult abuse registry checks and obtain service letters in accordance with 19 Del Code Section 708 and 11 Del Code Sections 8563 and 8564 and not have any adverse registry findings in the performance of the service.

Be state licensed (as applicable) or registered in their profession as required by state law. In the case of direct care personnel, possess certification through successful completion of training program as required by the Department. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Career Exploration Agency Department or Designee Initially and annually or more based on service monitoring concerns. Service Delivery Method. (Check each that applies): Participant-directed X Provider managed Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Supported Employment-Individual Service Definition (Scope): Individual Supported Employment services are the ongoing supports provided, at a one-to-one participant to staff ratio, to participants who, because of their disabilities, need intensive on-going support to obtain and maintain an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce. Jobs in competitive and customized employment must provide compensation at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is sustained paid employment at or above the minimum wage in an integrated setting in the general workforce, in a job that meets personal and career goals. Individual Supported Employment may also include support to establish or maintain self-employment, including home-based self-employment with business generated income for the participant. Supported employment services are individualized and may include any combination of the following services: vocational/job-related discovery or assessment, person-centered employment planning, job placement, job development, negotiation with prospective employers, job analysis, job

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 25 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

carving, training and systematic instruction, job coaching, benefits support, training and planning, transportation, asset development and career advancement services, and other workplace support services including services not specifically related to job skill training that enable the participant to be successful in integrating into the job setting. Competitive and integrated employment, including self-employment, shall be considered the first option when serving persons with disabilities who are of working age to obtain employment. Services must be delivered in a manner that supports the participant’s communication needs including, but not limited to, age-appropriate communication, translation services for participants that are of limited-English proficiency, or who have other communication needs requiring translation. Services must be delivered in a setting that complies with HCBS standards. Documentation is maintained that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits):

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 26 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Individual Supported Employment does not include facility-based or other similar types of vocational services furnished in specialized facilities that are not a part of the general workplace.

Individual Supported Employment services do not include volunteer work and may not be used for job placements paying below minimum wage.

Job placement support provided as a component of this service is time-limited, requiring re-authorization every 90 days, up to 6 months in a benefit year. At each 90-day interval, the service plan team will meet to clarify goals and expectations and review the job placement strategy. The Individual Supported Employment Services service provider must maintain documentation in accordance with Department requirements.

Except as permitted in accordance with requirements contained in Department guidance, policy and regulations, this service may not be provided on the same day and at the same time as services that contain elements integral to the delivery of this service.

FFP is not claimed for incentive payments, subsidies, or unrelated vocational training expenses.

Individual Supported Employment Services does not include payment for supervision, training, support, and adaptations typically available to workers without disabilities. Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Supported Employment Agency State Business License or 501 (c)(3) status Pathways Certified Provider (utilizing DDDS Criteria) Comply with Department standards, including regulations, contract requirements, policies, and procedures relating to provider qualifications.

Ensure employees complete Department-required training, including training on the participant’s service plan and the participant’s unique and/or disability-specific needs, which may include, but is not limited to, communication, mobility, and behavioral needs.

Individuals employed by providers must: • Have criminal background investigations in accordance with state requirements.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 27 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

• Have a screening against the child abuse and adult abuse registry checks and obtain service letters in accordance with 19 Del Code Section 708 and 11 Del Code Sections 8563 and 8564 and not have an adverse 8564 and not have any adverse registry findings in the performance of the service. • Be state licensed (as applicable) or registered in their profession as required by state law. In the case of direct care personnel, possess certification through successful completion of training program as required by the Department Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Supported Employment Agency Department or Designee Initially and annually (or more frequent based on service monitoring concerns)

Service Delivery Method. (Check each that applies): Participant-directed X Provider managed Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Supported Employment-Small Group Service Definition (Scope): Small Group Supported Employment are services and training activities provided in regular business, industry and community settings for groups of two (2) to no more than four (4) workers with disabilities. Examples include mobile crews and other business-based workgroups employing small groups of workers with disabilities in employment in the community. Small Group Supported Employment must be provided in a manner that promotes integration into the workplace and interaction between participants and people without disabilities in those workplaces and be compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is sustained paid employment and work experience leading to further career development and individual integrated community-based employment for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. Small Group Supported Employment does not include vocational services provided in

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 28 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

facility-based work settings, enclaves or other non-competitive or non-integrated job placements. Small Group Supported Employment may include any combination of the following services: vocational/job-related discovery or assessment, person-centered employment planning, job placement, job development, negotiation with prospective employers, job analysis, training and systematic instruction, job coaching, benefits support, training and planning transportation and career advancement services. Other workplace support services may include services not specifically related to job skill training that enable the participant to be successful in integrating into the job setting. Small Group Supported Employment emphasizes the importance of rapid job search for a competitive job and provide work experiences where the participant can develop strengths and skills that contribute to employability in individualized paid employment in integrated community settings Services must be delivered in a manner that supports the participant’s communication needs including, but not limited to, age-appropriate communication, translation services for participants who have limited-English proficiency or who have other communication needs. Services must be delivered in a setting that complies with HCBS standards. Documentation is maintained that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits):

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 29 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Continuation of Small Group Supported Employment requires a review and reauthorization every 6 months in accordance with Department requirements and shall not exceed 12 continuous months without exploration of alternative services. The review and reauthorization should verify that there have been appropriate attempts to prepare the participant for a transition to Individualized Employment Support Services (IESS) and that the participant continues to prefer Small Group Supported Employment, despite these attempts.

Job placement support provided as a component of this service is time-limited, requiring re-authorization every 90 days, up to 6 months in a benefit year. At each 90-day interval, the service plan team will meet to clarify goals and expectations and review the job placement strategy.

Small Group Supported Employment does not include facility-based or other similar types of vocational services furnished in specialized facilities that are not a part of the general workplace.

Small Group Supported Employment services do not include volunteer work and may not be for job placements paying below minimum wage.

The Small Group Supported Employment Services service provider must maintain documentation in accordance with Department requirements.

Except as permitted in accordance with requirements contained in Department guidance, policy and regulations, this service may not be provided on the same day and at the same time as services that contain elements integral to the delivery of this service.

FFP is not claimed for incentive payments, subsidies, or unrelated vocational training expenses. Small Group Supported Employment Services does not include payment for supervision, training, support, and adaptations typically available to workers without disabilities. Small Group Supported Employment services is not a pre-requisite for Individual Supported Employment. Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Supported Employment agency State Business License or 501 (c)(3) status Pathways Certified Provider (utilizing DDDS Criteria)

Comply with Department standards, including regulations, contract requirements, policies, and procedures relating to provider qualifications. Ensure employees complete Ensure employees complete Department-required training, including training on the participant’s service plan

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 30 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

and the participant’s unique and/or disability-specific needs, which may include, but is not limited to, communication, mobility, and behavioral needs.

Individuals employed by providers must: • Have criminal background investigations in accordance with state requirements. • Have a screening against the child abuse and adult abuse registry checks and obtain service letters in accordance with 19 Del Code Section 708 and 11 Del Code Sections 8563 and 8564 and not have any adverse registry findings in the performance of the service. • Be state licensed (as applicable) or registered in their profession as required by state law. In the case of direct care personnel, possess certification through successful completion of training program as required by the Department. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Supported Employment Agency Department or Designee Initially and annually (or more frequent based on service monitoring concerns) Service Delivery Method. (Check each that applies): Participant-directed X Provider managed Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Benefits Counseling Service Definition (Scope): Benefits Counseling provides work incentive counseling services to Pathways to Employment participants seeking to work while maintaining access to necessary healthcare and other benefits. Benefits counseling will provide information to individuals regarding available benefits and assist participants to understand options for making an informed choice about going to work while

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 31 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

maintaining essential benefits. This service will assist participants to understand the work incentives and support programs available and the impact of work activity on those benefits. This service will assist participants to understand their benefits supports and how to utilize work incentives and other tools to assist them to achieve self-sufficiency through work. This service will also include the development and maintenance of proper documentation of services, including creating Benefits Summaries and Analyses and Work Incentive Plans. Services must be delivered in a setting that complies with HCBS standards and in a manner that supports the participant’s communication needs including, but not limited to, age appropriate communication, translation/interpretation services for participants who have limited-English proficiency or who have other communication needs requiring translation, assistance with the provider’s understanding and use of communication devices used by the participant. This service is in addition to information provided by the Aging and Disability Resource Centers (ADRC) or other entities providing information regarding long-term services and supports. Documentation is maintained that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Delaware will ensure that individuals do not otherwise have access to this service through any other source, including SSA and WIPA. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits): 20 hours per year maximum with exceptions possible with explicit written Departmental approval. Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Benefits Counseling Agency State Business License or 501 (c)(3) status

Comply with Department standards, including regulations, contract requirements, policies, and procedures

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 32 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

relating to provider qualifications.

Ensure employees and/or contractors complete Department-required training, including training on the participant’s service plan and the participant’s unique and/or disability-specific needs, which may include, but is not limited to, communication, mobility, and behavioral needs.

Individuals employed or contracted by providers must: • Have a screening against the child abuse and adult abuse registry checks and obtain service letters in accordance with 19 Del Code Section 708 and 11 Del Code Sections 8563 and 8564 and not have any adverse registry findings in the performance of the service. • Be state licensed (as applicable) or registered in their profession as required by state law. In the case of direct care personnel, possess certification through successful completion of training program as required by the Department. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Benefits Counseling Agency Department or Designee Initially and annually (or more frequent based on service monitoring concerns)

Service Delivery Method. (Check each that applies): Participant-directed X Provider managed Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Financial Coaching Plus Service Definition (Scope):

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 33 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Financial Coaching Plus uses a financial coaching model to assist participants in establishing financial goals, creating a plan to achieve them, and providing information, support, and resources needed to implement stated goals in the financial plan. The financial coach will assist the participant seeking to improve his/her financial well-being in order to improve economic self-sufficiency. Financial Coaching Plus includes the development of a personal budget and identifies reliable and trusted savings, credit, and debt management programs that promote financial stability. The content and direction of the coaching is customized to respond to the individual financial goals set by the participant. Financial coaching is provided to the participant one-on-one in a setting convenient for the participant over a time-limited series of sessions and follow-up to increase the opportunity for self-directed behavior skills learning. The Financial Coaching will: • Assist the participant in developing financial strategies to reach participant’s goals with care to ensure that personal strategies reflect considerations related to benefits, as identified through benefits counseling; • Ensure that participants understand the availability of various tax credits such as the Earned Income Tax Credit, Child Care Tax Credit, and others; • Refer participants as needed to benefit counselors; • Provide information to complement information provided through benefits counseling regarding appropriate asset building; • Use an integrated dashboard of available community-based asset building opportunities and financial tools/services to ensure participants are leveraging all resources to increase economic self-sufficiency; • Provide information about how to protect personal identify and avoid predatory lending schemes; • Provide assistance with filing yearly taxes either through the IRS VITA program or its virtual program that involves self-filing.

The Financial Coaching Plus service will include the collection and maintenance of proper documentation of services provided as required by the Department that will track goals, actions, and outcomes of individual participants. The Financial Coaching Plus service may complement information provided on the use of public benefits and/or work incentives through Benefits Counseling or other services. Services must be delivered in a setting that complies with HCB standards. Documentation is maintained that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.) or other services. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 34 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits): Financial Coaching Plus service limited to five hours per participant per year. Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Financial Coaching Agency State Business License or 501 (c)(3) status An agency must demonstrate that Financial Coaches who will provide this service are certified in the financial coaching curriculum developed by the Department of Health and Social Services and the University of Delaware Alfred Lerner College of Business and Economics and the Division of Professional Continuing Studies. Comply with Department standards, including regulations, contract requirements, policies, and procedures relating to provider qualifications.

The provider, including its parent company and its subsidiaries, and any sub provider, including its parent company and subsidiaries, agree to comply with the provisions of 29 Del Code Chapter 58, Laws Regulating the Conduct of Officers and Employees of the State and in particular with Section 5805 (d) Post Employment Restrictions.

Ensure employees and/or contractors complete Department required training, including training on the participant’s service plan and the participant’s unique and/or disability specific needs, which may include, but is not limited to, communication, mobility, and behavioral needs.

Individuals employed or contracted by providers must: • Have criminal background investigations in accordance with state requirements. • Have a screening against the child

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 35 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

abuse and adult abuse registry checks and obtain service letters in accordance with 19 Del Code Section 708 and 11 Del Code Sections 8563 and 8564 and not have any adverse registry findings in the performance of the service. • Be state licensed (as applicable) or registered in their profession as required by state law. • In the case of direct care personnel, possess certification through successful completion of training program as required by the Department.

An agency must demonstrate that Financial Coaches who will provide this service: • Have at least one year of full time financial coaching experience. • Are trained in Financial Coaching Plus strategies specific to the Pathways population.

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Financial Coaching Plus Agency Department or Designee Initially and annually (or more frequent based on service monitoring concerns) Service Delivery Method. (Check each that applies): Participant-directed X Provider managed Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Non-Medical Transportation Service Definition (Scope): Service offered in order to enable participants to gain access to employment services, as specified by the service plan. This service is offered in addition to medical transportation required under 42 CFR

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 36 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

§431.53 and transportation services under the State plan, defined at 42 CFR §440.170(a) (if applicable), and does not replace them. Transportation services under the Pathways program are offered in accordance with the participant’s service plan. Whenever possible and as determined through the person-centered planning process, family, neighbors, friends, carpools, coworkers, or community agencies which can provide this service without charge must be utilized. Non-medical Transportation services are offered, in addition to any medical transportation furnished under the 42 CFR 440.17(a) in the State Plan. Non-medical Transportation services are necessary, as specified by the person-centered employment plan to enable individuals to gain access to employment services. In order to be approved, non-medical transportation would need to be directly related to a goal on the participant’s person-centered employment plan (e.g., to a supported employment site) and not for the general transportation needs of the client (e.g., regular trips to the grocery store). This service will be provided to meet the participant’s needs as determined by an assessment performed in accordance with Department requirements and as specifically outlined in the participant’s person- centered employment plan. Transportation services will be delivered through a transportation broker who will arrange and/or provide services pursuant to the person-centered employment plan. Such transportation may also include public transportation. The utilization of public transportation promotes self-determination and is made available to participants as a cost-effective means of accessing services and activities. This service provides payment for the participant’s use of public transportation to access employment. The Employment Navigator will monitor this service quarterly and will provide ongoing assistance to the participant to identify alternative community-based sources of transportation. Documentation is maintained that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973, the IDEA (20 U.S.C. 1401 et seq.) or any other source. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits): The service does not provide for mileage reimbursement for a person to drive himself to work. Individuals may not receive this service at the same time as Supported Employment (individual or group) if those services are providing transportation to and from the employment setting. Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify):

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 37 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Transportation Broker Agency The providers of this service will be limited per concurrent operation with the Pathways 1915(b)(4) waiver of free choice of providers for this service, necessary to ensure conflict free status, access and quality. State Business License or 501 (c)(3) status Broker All drivers possess a valid driver’s license. All vehicles are properly registered and insured.

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Transportation Agency Department or Designee Initially and annually (or more frequent based on service monitoring concerns) Service Delivery Method. (Check each that applies): Participant-directed X Provider managed Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Personal Care Service Definition (Scope): Personal care includes assistance with ADLs (bathing, dressing, personal hygiene, transferring, toileting, skin care, eating and assisting with mobility), as needed to assist participants in the workplace. When specified in the person-centered employment plan, this service may include assistance with instrumental activities of daily living (IADL) (e.g. task completion). Assistance with IADL’s must be essential to the health and welfare of the participant. Personal care may also provide stand-by assistance in the workplace to participants who may require support on an intermittent basis due to a disability or medical condition. This service is intended to provide personal care for participants in getting ready for work, in getting to work or at the workplace. This service does not duplicate a service provided under the State plan as an expanded EPSDT service or services available to the individual through other Medicaid programs, including the DSHP Plus and any other Delaware HCBS waiver.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 38 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Personal Care may include escorting participants to the workplace. Services must be delivered in a setting that complies with HCB standards and in a manner that supports the participant’s communication needs including, but not limited to, age-appropriate communication, translation services for participants who have limited-English proficiency or who have other communication needs. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits): This service is over and above that which is available to the individual through the State Plan EPSDT benefit, the DSHP Plus program, or any other Delaware HCBS waiver, as applicable. Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Home Health Agency State Business License or 501 (c)(3) status; and State Home Health Agency License from Office of Health Facilities Licensing and Certification per Delaware Code Title 16-4406 Home Health Agencies (Licensure). N/A Comply with Department standards, including regulations, contract requirements, policies, and procedures relating to provider qualifications.

Complete and ensure employees complete Department-required training, including training on the participant’s service plan and the participant’s unique and/or disability-specific needs, which may include, but is not limited to, communication, mobility, and behavioral needs.

Individuals employed by providers must: • Be legally able to work in the state of Delaware. • Have criminal background investigations in accordance with state requirements.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 39 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

• Have a screening against the child abuse and adult abuse registry checks and obtain service letters in accordance with 19 Del Code Section 708 and 11 Del Code Sections 8563 and 8564 and not have any adverse registry findings in the performance of the service.

Possess certification through successful completion of training program as required by the Department. Personal Assistance Services Agency State Business License or 501(c)(3) status; and State Personal Assistance Services Agency License from Office of Health Facilities Licensing and Certification per Delaware Code Title 16-4469. N/A Comply with Department standards, including regulations, contract requirements, policies, and procedures relating to provider qualifications.

Complete and ensure employees complete Department-required training, including training on the participant’s service plan and the participant’s unique and/or disability-specific needs, which may include, but is not limited to, communication, mobility, and behavioral needs.

Individuals employed by providers must: • Be legally able to work in the state of Delaware. • Have criminal background investigations in accordance with state requirements. • Have a screening against the child abuse and adult abuse registry checks and obtain service letters in accordance with 19 Del Code Section 708 and 11 Del Code Sections 8563 and 8564 and not have any adverse registry findings in the performance of the service. Possess certification through successful completion of training program as required by the Department. Personal Attendant N/A N/A • Must have the ability to carry out the tasks required by the participant. • Must have the ability to communicate effectively with the participant.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 40 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

• Have criminal background investigations in accordance with state requirements. Have a screening against the child abuse and adult abuse registry checks and obtain service letters in accordance with 19 Del Code Section 708 and 11 Del Code Sections 8563 and 8564 and not have any adverse registry findings in the performance of the service. • Be legally able to work in the state of Delaware. • Must complete training through Support for Participant Direction vendor within 90 days of enrollment as a provider. (Exceptions to the training requirement are made by the Support for Participant Direction vendor on a case-by-case basis for emergency back-up providers.) Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Home Health Agency Department or Designee Initially and annually (or more frequent based on service monitoring concerns) Personal Assistance Services Agency Department or Designee Initially and annually (or more frequent based on service monitoring concerns) Personal Attendant Department or Designee Initially and annually (or more frequent based on service monitoring concerns) Service Delivery Method. (Check each that applies): Participant-directed X Provider managed Service Specifications: (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Orientation, Mobility, and Assistive Technology Service Definition (Scope): Assistive technology device means an item, piece of equipment or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 41 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

functional capabilities of participants. Assistive technology means a service that directly assists a participant in the selection, acquisition, or use of an assistive technology device to increase independence in the workplace. Independent evaluations conducted by a certified professional, not otherwise covered under the State Plan services, may be reimbursed as a part of this service. Evaluations to determine need for assistive technology and to identify the appropriate technology to support participants in employment settings are required. Assistive technology includes: (A) the evaluation and assessment of the assistive technology needs of a participant, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant; (B) the cost of the item, including; purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices for participants; (C) services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices; (D) coordination and use of necessary therapies, interventions, or services with assistive technology devices, such as therapies, interventions, or services associated with other services in the service plan; (E) training, demonstrations and/or technical assistance for the participant, or, where appropriate, the family members, guardians, advocates, or authorized representatives of the participant; and (F) training, demonstrations and/or technical assistance for professionals or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of participants. Assistive technology may include augmentative communication devices, adapted watches, high and low tech adaptive/assistive equipment such as video magnifiers, Braille displays, hardware and software. Orientation and Mobility Orientation and Mobility provides participants training to develop the necessary skills to travel independently and safely. This is accomplished one on one with the usage of white canes, guide dogs, or other equipment. Orientation and Mobility instruction is a sequential process where visually impaired individuals are taught to utilize their remaining senses to determine their position within their environment and to negotiate safe movement from one place to another. This service does not duplicate a service provided under the State plan EPSDT benefit. Items designed for general use shall only be covered to the extent necessary to meet the participant’s assessed needs and are primarily used by a participant to address a therapeutic purpose. Documentation is maintained that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973, the IDEA (20 U.S.C. 1401 et seq.) or any other source. Services must be delivered in a setting that complies with HCB standards. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 42 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categorically needy (specify limits): These assessments, items or services must not otherwise be available to participants under the DSHP.

Assistive Technology devices must be obtained at the lowest cost.

The amount of this service for Assistive Technology devices is limited to $10,000 for the participant’s lifetime. This amount includes replacement parts and repair when it is more cost effective than purchasing a new device. Exceptions to this limit may be considered based upon a needs assessment and prior authorization by the Department. Medically needy (specify limits):

Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Certified Orientation and Mobility Specialist n/a COMS Meet minimum standards as set forth by Department of Vocational Rehabilitation or Division for the Visually Impaired as applicable for comparable services. Certified Vision Rehabilitation Therapist n/a CVRT Meet minimum standards as set forth by Department of Vocational Rehabilitation or Division for the Visually Impaired as applicable for comparable services. Occupational Therapist OTR/L AOTA SCEM Meet minimum standards as set forth by Department of Vocational Rehabilitation or Division for the Visually Impaired as applicable for comparable services. Assistive Technology Professional n/a ATP RESNA Rehabilitation Engineering and Assistive Technology Society of North America Meet minimum standards as set forth by Department of Vocational Rehabilitation or Division for the Visually Impaired as applicable for comparable services.

Low Vision Therapist n/a LVT - Academy for Certification of Vision Rehabilitation Meet minimum standards as set forth by Department of Vocational Rehabilitation or Division for the Visually Impaired as applicable for comparable services.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 43 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

and Education Professionals (ACVREP)

Durable Medical Equipment Suppliers State Business License or 501 (c)(3) status

Assistive Technology Suppliers State Business License or 501 (c)(3) status

Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): All Provider Types Department or Designee Initially and annually (or more frequent based on service monitoring concerns) Service Delivery Method. (Check each that applies): Participant-directed X Provider managed

2. X Policies Concerning Payment for State plan HCBS Furnished by Relatives, Legally Responsible Individuals, and Legal Guardians. (By checking this box the state assures that): There are policies pertaining to payment the state makes to qualified persons furnishing State plan HCBS, who are relatives of the individual. There are additional policies and controls if the state makes payment to qualified legally responsible individuals or legal guardians who provide State Plan HCBS. (Specify (a) who may be paid to provide State plan HCBS; (b) the specific State plan HCBS that can be provided; (c) how the state ensures that the provision of services by such persons is in the best interest of the individual; (d) the state’s strategies for ongoing monitoring of services provided by such persons; (e) the controls to ensure that payments are made only for services rendered; and (f) if legally responsible individuals may provide personal care or similar services, the policies to determine and ensure that the services are extraordinary (over and above that which would ordinarily be provided by a legally responsible individual): (a) Spouses of participants may be paid to provide personal care services under the circumstances described below. (b) Payment is authorized for spouses to provide only those personal care services designated in the person-centered employment plan, which respond to a specific deficit or deficits in a participant's capacity to carry out ADLs and/or IADLs and which represent extraordinary care not typically provided by spouses in the absence of these deficits. The service plan includes authorization for service hours that include only those services and supports not ordinarily provided by a spouse in the absence of ADL and/or IADL deficits, including such supports as health maintenance activities; bathing and personal hygiene; bowel or urinary evacuation; and feeding. Activities which might, in the absence of ADL and/or IADL deficits, be considered shared responsibilities of spouses or

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 44 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

members of a household, such as shopping, cleaning, or bill payment, are not considered for reimbursement for spousal personal care attendants under the Pathways program, except under unusual circumstances and at the discretion of the Employment Navigator. (c) Under this program, participants who choose to self-direct some or all of their personal care services have employer authority. A specified number of personal care hours are authorized in a person-centered employment plan based on his/her individual needs. The participant, as employer of a personal care provider, including a spousal provider, is responsible for making sure that the personal care service is delivered by his/her attendant in such a way as to address the specific ADL and/or IADLs noted in the person-centered employment plan. Regular contact between the participant and the Employment Navigator, and the Support for Participant Direction provider ensure that the participant's service needs are being met, including those service needs being met by the spousal personal care attendant. Face-to-face visits between the Support for Participant Direction Provider and the participant are held at a minimum twice per year when the participant chooses to employ a spouse to provide some or all of his or her authorized personal care services. (d) Delaware will ensure that information regarding DOL requirements are available to all providers.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 45 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Participant-Direction of Services Definition: Participant-direction means self-direction of services per §1915(i)(1)(G)(iii). 1. Election of Participant-Direction. (Select one): The state does not offer opportunity for participant-direction of State plan HCBS. X Every participant in State plan HCBS (or the participant’s representative) is afforded the opportunity to elect to direct services. Alternate service delivery methods are available for participants who decide not to direct their services. Participants in State plan HCBS (or the participant’s representative) are afforded the opportunity to direct some or all of their services, subject to criteria specified by the state. (Specify criteria):

2. Description of Participant-Direction. (Provide an overview of the opportunities for participant- direction under the State plan HCBS, including: (a) the nature of the opportunities afforded; (b) how participants may take advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that they provide; and, (d) other relevant information about the approach to participant-direction): Personal care is the only service offered under the 1915(i) for which there are self-direction opportunities. All participants in Pathways who receive personal care services are offered the opportunity for employer authority to self-direct these personal care services. Participants are informed of the opportunity for self-direction during the person-centered planning process. The Employment Navigator provides information, both verbally and in writing, about: the benefit, available supports (such as assistance from the fiscal management entity, what assistance is provided and how to contact the vendor/fiscal employer agent) and information regarding their responsibilities when they elect to self-direct personal care services. Individuals (or parents in the case of minor children) may elect to serve as the employer of record for these services. Individuals receive information and assistance in support of participant direction and vendor/fiscal employer agent support from an entity(ies) contracted with the State for the provision of these services. The vendor/fiscal employer agent function is performed as a Medicaid administrative activity. 3. Limited Implementation of Participant-Direction. (Participant direction is a mode of service delivery, not a Medicaid service, and so is not subject to statewideness requirements. Select one): X Participant direction is available in all geographic areas in which State plan HCBS are available. Participant-direction is available only to individuals who reside in the following geographic areas or political subdivisions of the state. Individuals who reside in these areas may elect self- directed service delivery options offered by the state or may choose instead to receive

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 46 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

comparable services through the benefit’s standard service delivery methods that are in effect in all geographic areas in which State plan HCBS are available. (Specify the areas of the state affected by this option):

4. Participant-Directed Services. (Indicate the State plan HCBS that may be participant-directed and the authority offered for each. Add lines as required): Participant-Directed Service Employer Authority Budget Authority Personal Care X

5. Financial Management. (Select one) : Financial Management is not furnished. Standard Medicaid payment mechanisms are used. X Financial Management is furnished as a Medicaid administrative activity necessary for administration of the Medicaid State plan. 6. X Participant–Directed Person-Centered Service Plan. (By checking this box the state assures that): Based on the independent assessment required under 42 CFR §441.720, the individualized person- centered service plan is developed jointly with the individual, meets federal requirements at 42 CFR §441.725, and:

Specifies the State plan HCBS that the individual will be responsible for directing;

Identifies the methods by which the individual will plan, direct or control services, including whether the individual will exercise authority over the employment of service providers and/or authority over expenditures from the individualized budget;

Includes appropriate risk management techniques that explicitly recognize the roles and sharing of responsibilities in obtaining services in a self-directed manner and assures the appropriateness of this plan based upon the resources and support needs of the individual; Describes the process for facilitating voluntary and involuntary transition from self-direction including any circumstances under which transition out of self-direction is involuntary. There must be state procedures to ensure the continuity of services during the transition from self-direction to other service delivery methods; and

Specifies the financial management supports to be provided.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 47 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

7. Voluntary and Involuntary Termination of Participant-Direction. (Describe how the state facilitates an individual’s transition from participant-direction, and specify any circumstances when transition is involuntary): Voluntary Termination of Participant Direction An individual who elects to receive participant-directed personal care services can elect to terminate participant direction at any time. The state ensures the continuity of services for and the health and welfare of the participant who elects to terminate participant-directed personal care services. A participant who elects to terminate participant direction is able to receive personal care services through an agency, which has an agreement to provide such services under the Pathways program. Employment Navigators shall facilitate a seamless transition to an alternative service delivery method so that there are no interruptions or gaps in services. Employment Navigators shall ensure that personal care attendants remain in place until alternative providers are obtained and are scheduled to provide services. Employment Navigators shall monitor the transition to ensure that the service is provided consistent with the employment plan and in keeping with the participant goals and objectives. Involuntary Termination of Participant Direction Participants who opt to self-direct some or all of their personal care service hours receive a great deal of support to assist them in carrying out their responsibilities. This support leads to successful participant-direction in most cases. However, there are a several circumstances under which the State would find it necessary to terminate participant direction. Specifically, the State involuntarily terminates the use of participant direction under the following circumstances: Inability to self-direct. If an individual consistently demonstrates a lack of ability to carry out the tasks needed to self-direct personal care services, including hiring, training, and supervising his or her personal care attendant, and does not have a representative available and able to carry out these activities on his/her behalf, then the State would find it necessary to terminate the use of participant direction. Fraudulent use of funds. If there is substantial evidence that a participant has falsified documents related to participant directed services (for example authorizing payment when no services were rendered or otherwise knowingly submitting inaccurate timesheets), then the State would find it necessary to terminate the use of participant direction. Health and welfare risk. If the use of participant direction results in a health and welfare risk to the participant that cannot be rectified through intervention on the part of the Support for Participant Direction provider and/or the Employment Navigator, then the State would find it necessary to terminate the use of participant direction. In cases in which participant direction is discontinued, the Employment Navigator makes arrangements immediately with the participant to select from a list of provider-managed personal care entities (i.e., those home health agencies and personal assistance services agencies enrolled to provide the 1915 (i) services). Once the participant has selected a new personal care provider, the Employment Navigator makes arrangements to have the agency-based service begin as soon as possible to minimize or eliminate any possible gap in service. Employment Navigators shall facilitate a seamless transition to alternative service delivery method so that there are no interruptions or gaps in services. Employment Navigators shall ensure that employees

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: DE 21-009 Page 48 Effective: January 1, 2022 Approved: Supersedes: DE 19-003

remain in place until alternative providers are obtained and are scheduled to provide services. Employment Navigators shall monitor the transition to ensure that the service is provided consistent with the employment plan and in keeping with the participant goals and objectives.

8. Opportunities for Participant-Direction a. Participant–Employer Authority (individual can select, manage, and dismiss State plan HCBS providers). (Select one): The state does not offer opportunity for participant-employer authority. X Participants may elect participant-employer Authority (Check each that applies): Participant/Co-Employer. The participant (or the participant’s representative) functions as the co-employer (managing employer) of workers who provide waiver services. An agency is the common law employer of participant-selected/recruited staff and performs necessary payroll and human resources functions. Supports are available to assist the participant in conducting employer-related functions. X

Participant/Common Law Employer. The participant (or the participant’s representative) is the common law employer of workers who provide waiver services. An IRS-approved Fiscal/Employer Agent functions as the participant’s agent in performing payroll and other employer responsibilities that are required by federal and state law. Supports are available to assist the participant in conducting employer-related functions. b. Participant–Budget Authority (individual directs a budget that does not result in payment for medical assistance to the individual). (Select one): X The state does not offer opportunity for participants to direct a budget. Participants may elect Participant–Budget Authority. Participant-Directed Budget. (Describe in detail the method(s) that are used to establish the amount of the budget over which the participant has authority, including the method for calculating the dollar values in the budget based on reliable costs and service utilization, is applied consistently to each participant, and is adjusted to reflect changes in individual assessments and service plans. Information about these method(s) must be made publicly available and included in the person-centered service plan.):

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

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 49 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

Quality Improvement Strategy Quality Measures

(Describe the state’s quality improvement strategy. For each requirement, and lettered sub-requirement, complete the table below): 1. Service plans a) address assessed needs of 1915(i) participants; b) are updated annually; and (c document choice of services and providers.

2. Eligibility Requirements: (a) an evaluation for 1915(i) State plan HCBS eligibility is provided to all applicants for whom there is reasonable indication that 1915(i) services may be needed in the future; (b) the processes and instruments described in the approved state plan for determining 1915(i) eligibility are applied appropriately; and (c) the 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or if more frequent, as specified in the approved state plan for 1915(i) HCBS.

3. Providers meet required qualifications.

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

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

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

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

(Table repeats for each measure for each requirement and lettered sub-requirement above.) Requirement Settings meet the home and community-based settings requirements as specified in this SPA and in accordance with 42 CFR 441.710(a)(1) and (a)(2) Discovery Discovery Evidence (Performance Measure) 1. The percentage of Pathways participants that are residing in settings that comply with HCBS setting requirements. 2. The percentage of Pathways participants receiving Pathways services in settings that comply with HCBS settings requirements. Discovery Activity (Source of Data & sample size) 1. Record Review. Representative Sample; Confidence Interval = 95%

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 50 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

Monitoring Responsibilities (Agency or entity that conducts discovery activities) DDDS Frequency Continuously and Ongoing Remediation

Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) 1. Employment Navigators in the operating divisions will regularly monitor the settings in which participants reside. Anyone found to no longer reside in an HCBS setting will be dis-enrolled from the program.

2. Employment Navigators will regularly monitor the settings in which participants receive Pathways services. Non-compliant HCB Settings will no longer be allowed as setting sites. Frequency (of Analysis and Aggregation) Quarterly and Annually

Requirement Eligibility Requirements: (a) an evaluation for 1915(i) State plan HCBS eligibility is provided to all applicants for whom there is reasonable indication that 1915(i) services may be needed in the future; (b) the processes and instruments described in the approved state plan for determining 1915(i) eligibility are applied appropriately; and (c) the 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or if more frequent, as specified in the approved state plan for 1915(i) HCBS. Discovery Discovery Evidence (Performance Measure) 1. The percentage of Pathways participants enrolled during the period who met the eligibility criteria prior to the initiation of Pathways services. 2. The percentage of Pathways participants that met initial eligibility when the eligibility criteria was applied correctly. 3. The percentage of Pathways participants whose eligibility was reevaluated at a minimum of annually. Discovery Activity (Source of Data & sample size) 100% Record Review Monitoring Responsibilities (Agency or entity that conducts discovery activities) DDDS

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 51 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

Frequency Continuously and Ongoing Remediation Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) The operating division will serve an active role in correcting identified problems. The division will aggregate and analyze the data for the program, and will utilize the Pathways Workgroup, which includes DMMA to lead program remediation strategies.

Remediation is expected upon detection of issue. Issues are initially discussed among involved parties so as to clearly communicate findings and desired outcomes, followed by a written report reiterating those areas and the date by which issues must be resolved. Frequency (of Analysis and Aggregation) Quarterly and Annually Requirement Service plans address assessed needs of 1915(i) participants, are updated annually, and document choice of services and providers. Discovery Discovery Evidence (Performance Measure) Service plans address assessed needs of 1915(i) participants, are updated annually, and document choice of services and providers. 1. The number and percentage of participants that report that they helped develop their employment plan. (The number of participants documented as participating in the development of their employment plan/ the number of employment plans developed during the reporting period) 2. Number and percent of participants with employment plans consistent with their individual assessments. (The number of participants whose employment plans are documented as being consistent with their employment plan/ the number of employment plans developed during the reporting period) 3. The percentage of participants whose service plan contains documentation that the participant was supported to make an informed choice about their providers(s). (The number of participants whose service plans contain documentation that the participant was supported to make an informed choice about their provider(s)/total number of participants whose plans were reviewed.)

Discovery Activity (Source of Data & sample size) 1. Record Review. Representative Sample; Confidence Interval = 95%

2. Record Review. Representative Sample; Confidence Interval = 95%

3. Record review. Representative Sample; Confidence Interval = 95%

Monitoring Responsibilities DDDS

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 52 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

(Agency or entity that conducts discovery activities)

Frequency

Continuously and Ongoing Remediation

Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) The operating division will serve an active role in correcting identified problems. The division will aggregate and analyze the data for the program, and will utilize the Pathways Workgroup, which includes DMMA to lead program remediation strategies. Delaware will collect data to establish a benchmark against which future improvement will be measured.

Remediation is expected upon detection of issue. Issues are initially discussed among involved parties so as to clearly communicate findings and desired outcomes, followed by a written report reiterating those areas and the date by which issues must be resolved. Frequency (of Analysis and Aggregation) Quarterly and Annually

Requirement Providers meet required qualifications Discovery Discovery Evidence (Performance Measure) 1. The percent of providers that meet the standards for provider qualification at annual review.

Discovery Activity (Source of Data & sample size) 1. Provider Record Review. Representative Sample; Confidence Interval = 95%

Monitoring Responsibilities (Agency or entity that conducts discovery activities) DDDS

Frequency

Continuously and Ongoing Remediation

Remediation Responsibilities (Who corrects, analyzes, and aggregates The operating division will serve an active role in correcting identified problems. The division will aggregate and analyze the data for the program, and will utilize the Pathways Workgroup, which includes DMMA to lead program remediation strategies

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 53 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

remediation activities; required timeframes for remediation)

Remediation is expected upon detection of issue. Issues are initially discussed among involved parties so as to clearly communicate findings and desired outcomes, followed by a written report reiterating those areas and the date by which issues must be resolved. Frequency (of Analysis and Aggregation) Quarterly and Annually

Requirement The SMA retains authority and responsibility for program operations and oversight Discovery Discovery Evidence (Performance Measure) 1. Percent of needs-based eligibility assessments where the decision of the reviewer was validated by DMMA

2. Number and percent of performance reports reviewed by the DMMA (Number of performance reports reviewed by DMMA/total number of performance reports).

3. Percent of DMMA’s quarterly performance review meetings during which PTE quality assurance and improvement are discussed (Number of DMMA’s quarterly meetings during which PTE QA/I are discussed/ all quarterly DMMA performance review meetings.) Discovery Activity (Source of Data & sample size) 1. Record Review. Representative Sample; Confidence Interval = 95%

2. Administrative Records Representative Sample; Confidence Interval = 95%

3. Administrative records. Representative Sample; Confidence Interval = 95%

Monitoring Responsibilities (Agency or entity that conducts discovery activities) DMMA Frequency

Ongoing Remediation

Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for The operating divisions will serve an active role in correcting identified problems, with DMMA providing oversight.

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 54 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

remediation) Frequency (of Analysis and Aggregation) Quarterly

Requirement The SMA maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers. Discovery Discovery Evidence (Performance Measure) 1. Number and percent of rates adhering to reimbursement methodology in the approved State plan amendment. (Number of rates verified by DMMA as adhering to approved reimbursement methodology/number of rates on the Pathways fee schedule during the reporting period)

2. Number and percent of employment plans where services were delivered in accordance with service plan with regard to duration/frequency. (Number of employment plans where services were delivered in accordance with the employment plan in regard to duration/frequency as detailed in the service plan/Total number of employment plans reviewed.)

Discovery Activity (Source of Data & sample size) 1. Administrative Data and Record Review Representative Sample; Confidence Interval = 95%

2. Administrative data; Record Review Representative Sample; Confidence Interval = 95%

Monitoring Responsibilities (Agency or entity that conducts discovery activities) DMMA

Frequency Continuously and Ongoing Remediation

Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for The operating divisions will serve an active role in correcting identified problems. The divisions will aggregate and analyze the data and will utilize the Pathways Workgroup (which includes each operating division and DMMA) to lead cross-program remediation strategies.

Remediation is expected upon detection of issue. Issues are initially discussed among involved parties so as to clearly communicate findings and desired outcomes, followed by a written report reiterating those areas and the date by

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 55 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

remediation) which issues must be resolved. Frequency (of Analysis and Aggregation) Quarterly and Annually

Requirement The State identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation, including the use of restraints. Discovery Discovery Evidence (Performance Measure) 1. The percentage of incidents of Abuse/Neglect/Mistreatment that were reported in accordance with Pathways requirements. (Number of incidents of Abuse/Neglect/Mistreatment reported in accordance with Pathways requirements/ Number of incidents of Abuse/Neglect/Mistreatment reported for the reporting period) 2. The percentage of incidents of Abuse/Neglect/Mistreatment/Unexplained Death that occurs in a provider managed setting by type in which follow-up was completed in accordance with applicable Department requirements. (Number of incidents of Abuse/Neglect/Mistreatment/Unexplained Death occurring in a provider managed setting reported by type where follow up met Department requirements/Number of specified incidents occurring in a provider managed setting reported by type for the reporting period) 3. The percentage of employed participants reporting that they feel safe at work. (The number of participants reporting that feel safe at work/number of participants whose services and supports were reviewed) 4. The percentage of reported incidents of emergency restrictive behavior intervention strategies implemented according to protocol per DDDS Use of Restraints and Restrictive Procedures for Behavior Support Policy. (Number of reported incidents of emergency restrictive behavior intervention strategies implemented according to DDDS Policy/Number of reported incidents of the use of emergency restrictive behavior intervention strategies for the reporting period)

Discovery Activity (Source of Data & sample size) 1. Record Review. Representative Sample; Confidence Interval = 95% 2. Record Review. Representative Sample; Confidence Interval = 95% 3. Participant Questionnaire. Representative Sample; Confidence Interval = 95% 4. Representative Sample; Confidence Interval = 95%.

Monitoring Responsibilities (Agency or entity that conducts discovery activities) DDDS

Frequency

Continuously and Ongoing Remediation

Remediation Responsibilities (Who corrects, The operating divisions will serve an active role in correcting identified problems. The divisions will aggregate and analyze the data and will utilize the Pathways Workgroup (which includes each operating division and DMMA) to lead

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 56 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

analyzes, and aggregates remediation activities; required timeframes for remediation) cross-program remediation strategies. Remediation is expected upon detection of issue. Issues are initially discussed among involved parties so as to clearly communicate findings and desired outcomes, followed by a written report reiterating those areas and the date by which issues must be resolved. Frequency (of Analysis and Aggregation) Quarterly and Annually

Requirement Employment Related Measures

Discovery Discovery Evidence (Performance Measure) Percent of participants who: (a) have a paid job in the community (b) do not have a paid job in the community but would like to have a paid job in the community (c) like working at their job (d) would like to work someplace other than their current job (e) chose to work at their current job

Discovery Activity (Source of Data & sample size) Participant Questionnaire; Representative Sample; Confidence Interval = 95%

Monitoring Responsibilities (Agency or entity that conducts discovery activities) DDDS

Frequency Continuously and Ongoing (all PMs) Remediation

Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) The operating division will serve an active role in correcting identified problems. The division will aggregate and analyze the data for the program, and will utilize the Pathways Workgroup, which includes DMMA to lead program remediation strategies. Delaware will collect data to establish a benchmark against which future improvement will be measured.

Remediation is expected upon detection of issue. Issues are initially discussed among involved parties so as to clearly communicate findings and desired outcomes, followed by a written report reiterating those areas and the date by

State: Delaware §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: DE 21-009 Page 57 Effective: January 1, 2022 Approved: Supersedes: TN DE 19-003

which issues must be resolved. Frequency (of Analysis and Aggregation) Quarterly and Annually

System Improvement (Describe the process for systems improvement as a result of aggregated discovery and remediation activities.)

1. Methods for Analyzing Data and Prioritizing Need for System Improvement Through reports generated by target group and for the Pathways program as a whole; priorities will be established for systems improvements based upon the following hierarchy: • Ensuring the health, safety and welfare of participants served; • Providing services in a manner consistent with a participant’s service plan; • Helping participants meet their individual employment objectives; • Other systems improvements.

Of paramount importance is to ensure the individual satisfaction of each participant and to ensure that they are getting needed services. That said, impediments to employment must be addressed swiftly and systematically to ensure the ongoing efficacy of the Pathways program.

2. Roles and Responsibilities The Pathways Workgroup will routinely review aggregated discovery and remediation data to determine areas requiring systems improvement.

3. Frequency Continuously and ongoing

4. Method for Evaluating Effectiveness of System Changes Through data on interventions and through analysis of ongoing discovery data, the Workgroup will assess the effectiveness of the system improvement strategies.

State: Delaware §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: DE 21-009

Effective: January 1, 2022 Approved: Supersedes: DE 19-003

Methods and Standards for Establishing Payment Rates 1. Services Provided Under Section 1915(i) of the Social Security Act. For each optional service, describe the methods and standards used to set the associated payment rate. (Check each that applies, and describe methods and standards to set rates): X HCBS Case Management The Employment Navigation rate is computed from annual provider costs from the prior period. The following list outlines the major allowable cost components used in rate development using federally accepted cost principles (2 CFR 200 cost principles). Staffing Assumptions and Staff Wages Employee-Related Expenses – Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) Staff Productivity Assumptions (e.g., time spent on billable activities) Program-Related Expenses (e.g., technology related expenses, supplies) Provider Overhead Expenses Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of case management. The agency’s fee schedule rate was set as of 7/1/21 and is effective for services provided on and after that date. All rates are published on DDDS’s website at the following address: DDDS Waiver and Pathways Provider Rates - Delaware Health and Social Services - State of Delaware HCBS Homemaker HCBS Home Health Aide X HCBS Personal Care Personal care rates are computed depending on the type of Pathways provider delivering Personal Care as follows: Home Health Agency Rate: As established under attachment 4.19-B of the Delaware State Plan for Medical Assistance, page 6 for an HH Aide. Personal Care Agency Rate: 75% of the Medicaid rate for HHAs for an aide. This percentage was derived by comparing usual and customary hourly rates for aide services delivered through HHAs as opposed to PASA agencies and establishing the relationship between the rates. Participant-directed Rate: The fiscal intermediary will establish the rate with input from the waiver member. The fiscal intermediary will ensure that all rates and payments comply with the US DOL Fair Labor Standards Act and that all applicable federal and state payroll taxes are paid. All rates are published on DDDS’s website at the following address:

State: Delaware §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: DE 21-009

Effective: January 1, 2022 Approved: Supersedes: DE 19-003

DDDS Waiver and Pathways Provider Rates - Delaware Health and Social Services - State of Delaware HCBS Adult Day Health HCBS Habilitation HCBS Respite Care For Individuals with Chronic Mental Illness, the following services: HCBS Day Treatment or Other Partial Hospitalization Services

HCBS Psychosocial Rehabilitation

HCBS Clinic Services (whether or not furnished in a facility for CMI)

X Other Services (specify below) Career Exploration and Assessment The rate for Career Exploration and Assessment was calculated using a market basket methodology. Staffing Assumptions and Staff Wages Employee-Related Expenses – Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) Staff Productivity Assumptions (e.g., time spent on billable activities) Program Indirect Expenses (e.g., supplies) Provider Overhead Expenses Wage data was obtained from authoritative sources such as the U.S. DOL Bureau of Labor Statistics for job classifications with similar requirements and duties as the direct support professionals performing this service in order to derive an appropriate DSP hourly wage rate. In developing the other rate components, provider cost data for the allowable costs included in the "market basket" was collected. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Career Exploration and Assessment. The agency’s fee schedule rate was set as of 1/1/15 and is effective for services provided on and after that date. All rates are published on DDDS’s website at the following address: DDDS Waiver and Pathways Provider Rates - Delaware Health and Social Services - State of Delaware. Supported Employment – Individual

State: Delaware §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: DE 21-009

Effective: January 1, 2022 Approved: Supersedes: DE 19-003

The methodology and rate for Individual Supported Employment is the same as those computed under Delaware’s Lifespan 1915(c) waiver (DE 0009). The Individual Supported Employment rate was calculated using a market basket methodology. This rate methodology is comprised of the following key components: Staffing Assumptions and Staff Wages Employee-Related Expenses – Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) Staff Productivity Assumptions (e.g., time spent on billable activities) Program Indirect Expenses (e.g., supplies) Provider Overhead Expenses Wage data was obtained from authoritative sources such as the U.S. DOL Bureau of Labor Statistics for job classifications with similar requirements and duties as the direct support professionals performing this service in order to derive an appropriate DSP hourly wage rate. In developing the other rate components, provider cost data for the allowable costs included in the "market basket" was collected. These costs are converted to percentages that are multiplied by the direct support hourly wage rate as a set of recursive percentages in order to develop an hourly provider DSP rate. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Supported Employment. The agency’s fee schedule rate was set as of 7/1/21 and is effective for services provided on and after that date. All rates are published on DDDS’s website at the following address: DDDS Waiver and Pathways Provider Rates - Delaware Health and Social Services - State of Delaware Supported Employment - Small Group Rates for Small Group Supported Employment are the same as those computed under Delaware’s Lifespan 1915(c) waiver (DE 0009). Small Group Supported Employment rates were calculated using a market basket methodology. This rate methodology is comprised of the following key components: Staffing Assumptions and Staff Wages Employee-Related Expenses – Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) Staff Productivity Assumptions (e.g., time spent on billable activities) Program Indirect Expenses (e.g., supplies) Provider Overhead Expenses Wage data was obtained from authoritative sources such as the U.S. DOL Bureau of Labor Statistics for job classifications with similar requirements and duties as the direct support professionals performing this service in order to derive an appropriate DSP hourly wage rate. In

State: Delaware §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: DE 21-009

Effective: January 1, 2022 Approved: Supersedes: DE 19-003

developing the other rate components, provider cost data for the allowable costs included in the "market basket" was collected. These costs are converted to percentages that are multiplied by the direct support hourly wage rate as a set of recursive percentages in order to develop an hourly provider DSP rate. A separate rate is established for each group size, up to 4 HCBS recipients, by dividing by the base rate by the number of individuals in the group. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Supported Employment. The agency’s fee schedule rate was set as of 7/1/21 and is effective for services provided on and after that date. All rates are published on DDDS’s website at the following address: DDDS Waiver and Pathways Provider Rates - Delaware Health and Social Services - State of Delaware Non-Medical Transportation Non-Medical transportation will be implemented utilizing a transportation broker. The state will pay the broker on a fee-for-service basis with administrative compensation for the coordination and delivery of transportation. The rates will be one of the following, depending on the most direct, cost effective mode of transport: - Per mile (using established state reimbursement per mile) - Per public transportation trip using fees established by public transportation agency(ies) - Per trip, using a methodology based upon average miles per trip, number of individuals in transport and any specialized mode of transportation required. Benefits Counseling The rate for Benefits Counseling was calculated using a market basket methodology. This rate methodology is comprised of the following key components: Staffing Assumptions and Staff Wages Employee-Related Expenses – Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) Staff Productivity Assumptions (e.g., time spent on billable activities) Program Indirect Expenses (e.g., supplies) Provider Overhead Expenses Wage data was obtained from authoritative sources such as the U.S. DOL Bureau of Labor Statistics for job classifications with similar requirements and duties as the direct support professionals performing this service in order to derive an appropriate DSP hourly wage rate. In developing the other rate components, provider cost data for the allowable costs included in the "market basket" was collected. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Supported Employment. The agency’s fee schedule rate was set as of 1//1/15 and is effective for services provided on and after that date. All rates are

State: Delaware §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: DE 21-009

Effective: January 1, 2022 Approved: Supersedes: DE 19-003

published on DDDS’s website at the following address: DDDS Waiver and Pathways Provider Rates - Delaware Health and Social Services - State of Delaware Financial Coaching Plus The rate for Financial Coaching Plus was calculated using a market basket methodology. This rate methodology is comprised of the following key components: Staffing Assumptions and Staff Wages Employee-Related Expenses – Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) Staff Productivity Assumptions (e.g., time spent on billable activities) Program Indirect Expenses (e.g., supplies) Provider Overhead Expenses Wage data was obtained from authoritative sources such as the U.S. DOL Bureau of Labor Statistics for job classifications with similar requirements and duties as the direct support professionals performing this service in order to derive an appropriate DSP hourly wage rate. In developing the other rate components, provider cost data for the allowable costs included in the "market basket" was collected. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Financial Coaching. The agency’s fee schedule rate was set as of 1//1/15 and is effective for services provided on and after that date. All rates are published on DDDS’s website at the following address: DDDS Waiver and Pathways Provider Rates - Delaware Health and Social Services - State of Delaware Orientation, Mobility, and Assistive Technology The methodology and rates for Assistive Technology assessment and training are the same as those computed under Delaware’s Lifespan 1915(c) waiver (DE 0009). The rate for these services were calculated using a market basket methodology. This rate methodology is comprised of the following key components: Staffing Assumptions and Staff Wages Employee-Related Expenses – Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) Staff Productivity Assumptions (e.g., time spent on billable activities) Program Indirect Expenses (e.g., supplies) Provider Overhead Expenses Wage data was obtained from authoritative sources such as the U.S. DOL Bureau of Labor Statistics for job classifications with similar requirements and duties as the direct support

State: Delaware §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: DE 21-009

Effective: January 1, 2022 Approved: Supersedes: DE 19-003

professionals performing this service in order to derive an appropriate DSP hourly wage rate. In developing the other rate components, provider cost data for the allowable costs included in the "market basket" was collected. Assistive Technology devices are reimbursed based on the cost charged to the general public for the item. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Orientation, Mobility, and Assistive Technology. The agency’s fee schedule rate was set as of 1//1/15 and is effective for services provided on and after that date. All rates are published on DDDS’s website at the following address: DDDS Waiver and Pathways Provider Rates - Delaware Health and Social Services - State of Delaware

State: §1915(i) State plan HCBS State plan Attachment 2.2-A: TN:

Effective: Approved: Supersedes:

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 0938-1188. The time required to complete this information collection is estimated to average 114 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.

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group

September 23, 2022

Stephen Groff Director Division of Medicaid Medical Assistance P.O. Box 906 New Castle, DE, 19720

Re: Delaware (DE) State Plan Amendment (SPA) 22-0003-0

Dear Mr. Groff:

The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 22-0003-0. This amendment proposes to update Delaware State Plan to allow Medicaid recipients institutionalized in long- term care facilities to retain an allowance of income to pay for guardianship costs.

We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act. This letter is to inform you that Delaware Medicaid SPA 22-0003-0 was approved on September 22, 2022, with an effective date of April 1, 2022.

If you have any questions, please contact Talbatha Myatt at 215-861-4259 or via email at Talbatha.Myatt@cms.hhs.gov.

Sincerely,

James G. Scott, Director Division of Program Operations

cc: Kimberly Xavier, Chief, Policy & Planning Melissa Dohring, State Plan Coordinator CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDTCARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 2 - 0 0 0 3 DE -- - --- -- 3. PROGRAM IDENTIFICATION TITLE OF THE SOCIAL SECURITY ACT 0 XIX () XXI 4. PROPOSED EFFECTIVE DATE April 1, 2022 FORMAPPROVEO 0 MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) § 1902(a)(50)(q) of the Social Security Act 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 2.6-A Page 4 Addendum 9. SUBJECT OF AMENDMENT Guardianship Fees - Post-Eligibility Protection of Income 10. 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 a. FFY 2022 $ 0 b. FFY 2023 $ 273 600 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 2 .6-A Page 4 Addendum 0 OTHER, AS SPECIFIED 15. RETURN TO 1 N Stephen M. Groff Stephen M. Groff, Director, DMMA, P.O. Box 906 New Castle, ------------------------ DE19720 13. TITLE Director 14. DATE SUBMITTED 16. DATE RECEIVED 06/28/2022 FOR CMS USE ONLY 17. DATE APPROVED 09/22/2022 PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 04/01/2022 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS FORM CMS-179 (09124) 19. SIGNA - - . ---. . ' C_ 21 . TITLE OF APPROVING OFFICIAL Director, Division of Program Operations Instructions on Back

ATTACHMENT 2.6-A Page 4 Addendum TN No. SPA 22-0003 Supersedes TN No. SPA #16-008 Approval Date 09/22/2022

Effective Date April 1, 2022

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: DELAWARE ELIGIBILITY CONDITIONS AND REQUIREMENTS

42 CFR 435.725; 43 CFR 435.733; 42 CFR 435.832

B. Post-Eligibility Treatment of Institutionalized Individuals (continued)

For the following individuals with a greater need (continued)

d. $50/month for NF and ICF/IID residents engaging in frequent and regular rehabilitation out-of-facility activities.

e. For nursing facility residents who are participating in gainful employment, the following amounts, not to exceed the adult foster care rate (SSI benefit amount + $140), will be deducted from gross earned income:

i. Mandatory payroll deductions that are a condition of employment including, but not limited to: 1. Federal, State, and Local taxes 2. FICA 3. Union Dues 4. Insurance Premiums 5. Pension Contributions.

i. Transportation costs as paid to and from employment.

ii. Clothing and personal needs allowance of $75/month.

f. For nursing facility residents requiring a court appointed guardian, the following amounts will be deducted from the gross income:

i. Monthly guardianship fees not to exceed $100 ii. Initial establishment of a guardianship (to include attorney’s fees) not to exceed $750

The maximum amount of income to be protected will not exceed the amount required to maintain an individual in adult foster/residential care. This amount is currently the SSI benefit plus $140.

II 11

Table of Contents

State/Territory Name: DE State Plan Amendment (SPA) #: 22-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group November , 2022 Stephen Groff, Director Division of Medicaid Medical Assistance P.O. Box 906 New Castle, DE 19720 Re: Delaware State Plan Amendment (SPA) 22-0006 Dear Director Groff: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 22-0006. This amendment proposes to update Delaware State Plan to bring the state in compliance with the Third-Party Liability Requirements under the Bipartisan Budget Act (BBA) of 2018 and Medicaid Services Investment and Accountability Act (MSIAA) of 2019 practices. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act. This letter is to inform you that Delaware Medicaid SPA Transmittal Number 22-0006 was approved on November , 2022, with an effective date of September 1, 2022. Enclosed are copies of the approved CMS-179 and SPA Pages to be incorporated into the Delaware State Plan. If you have any questions, please contact Talbatha Myatt at (215) 861-4259 or via email at Talbatha.Myatt@cms.hhs.gov Sincerely, James G. Scott, Director Division of Program Operations Enclosures cc: Kimberly Xavier, Chief, Policy & Planning Melissa Dohring, State Plan Coordinator CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

DocuSign Envelope ID: 4107355A 4377 41 OD 88C2 5607BDEF54AC UCf""l-\1"'( I IVICl't I ur ncl-\L In 1-\l'CUnUIVV·\J'\I .:,cl"'(VIVC.:t CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 2 - 0 0 0 6 DE -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (i) XIX 0 XXI 4. PROPOSED EFFECTIVE DATE September 1, 2022 FORM APPROVED 0MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION BiJlaftisaA B(:ja§et,11,et 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2023 $ 0 BBA) ef 2Q18 (P!jb_ L. 11 § 123) Meaicaia Se Federal Budget Legislation ( B ipartisan Budget Act of 2018 - Third Party Liability 42 CFR 433.136 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 4.22-A Page 1 Attachment 4.22-B Page 1 9. SUBJECT OF AMENDMENT Third Party Liability 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED W ITHIN 45 DAYS OF SUBMITTAL N.ATlJRE OF STATE AGENCY OFFICIAL t.t,..H.4~ ' ·- b. FFY 2024 $ 0 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 4.22-A Page 1 (TN# 08-002) Attachment 4.22-B Page 1 (TN# 345) 0 OTHER, AS SPECIFIED: 15. RETURN TO 12. TYPED NAME Stephen M. Groff Stephen M. Groff, Director, DMMA, P.O. Box 906 New Castle, -------------------- DE19720 13. TITLE Director 16. DATE RECEIVED 09/30/2022 FOR CMS USE ONLY 17. DATE APPROVED 11/01/2022 PLAN APPROVED - ONE COPY A TTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 09/01/2022 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS 19. SIG Director, Division of Program Operations 10-31-22-State requested pen & ink change to update Box 8: 4.22-A page 1 (TN# 08-002) & 4.22-8 page 1 (TN# 345) 10-31-22 State requested pen & ink change to Box 5 to update Federal Statute/Regulation-Federal Budget Legislation Bipartisan Budget Act of 2018 -Third Party Liability 42 CFR 433.136. FORM CMS-179 (09/24) Instructions on Back

TN No. SPA 22Ͳ0006 Supersedes TN No. SPA 08Ͳ002 Approval Date November 1, 2022 Effective Date September 1, 2022 Attachment 4.22-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE Requirements for Third Party Liability (TPL) - Identifying Liable Resources 1. Data exchanges 42 CFR 433.138 (d)(1), (d)(3) and (d)(4) and (e) a. SSA wage - quarterly b. IV-A agency - in Delaware is the same as the Title XIX agency and updates are available, daily c. State Workmen's - not Compensation files - weekly d. Motor vehicle - not computerized - no match available e. SWICA - quarterly f. Health Insurance Carriers - no less than once every two (2) months, unless written permission is given in advance by the agency 2. Follow-up requirements of 42 CFR 433.138 (g)(1)(i) and (g)(2)(i): As soon as any matches on employers are received by the Delaware Client Information System (DCIS), the system will automatically generate a letter to verify health insurance coverage. This action will be taken within 30 days of the receipt of the match data. 3. State motor vehicle match is unavailable because of the information needed for TPL is not carried in the State's motor vehicle automated system. 42 CFR 433.138(g)(3) 4. Trauma code reports are produced weekly by the fiscal agent pursuant to 42 CFR 433(e). The TPL unit sends an accident inquiry form to the client/provider within two weeks regarding potential TPL. Positive responses result in a request for claims history and subsequent bills generated to applicable insurance company or attorney. Any information on ongoing legally liable third party resources is immediately entered into the third party database, which is part of the Medicaid Management Information System (MMIS). 42 CFR 433(e) II 11

TN No. SPA 22Ͳ0006 Supersedes TN No. SPA 345 Approval Date November 1, 2022 Effective Date September 1, 2022 Attachment 4.22-B Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE Requirements for Third Party Liability - Payment of Claims The State’s MMIS identifies liable third parties and all claims submitted for payments are processed through this system. If the provider has not compiled with TPL requirements, the claim suspends for manual review and appropriate action is taken. The State of Delaware Title XIX Program seeks reimbursement from liable third in the following instances: Cost Avoidance Post Payment Recoveries Pre-payment Pended Claims Third Party Claims for Accidental Injury Non-Accident-Related Claims Amount of money below which it is not effective to pursue a claim. All claims where probable existence of TPL is established are cost avoided except as provided for in the TPL Action Plan. $500.00 $100.00 Time limit for which reimbursement is sought. Date of accident forward. As accumulated over the two-year period to the start of recovery proceedings. Cost Avoidance Prenatal Services The state will use standard coordination of benefits cost avoidance process when adjudicating claims for prenatal services which includes labor, delivery and postpartum care claims. If it is determined that a third party is likely liable for a prenatal claim, the claim will be rejected, but not denied and the claim will be returned back to the provider noting the third party that Medicaid believes to be legally responsible for payment. If, after the provider bills the liable third party and a balance remains or the claim is denied payment for a substantive reason, the provider can submit a claim to the state for payment of the balance, up to the maximum Medicaid payment amount established for the service. Per 1902(a)(25)(E) the state will make payments without regard to third party liability for pediatric preventive services unless the state has made a determination related to cost-effectiveness and access to care that warrants cost avoidance for up to 90 days. 1902(a)(25)(F) permits the state to make payment for a child support enforcement beneficiary’s claim if the third party has not paid the provider’s claim within a 100-day wait-and-see period. The state may instead choose, if the state determines doing so is cost-effective and necessary to ensure access to care, to make payment within 30 days. II 11

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 January 27, 2023 Mr. Theodore G. Mermigos, Jr. Acting Division Director Division of Medicaid Medical Assistance P.O. Box 906 New Castle, DE 19720 Re: Delaware State Plan Amendment (SPA) DE-22-0013 Dear Mr. Mermigos: The Centers for Medicare & Medicaid Services (CMS) reviewed the proposed Medicaid State Plan Amendment (SPA) originally submitted under transmittal number (TN) DE-22-0013. SPA 22-0013 proposes to temporarily extend the suspension of member copays and premiums for six months following the end of the PHE, originally approved in Disaster Relief SPA 20-0002. CMS conducted our review of your submittal according to statutory requirements in Title XIX of the Act and implementing regulations. This letter is to inform you that Delaware’s Medicaid SPA Transmittal Number 22-0013 is approved effective the day after the end of the PHE. If you have any questions, please contact Talbatha Myatt at 215-861-4259 or via email at Talbatha.Myatt@cms.hhs.gov. Sincerely, Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2023.01.25 08:08:55 -05'00'

DocuSign Envelope ID: 1270D1B8 B19E 4FOF AA07 65E1C316A2A7

UCPARTMICN! UF ACALIN ANUNUMAN SCRVILCS

CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED ‘OMB No. 0938-0193

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

1. TRANSMITTAL NUMBER 2. STATE 2 2 —0 0 1 3 DE

3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT © xx_ © xx

TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE Sbcmenths One day after PHE ends

5. FEDERAL STATUTE/REGULATION CITATION . . ., litle XIX of the Social Security Act

6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY__2023 $0 b. FFY__2024 $0

7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7.4-B

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

Section 48

9. SUBJECT OF AMENDMENT

Temporary Extension to the COVID-19 Disaster Relief Co-pay & Premium Provisions

10. GOVERNOR'S REVIEW (Check One)

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

© oTHER, AS SPECIFIED:

ATE AGENCY OFFICIAL 15.

Stephen M. Groff

RETURN TO

Stephen M. Groff, Director, DMMA, P.O. Box 906 New Castle,

DE19720 13. TITLE Director 1372873632 73:40" em est FOR CMS USE ONLY 16. DATE RECEIVED 17. DATE APPROVED

12/28/2022

01/27/2023

PLAN APPROVED - ONE COPY ATTACHED

18. EFFECTIVE DATE OF APPROVED MATERIAL 19.

1 day after PHE ends

SIGNATURE OF APPROVING OFFICIAL

Alissa M. Deboy pasyvsare?y Asse c Date: 2023.01.25 08:09:16

20. TYPED NAME OF APPROVING OFFICIAL Alissa Mooney DeBoy On Behalf of Anne Marie Costello

21. Deputy Director, Center for Medicaid and CHIP Services

TITLE OF APPROVING OFFICIAL

22. REMARKS

1-17-23 state requested pen & ink change to update Box 5 to reflect Title XIX of the Social Security Act. 1-23-23 CMS pen and ink change to Boxes 4 and 8 to correct the proposed SPA effective date and to delete the reference to the superseded

page.

FORM CMS-179 (09/24)

Instructions on Back

State/Territory: Delaware TN: 22-001ϯ Supersedes TN: E t Approval Date: 01/27/2023 Effective Date: ϭ Day after end of the PHE Section 7 – General Provisions 7.4Ͳ. Temporary Extension to the Medicaid Disaster Relief Policies for the COVID-19 National Emergency Effective the day after the end of the PHE until 6 months following the end of the month in which the PHE ends the agency temporarily extends the following election(s) in section 7.4 (approved on 05/27/2020 in SPA Number DE-20-0002) of the state plan. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: DHSS suspends all copayments for all beneficiaries effective March 26, 2020. 2. _X____ The agency suspends enrollment fees, premiums and similar charges for: a. _X____ All beneficiaries b. _____ The following eligibility groups or categorical populations: DHSS suspends all premiums for all beneficiaries effective April 1, 2020.

Table of Contents State/Territory Name: Delaware State Plan Amendment (SPA) #: 23-0002 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

Records / Submission Packages - View All DE - Submission Package - DE2023MS0001O - (DE-23-0002) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St. Room 355 Kansas City , MO 64106 Center for Medicaid & CHIP Services June 23, 2023 Theodore G. Mermigos, Jr. Director, DMMA Division of Medicaid and Medical Assistance 1901 N. DuPont Highway P.O. Box 906 New Castle, DE 19720 Re: Approval of State Plan Amendment DE-23-0002 Dear Theodore G. Mermigos, Jr., On March 31, 2023, the Centers for Medicare and Medicaid Services (CMS) received Delaware State Plan Amendment (SPA) DE-23-0002, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002. We approve Delaware State Plan Amendment (SPA) DE-23-0002 with an effective date(s) of January 01, 2023. If you have any questions regarding this amendment, please contact Talbatha Myatt at Talbatha.Myatt@cms.hhs.gov Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services CMS Cf US JOR MEDICARE &MEDICAJO SIIMCES

Records / Submission Packages - View All DE - Submission Package - DE2023MS0001O - (DE-23-0002) - Eligibility ⇐ All Reviewable Units Submission - Public Comment → View Compare Doc Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2023MS0001O | DE-23-0002 Spell Check Instructions | Request System Help CMS-10434 OMB 0938-1188 Not Started In Progress Complete Package Header Package ID DE2023MS0001O Submission Type Official Approval Date 06/23/2023 Superseded SPA ID N/A SPA ID DE-23-0002 Initial Submission Date 3/31/2023 Effective Date N/A View Implementation Guide State Information Collapse State/Territory Name: Delaware Medicaid Agency Name: Division of Medicaid and Medical Assistance Submission Component Collapse Submission Type Collapse Selecting Official Submission Package means that the official 90-day review period will start upon submission. Allow this official package to be viewable by other states? Key Contacts Collapse Name Title Phone Number Email Address Program Zimmerman, Lisa Deputy Director (302)255-9573 Lisa.Zimmerman@state.de.us Medicaid SPA ID and Effective Date Collapse SPA ID DE-23-0002 VIEW PRINT PREVIEW Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions VIEW ALL RESPONSES State Plan Amendment Medicaid CHIP Official Submission Package Draft Submission Package Yes No 0 0 0 0 0 0 0

Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2023 DE-19-0008 Former Foster Care Children 1/1/2023 DE-13-0005-MM Page Number of the Superseded Plan Section or Attachment (If Applicable): Executive Summary Collapse Summary Description Including Goals and Objectives An amendment to our Medicaid State Plan to update the eligibility group for Former Foster Care Children to align with changes required by section 1002(a) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, per CMS guidance. Dependency Description Collapse Description of any dependencies between this submission package and any other submission package undergoing review Disaster-Related Submission Collapse This submission is related to a disaster Federal Budget Impact and Statute/Regulation Citation Collapse Federal Budget Impact Federal Fiscal Year Amount First 2023 $0 Second 2024 $0 Federal Statute / Regulation Citation Section 1902(a)(10)(A)(i)(IX) of the Social Security Act 42 C.F.R. § 435.150 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Governor's Office Review Collapse Authorized Submitter Collapse The following information will be provided by the system once the package is submitted to CMS. Name of Authorized Submitter Melissa Dohring Yes No No comment Comments received No response within 45 days Other 0 0 0 0 0 0

Phone number Email address melissa.dohring@delaware.gov Authorized Submitter's Signature Melissa Dohring PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. I hereby certify that I am authorized to submit this package on behalf of the Medicaid Agency. ~

Records / Submission Packages - View All DE - Submission Package - DE2023MS0001O - (DE-23-0002) - Eligibility ⇐ All Reviewable Units ← Submission - Tribal Input | Former Foster Care Children → View Compare Doc Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2023MS0001O | DE-23-0002 Spell Check Instructions | Request System Help CMS-10434 OMB 0938-1188 Not Started In Progress Complete Package Header Package ID DE2023MS0001O Submission Type Official Approval Date 06/23/2023 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-23-0002 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 View Implementation Guide Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled VIEW PRINT PREVIEW Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions

[!] 6a □ 0 [!] I!!!) □ 0 [!] Ea □ 0 [!] Ea □ 0 [!] □ 0 [!] 6a ii 0 [!] Ea □ 0 [!] □ 0

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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.

Yes No

[!] □ 0 [!] □ 0 [!] ~ □ 0 [!] ~ □ 0 [!] 6a □ 0 [!] 6a □ 0 [!] 6a □ 0 [!] □ 0 0 0 □ 0

Records / Submission Packages - View All DE - Submission Package - DE2023MS0001O - (DE-23-0002) - Eligibility ⇐ All Reviewable Units ← Mandatory Eligibility Groups View Compare Doc Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | DE2023MS0001O | DE-23-0002 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. Spell Check Instructions | Request System Help CMS-10434 OMB 0938-1188 Not Started In Progress Complete Package Header Package ID DE2023MS0001O Submission Type Official Approval Date 06/23/2023 Superseded SPA ID DE-13-0005-MM User-Entered SPA ID DE-23-0002 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 View Implementation Guide The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Collapse Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered Collapse For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. 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. 2. In addition to B.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: VIEW PRINT PREVIEW Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions VIEW ALL RESPONSES a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends.

C. Individuals Covered Collapse For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to C.1., the state elects to cover individuals who were in foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to a state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: D. Additional Information (optional) Collapse PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. a. They were enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. b. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. c. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. □ ~

Table of Contents

State/Territory Name: Delaware State Plan Amendment (SPA) #: 23-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 $XJXVW , 2023 Theodore G. Mermigos, Jr. Acting Division Director Division of Medicaid Medical Assistance P.O. Box 906 New Castle, DE 19720 Re: Delaware State Plan Amendment (SPA) DE-23-0005 Dear Acting Division Director Mermigos: The Centers for Medicare & Medicaid Services (CMS) reviewed the proposed Medicaid State Plan Amendment (SPA) originally submitted under transmittal number (TN) DE-23-0005. This amendment proposes to align the resumption of premiums with the end of the unwinding period and to assign dates to the temporarily extended suspension of member copays and premiums originally approved in Disaster Relief SPA 20-0002. CMS conducted our review of your submittal according to statutory requirements in Title XIX of the Act and implementing regulations. This letter is to inform you that Delaware’s Medicaid SPA Transmittal Number 23-0005 is approved effective May 12, 2023. If you have any questions, please contact Talbatha Myatt at (215) 861-4259 or via email at Talbatha.Myatt@cms.hhs.gov. Sincerely, &RXUWQH\ 0LOOHU 2Q %HKDOI RI $QQH 0DULH &RVWHOOR 'HSXW\ 'LUHFWRU &HQWHU IRU 0HGLFDLG DQG &+,3 6HUYLFHV Enclosures Courtney L. Miller -S Digitally signed by Courtney L. Miller -S Date: 2023.08.03 06:11 09 -05'00'

DocuSign Envelope ID: 90681A27 FB49 4B13 B99F 015258A62919 FORM APPROVED OMB No. 0938-0193

UCPART MCN! UF AICALIN ANUNUMAN SCR VILCS

CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 23 0005 DE STATE PLAN MATERIAL _—— FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES See A eee FICATION: TITLE OF THE SOCIAL @ xx © xx TO: CENTER DIRECTOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICAID & CHIP SERVICES : May 12, 2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BHD BET IMPACT ( ints in WHOLE dollars)

Title XIX of the Social Security Act b. FFY__2024 $_0

7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable)

Section 7.4-B, Page 2 Seetion 7+4-8-

9. SUBJECT OF AMENDMENT Temp Extension to COVID-19 DR Co-pay & Premium Provisions

10. GOVERNOR'S Revdore (Mernhigue)

© GOVERNOR'S OFFICE REPORTED NO COMMENT ® COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

ICY OFFICIAL 15. RETURN TO

(®) oTHER, AS SPECIFIED:

Theodore Mermigos, Acting Director, DMMA, P.O. Box 906 New

Theodore Mermigos = Castle, DE19720

13. TITLE Acting Director

14. DATE SUBMITTED

June 30, 2023 FOR CMS USE ONLY 16. DATE RECEIVED 17. DATE APPROVED June 30, 2023 August 3, 2023 PLAN APPROVED - ONE COPY ATTACHED

19. SIGNATURE OF APPROVINGWMRRIVAL. Cory wiles Miller -S Bate, 20250808

May 12, 2023 20. TYPED NAME OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL On Behalf of Anne Marie Costello, Deputy Director, CMCS

18. EFFECTIVE DATE OF APPROVED MATERIAL

Courtney Miller

22. REMARKS 7-11-23 - State requested the following pen and ink change to Box 4: e Strike-through Dec 1, 2023 / Jan 1, 2024 and add May 12, 2023

7-21-23 - CMS requested and the state concurred with the following pen and ink changes:

e Box 7: Add missing page number, "page 2", after "Section 7.4-B" e Box 8: Strike-through Section 7.4-B

FORM CMS-179 (09/24) Instructions on Back

State/Territory: Delaware Page 2 Section 7 – General Provisions 7.4.ͲB Temporary Extension to the Medicaid Disaster Relief Policies for the COVIDͲ19 National Emergency Effective the day after the end of the PHE until December 1, 2023, the agency temporarily extends the following election(s) in section 7.4 (approved on 05/27/2020 in SPA Number DEͲ20Ͳ0002) of the state plan. x Section C.1 Ͳ DHSS suspends all copayments for all beneficiaries effective March 26, 2020. Effective the day after the end of the PHE until July 1, 2024, the agency temporarily extends the following election(s) in section 7.4 (approved on 05/27/2020 in SPA Number DEͲ20Ͳ0002) of the state plan. x Section C.2 Ͳ DHSS suspends all premiums for all beneficiaries effective April 1, 2020. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: DHSS suspends all copayments for all beneficiaries effective March 26, 2020. 2. _X____ The agency suspends enrollment fees, premiums and similar charges for: a. _X____ All beneficiaries b. _____ The following eligibility groups or categorical populations: DHSS suspends all premiums for all beneficiaries effective April 1, 2020. TN: 23-0005 Supersedes TN: NEW Approval Date: 08/09/2023 Effective Date: 05/12/2023

Table of Contents State/Territory Name: Delaware State Plan Amendment (SPA) #: 24-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA page

Records : Submission Packages - View All DE - Submission Package - DE2024MS0002O - (DE-24-0005) - Eligibility Summary Reviewable Units Versions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Correspondence Log 1 Center for Medicaid & CHIP Services May 10, 2024 Andrew Wilson Medicaid Director Division of Medicaid and Medical Assistance 1901 N. DuPont Highway P.O. Box 906 New Castle, DE 19720-0906 Re: Approval of State Plan Amendment DE-24-000S Dear Medicaid Director Wilson, Analyst Notes Approval Letter Transaction Logs News Related Actions -- MS CCl<TIRS IOR MIDICARl & MHJICAIO S[R\'ICIS On March 29, 2024, the Centers for Medicare and Medicaid Services (CMS) received Delaware State Plan Amendment (SPA) DE-24-0005 to provide 12 months of continuous eligibility to children under age 19 enrolled in Medicaid. We approve Delaware State Plan Amendment (SPA) DE-24-0005 with an effective date(s) of January 01, 2024. If you have any questions regarding this amendment, please contact Tai bath a Myatt at talbatha.myatt@cms.hhs.gov. Sincerely, Ruth A. Hughes Acting Director, Division of Program Operations Center for Medicaid & CHIP Services

Records I Submission Packages - View All DE - Submission Package - DE2024MS0002O - (DE-24-0005) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I DE2024MS0002O I DE-24-0005 CMS-10434 0MB 0938-1188 Package Header Package ID DE2024MS0002O Submission Type Official Approval Date 05/10/2024 Superseded SPA ID N/A State Information State/Territory Name: Delaware Submission Component O State Plan Amendment SPA ID DE-24-0005 Initial Submission Date 3/29/2024 Effective Date N/ A Medicaid Agency Name: Division of Medicaid and Medical Assistance 0Medicaid QCHIP

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I DE2024MS0002O I DE-24-0005 Package Header Package ID DE2024MS0002O Submission Type Official Approval Date 05/10/2024 Superseded SPA ID N/A SPA ID and Effective Date SPA ID DE-24-0005 Reviewable Unit Continuous Eligibility for Children Proposed Effective Date 1/1/2024 Page Number of the Superseded Plan Section or Attachment (If Applicable): SPA ID DE-24-0005 Initial Submission Date 3/29/2024 Effective Date N/ A Superseded SPA ID New

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I DE2024MS0002O I DE-24-0005 Package Header Package ID DE2024MS0002O Submission Type Official Approval Date 05/10/2024 Superseded SPA ID N/A Executive Summary Summary Description Including 12-month Continuous Eligibility for Children Goals and Objectives SPA ID DE-24-0005 Initial Submission Date 3/29/2024 Effective Date N/ A Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year First 2024 Second 2025 Federal Statute/ Regulation Citation 42 CFR 435.926 and 42 CFR 916(d)(1)(i) Amount $6623630 $8936521 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I DE2024MS0002O I DE-24-0005 Package Header Package ID DE2024MS0002O Submission Type Official Approval Date 05/10/2024 Superseded SPA ID N/A Governor's Office Review 0 No comment 0 Comments received 0 No response within 45 days QOther SPA ID DE-24-0005 Initial Submission Date 3/29/2024 Effective Date N/ A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/13/2024 8:52 AM EDT

Records Submission Packages - View All DE - Submission Package - DE2024MS0002O - (DE-24-0005) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News i@@ijjjj,j,ij Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Children MEDICAID I Medicaid State Plan I Eligibility I DE2024MS0002O I DE-24-0005 CMS-10434 0MB 0938-1188 Package Header Package ID DE2024MS0002O Submission Type Official Approval Date 05/10/2024 Superseded SPA ID New User-Entered The state provides continuous eligibility for children in accordance with the following provisions: SPA ID DE-24-0005 Initial Submission Date 3/29/2024 Effective Date 1/1/2024 A. Mandatory Continuous Eligibility for Hospitalized Children The state provides Medicaid to a child eligible for and enrolled under the Infants and Children under Age 19 (42 CFR 435.118) eligibility group until the end of an inpatient stay for which inpatient services are covered, if the child: 1. Was receiving inpatient services covered by Medicaid on the date the child becomes ineligible under the eligibility group based on the child's age; and 2. Would remain eligible but for attaining such age. B. Mandatory Continuous Eligibility for Children The state provides continuous eligibility to all children under age 19 and that: 1. The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends the last day of the earlier of the following periods: a. The month that the child turns 19 years old; b. 12 months. 2. Continuous eligibility is provided to children eligible under all mandatory and optional eligibility groups (excluding Medically Needy) who would otherwise lose eligibility because of any change in circumstances, unless: a. The child dies; b. The child or the child's representative voluntarily requests a termination of the child's eligibility; c. The child ceases to be a resident of the state; d. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or e. The child attains the maximum age specified in B. C. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 5/13/2024 8:53 AM EDT

Table of Contents State/Territory Name: Delaware State Plan Amendment (SPA) #: 24-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) Form CMS-179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVJCES Centers for Medicare & Medicaid Services 6ill E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group August 5, 2024 Andrew Wilson Medicaid Director Division of Medicaid and Medical Assistance Delaware Health and Social Services P.O. Box 906 New Castle, DE 19720-0906 Re: Delaware State Plan Amendment (SPA) 24-0007 Dear Medicaid Director Wilson: CMS CENTIRS FOR MEO!CAif & MIDICAID SERVICES CENTER FOR ME0IC.<\ID & CHIP SERVICES The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0007. This amendment proposes removing the premiums requirement for participation in the Medicaid Workers with Disabilities (MWD) Program. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act. This letter informs you that Delaware's Medicaid SPA 1N 24-0007 was approved on August 5, 2024, with an effective date of July 1, 2024. Enclosed are copies of Form CMS-179 and approved SP A pages to be incorporated into the Delaware State Plan. If you have any questions, please contact Talbatha Myatt at (215) 861-4259 or via email at Talbatha.Myatt@cms.hhs.gov. Enclosures James G. Scott, Director Division of Program Operations

DocuSign Envelope ID: 28987C1A-FBBC-4320-87AC-853FC80FE3A6 UCr'l"\n 11V1Cl"t I vr nc.t-\L.I n l"'\l'fUnVIVll"\l'f .:::,cn.v1\,,,C.:> CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 4 _Q 0 0 7 DE -- ----- -- 3. PROGRAM IDENTIFICATION TITLE OF THE SOCIAL SECURITY ACT (e) XIX 0 XXI 4. PROPOSED EFFECTIVE DATE 07/01/2024 FORM APPROVED 0MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) 1902(a)(10)(A)(ii)(XV) of the Social Security Act; 1916 of the Social Security Act a FFY 2024 $ 353 b. FFY 2025 $ 1 411 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attaohment 2.e A pages n o and /\ttaohment 2.e A Supplement 8A Al:taohment 2.e /\ pages n o and Mtaohment 2.e A

Attachment 2.6-A pages 12 n-o (09-005) 9. SUBJECT OF AMENDMENT Medicaid Workers with Disabilities Premiums 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL NCY OFFICIAL Sup,:>lement 8A page 1 Attachment 2.6-A pages 12 n-o (09-005) 0 OTHER, AS SPECIFIED: 15. RETURN TO l.d/;0l123E Andrew Wilson, Director, DMMA, P.O. Box 906 New Castle, ---------------------DE19720 13. TITLE Director 14. DATE SUBMITTED 5/10/2024 I 9:20 AM EDT FOR CMS USE ONLY 16. DATE RECEIVED 17 DATE APPROVED 05/14/2024 08/05/2024 PLAN APPROVED- ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 07/01/2024 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS 19. SIG 21. TITLE OF APPROVING OFFICIAL Director, Division of Program Operations 7 -30-24 -the state requested pen and ink changes to update box 7 and box 8 to strike-through Attachment 2.6A pages n -o and Attachment 2.6A Supplement SA page 1 and add Attachment 2.6-A pages 12 n-o (09-005). 7-30-24 -the state requested pen and ink change to box 5 to add 1902(a)(1 0)(A)(ii)(XV) of the Social Security Act; 1916 of the Social Security Act FORM CMS-179 (09/24) Instructions on Back

Citation(s) 1902( a)( 10)(A)(ii)(XI II), (XV), (XVI), and 1916(9) of the Act (cont.) TN No. SPA #24-0007 Supersedes TN No. SPA 09-005 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE Condition or Requirement Attachment 2.6 A Page 12n For individuals eligible under the Basic Coverage Group described in No. 24 on page 23d of the Attachment 2.2-A and the Medical Improvement Group described in No. 25 on page 23d of Attachment 2.2 -A: NOTE: Regardless of the option selected below, the agency MUST require that individuals whose annual adjusted gross income, as defined under IRS statute, exceeds $75,000 pay 100 percent of premiums. D The agency requires individuals to pay premiums or other cost-sharing charges on a sliding scale based on income. For individuals with net annual income below 450 percent of the Federal poverty level for a family of the size involved, the amount of premiums cannot exceed 7 .5 percent of the individual's income. The prerriums or other costȶsharing charges, and how they are applied, are described on page 120. Approval Date August 5, 2024 Effective Date July 1, 2024 I II

Citation(s) 19O2(a )(lO)(A)(ii) (XV), (XVI), and 1916(9) of the Act (cont.) IN NO. ::>PA ff.::'+·UUU/ Supersedes TN No. SPA 09-005 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE Condition or Requirement Premiums and Other Cost-Sharing Charges Attachment 2.6 A Page 120 For the Basic Coverage Group, the agency's prenium or other cost-sharing charges and how they are applied, are described below. Effective July 1, 2024, premiums are no longer required. Approval Date August 5, 2024 Effective Date July 1, 2024 [ " -- II

Table of Contents State/Territory Name: 'HODZDUH State Plan Amendment (SPA) #: 

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicai·e & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group June 1 7, 2024 Andrew Wilson Medicaid Director Division of Medicaid and Medical Assistance Delaware Health and Social Services P.O. Box 906 New Castle, DE 19720-0906 Re: Delaware State Plan Amendment (SP A) 24-0009 Dear Medicaid Director Wilson: MS CENTERS FOR MEOICARE & MEOICAIO SERVICES CENTER FOR MEDICAID & CHIP SERVICES The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0009. This amendment proposes to comply with the cunent law and revise the Medicaid State Plan to align with the Consolidated Appropriations Act of 2022 and Senate Bill 220 of the 152nd Delaware General Assembly. We conducted our review of your submittal according to statuto1y requirements in Title XIX of the Social Security Act. This letter is to info1m you that Delaware Medicaid SP A 24-0009 was approved on June 17, 2024, with an effective date of April 1, 2024. If you have any questions, please contact Talbatha Myatt at 215-861-4259, or via email at Talbatha.Myatt@cms.hhs.gov. James G. Scott, Director Division of Program Operations

DocuSign Envelope ID: FF5FB726-DDD8-4801-9F3D-1F65492DE40F UCf""l-\1"'( I IVICl't I ur ncl-\L I n 1-\l'CUnUIVV·\J'\I .:,cl"'(V I V C.:t CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 4 - 0 0 0 9 DE -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (e_) X IX 0 XXI 4. PROPOSED EFFECTIVE DATE 04/01/2024 FORM APPROVED 0 MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2024 $ 0 CAA 2022, Section 1902(a)(25)(A) of the Social Security Act 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Supplement to Attachment 4.22 9. SUBJECT OF AMENDMENT Third Party Liability 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED W ITHIN 45 DAYS OF SUBMITTAL b. FFY 2025 $ 0 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Supplement to Attachment 4.22 0 OTHER, AS SPECIFIED: 15. RETURN TO 12• ID#AM!il 499 ••• Andrew Wilson, Director, DMMA, P.O. Box 906 New Castle, _A_n_d_re_w_W _ ils_o_n ________________ DE19720 13. TITLE Director 14• DA57:ro~tf2Vi D 6 : 36 AM EDT FOR CMS USE ONLY 16. DATE RECEIVED 05/14/2024 17. DATE APPROVED 06/17/2024 PLAN APPROVED· ONE COPY A TTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 04/01/2024 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS FORM CMS-179 (09/24) Director, Division of Program Operations Instructions on Back

Supplement to Attachment 4.22

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE

STATE LAWS REQUIRING THIRD PARTIES TO PROVIDE COVERAGE ELIGIBILITY AND CLAIMS DATA

1902(A)(25)(I) The State has in effect laws that require third parties to comply with the provisions, including those which require third parties to provide the State with coverage, eligibility and claims data, of 1902(A)(25)(I) of the Social Security Act.

The Medicaid agency ensures that laws are in effect that bar liable third-party payers from refusing payment for an item or service solely on the basis that such item or service did not receive prior authorization under the third-party payer’s rules. These laws comply with the provisions of section 202 of the Consolidated Appropriations Act, 2022.

TN No. SPA# 24-0010 Supersedes TN No. # 08-002 Approval Date: 06/17/2024 Effective Date: April 1, 2024 II II

Table of Contents

State/Territory Name: Delaware State Plan Amendment (SPA) #: 24-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) Form CMS-179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group March 1, 2025 Andrew Wilson Medicaid Director Division of Medicaid and Medical Assistance Delaware Health and Social Services P.O. Box 906 New Castle, DE 19720-0906 Re: Delaware State Plan Amendment (SPA) 24-0015 Dear Mr. Wilson: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0015. This amendment proposes to modify the personal needs allowance amount for individuals residing in long-term care facilities. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act. This letter informs you that Delaware’s Medicaid SPA TN 24-0015 was approved on March 14, 2025, effective January 1, 2025. If you have any questions, please contact Talbatha Myatt at (215) 861-4259, or via email at Talbatha.Myatt@cms.hhs.gov. James G. Scott, Director Division of Program Operations Enclosures CMS CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Docusign Envelope ID: 56B61334-8D8F-4E30-947C-2D76FA44676F U C r-"1-\l"'t l lVICl't I ur n c ML In 1-\l'CU n utV11·\ 1"4 .::,cl"'( VIVC.:t CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 4 _ Q 0 1 5 DE -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (e_) X IX 0 XXI 4. PROPOSED EFFECTIVE DATE 01-01-2025 FORM APPROVED 0 MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2025 $ 419 793 §1902(a)(50), (q) of the Social Security Act, §1924(d)(1) of the Socia b. FFY 2026 $ 425 556 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 2.6-A page 4 Attachment 2.6-A page 4 Addendum 9. SUBJECT OF AMENDMENT Personal Needs Allowance 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED W ITHIN 45 DAYS OF SUBMITTAL FICIAL 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 2.6-A page 4 Attachment 2.6-A page 4 Addendum 0 OTHER, AS SPECIFIED: 15. RETURN TO Andrew Wilson Andrew Wilson, Director, DMMA, P.O. Box 906 New Castle, -------------------- DE19720 13. TITLE Director 14• DAl~M~H"l.r9 2 : 35 PM EST 16. DATE RECEIVED 12/19/2024 FOR CMS USE ONLY 17. DATE APPROVED 03/14/2025 PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 01/01/2025 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS FORM CMS-179 (09/24) 21. TITLE OF APPROVING OFFICIAL Director, Division of Program Operations Instructions on Back

ATTACHMENT 2.6-A Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: DELAWARE ELIGIBILITY CONDITIONS AND REQUIREMENTS 4 2 CFR 435.725; 43 CFR 435.733; 42 CFR 435.832

B. Post-Eligibility Treatment of Institutionalized Individuals

The following amounts are deducted from the gross income when computing the application of an individual or couples’ income to the cost of institutionalized care:

1. Personal Needs Allowance. a. Aged, blind, disabled- Individuals $75 Couples $150

For the following individuals with greater need-

See Page 4 Addendum b. AFDC related- Children $75 Adults $75

c. Individuals under age 21 covered in this plan as specified in Item B.7 of ATTACHMENT 2.2-A Page 16. $75

TN N0. SPA #24-0015

Approval Date March 14, 2025 Supersedes TN No. SP #16-008

īĞĐƟǀĞ ĂƚĞ January 1, 2025 II 11

ATTACHMENT 2.6-A Page 4 Addendum

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: DELAWARE ELIGIBILITY CONDITIONS AND REQUIREMENTS 42 CFR 435.725; 43 CFR 435.733; 42 CFR 435.832 B. Post-Eligibility Treatment of Institutionalized Individuals (continued) For the following individuals with a greater need (continued) d. NF and ICF/IID residents engaging in frequent and regular rehabilitation out-of-facility activities are subject to the personal needs allowance set forth on Attachment 2.6-A page 4, except as provided in e., below.

e. For nursing facility residents who are participating in gainful employment, the following amounts, not to exceed the adult foster care rate (551 benefit amount+ $140), will be deducted from gross earned income: i. Mandatory payroll deductions that are a condition of employment such as: 1. Federal, State, and Local taxes 2. FICA 3. Union Dues 4. Insurance Premiums 5. Pension Contributions.

ii. Transportation costs as paid to and from employment.

iii. Clothing and personal needs allowance of $75/month.

f. For nursing facility residents requiring a court appointed guardian, the following amounts will be deducted from the gross income:

i. Monthly guardianship fees not to exceed $100 ii. Initial establishment of a guardianship (to include attorney's fees) not to exceed $750

The maximum amount of income to be protected will not exceed the amount required to maintain an individual in adult foster/residential care. This amount is currently the SSI benefit plus $140.

TN No. SPA 24-0015 Supersedes TN No. SPA #22-0003 Approval Date March 14, 2025

Effective Date January 1, 2025

II II

Table of Contents

State/Territory Name: Delaware State Plan Amendment (SPA) #: 25-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) Form CMS-179 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group December 8, 2025 Andrew Wilson Medicaid Director Division of Medicaid and Medical Assistance Delaware Health and Social Services P.O. Box 906 New Castle, DE 19720-0906 Re: Delaware State Plan Amendment (SPA) - 25-0001 Dear Medicaid Director Wilson: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 25-0001. This amendment proposes to provide for mandatory coverage in accordance with section 1902(a)(84)(D) of the Social Security Act (the Act) for eligible juveniles that are incarcerated in a public institution post-adjudication of charges. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act. This letter informs you that Delaware’s Medicaid SPA TN 25-0001 was approved on December 8, 2025, effective January 1, 2025, and will sunset December 31, 2026 Enclosed are copies of Form CMS-179 and the approved SPA pages to be incorporated into the Delaware State Plan. Please note that accompanying this approval of SPA TN 25-0001, there is an enclosed companion letter regarding the need for Delaware to address identified actions that must be completed by December 31, 2026, to fully implement mandatory coverage in accordance with section 1902(a)(84)(D) of the Act. CMS is issuing the companion letter to document these actions and establish a timeframe for their completion. If you have any questions, please contact Taneka Rivera at (410) 786-9502, or via email at Taneka.Rivera@cms.hhs.gov. Sincerely, Wendy E. Hill Petras, Acting Director Division of Program Operations Enclosures cc: Melissa Dohring

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group

December 8, 2025

Andrew Wilson Medicaid Director Division of Medicaid and Medical Assistance Delaware Health and Social Services P.O. Box 906 New Castle, DE 19720-0906

Re: Delaware State Plan Amendment (SPA) – 25-0001

Dear Medicaid Director Wilson:

The Centers for Medicare & Medicaid Services (CMS) is sending this companion letter to DE-25- 0001, approved on December 8, 2025. This State Plan Amendment (SPA) amends the Medicaid State Plan to provide for mandatory coverage in accordance with section 1902(a)(84)(D) of the Social Security Act (the Act) for eligible juveniles that are incarcerated in a public institution post- adjudication of charges. As noted in the approval letter and State Plan, this SPA is effective January 1, 2025, and will be sunset on December 31, 2026. The state must complete the actions identified in this letter by the sunset date. Once these actions are completed, the state should submit a SPA to remove the sunset date from the State Plan.

Effective January 1, 2025, section 1902(a)(84)(D) of the Act requires states to have an internal operational plan and, in accordance with such plan, provide for the following for eligible juveniles as defined in section 1902(nn) of the Act (individuals who are under 21 years of age and determined eligible for any Medicaid eligibility group, or individuals determined eligible for the mandatory eligibility group for former foster care children under 42 C.F.R. § 435.150 who are at least age 18 but under age 26) who are within 30 days of their scheduled date of release from a public institution following adjudication:

x In the 30 days prior to release (or not later than one week, or as soon as practicable, after release from the public institution), and in coordination with the public institution, the state must provide any screenings and diagnostic services which meet reasonable standards of medical and dental practice, as determined by the state, or as otherwise indicated as medically necessary, in accordance with the Early and Periodic Screening, Diagnostic, and Treatment requirements, including a behavioral health screening or diagnostic service.

Page 2 – Medicaid Director Wilson x In the 30 days prior to release and for at least 30 days following release, the state must provide targeted case management services, including referrals to appropriate care and services available in the geographic region of the home or residence of the eligible juvenile, where feasible, under the Medicaid state plan (or waiver of such plan). We appreciate the state’s efforts to implement this mandatory coverage and recognize the progress that has been made as well as the complexities associated with full implementation. However, during the review of DE-25-0001, CMS identified actions that must be completed to fully implement mandatory coverage in accordance with section 1902(a)(84)(D) of the Act. CMS is issuing this companion letter to document these actions and establish a timeframe for their completion. The state must complete the following actions by December 31, 2026 to fully implement section 1902(a)(84)(D) of the Act. Once these actions are completed the state should submit a SPA to remove the sunset date from the State Plan. The state indicated that the Department of Services for Children, Youth, and Their Families (DSCYF) currently provides physical and behavioral health screening and diagnostic services consistent with section 1902(a)(84)(D) of the Act; and the Department of Correction (DOC) currently provides physical health screening and diagnostic services consistent with section 1902(a)(84)(D) of the Act. While the state indicated that these screening and diagnostic services are furnished consistent with section 1902(a)(84)(D) of the Act, the state identified changes that are still in the processes of implementation:  Systems and Eligibility: The state will complete work with their systems vendor and DS&<) to prepare for Medicaid billing and claiming as well as data sharing processes for youth Medicaid status, projected release dates, and service provision. The state will complete similar work with the vendor and the DOC to facilitate needed systems changes. The state will also work with the Division of Social Services (DSS) to make necessary changes to eligibility systems/policies and procedures.  Targeted Case Management: DSCYF and DOC will engage providers for pre- or post- release TCM. This will occur through a request for proposals (RFP) to solicit providers. The departments will continue the design of these services, including payment models and requirements for service provision such as processes for warm handoffs and case manager contact requirements.  Screening and Diagnostic Services: DOC provides physical health screening and diagnostic services to incarcerated individuals; however, DOC needs to implement behavioral health screenings and diagnostics to ensure consistency with section 1902(a)(84)(D) of the Act. DSCYF and DOC will engage dental providers to be able to provide dental screenings and diagnostics. If any screening and diagnostic services are unable to be provided by either department pre-release, they will be provided as soon as practicable post-release in the community as part of the current managed care contracts.

Page 3 – Medicaid Director Wilson 4. Policies and Procedures: The state, DSCYF, DOC, and DSS will update applicable policies and procedures, including interdepartmental memoranda of understanding, to ensure compliance with section 1902(a)(84)(D) of the Act. Processes requiring updates include initial Medicaid applications and renewals, and policies for both facility and community providers. As always, CMS is available to provide technical assistance on any of these actions. If you have any questions, please contact Taneka Rivera at (410) 786-9502 or via email at Taneka.Rivera@cms.hhs.gov. Sincerely, Wendy E. Hill Petras, Acting Director Division of Program Operations Enclosures cc: Melissa Dohring

Docusign Envelope ID: 5339E47F-2214-4F08-8F45-7E408328FF8F UCr-"1-\l"'tl lVICl't I ur ncML In 1-\l'CUnutV11·\1"4 .::,cl"'(VIVC.:t CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2 5 -0 0 0 1 2.STATE DE 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT e XIX XXI 4. PROPOSED EFFECTIVE DATE 01/01/2025 FORM APPROVED 0MB No. 0938-0193 5. c!"l:'l"'!'l:"l:rl!'T"°""l""l!"T'T'T'!''l:"!l:ïð;'C11:A"""''!'ll:T"'l"""""X"'P'lll""!'l':ir---------"'f"":: 6-:. F=:E::D::-:E::R:-:A-:-L-:B:":"U".":D:"":G::-:E=T:-:- 1 :-:M=-PA-:-CñT=-:-: (A_m_o_u-:nt-s':"" in -:-W:-:'.H:-:'O::".LòE:-d-:-o "':'.' lla-r-:s)ó- Sections 1902(a)(84) and 1905(a)(19) of the Social Security Act and 42 CFR 440.169 a FFY 2025 $ _0 ________ _ b. FFY 2026 $ 221,282 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Supplement 5 to Attaehfflent d.1 A page 7 Supplement 6 to Attaehfflent 3.1 A page 8 e=f d ti=r·lfXZ; 1Q £upplefflent 5 to Attaehfflent d.1 A page 11 £upplefflent 5 to Attaehfflent d.1 A page 12 9. SUBJECT OF AMENDMENT Juvenile Justice Initiative 10. GOVERNOR'S REVIEW (Check One) OR ATTACHMENT (If Applicable) WEW- WEW- WEW- 3.1M Page 1 and Page 2 NEW WEW­ WEW- ® GOVERNOR'S OFFICE REPORTED NO COMMENT O OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL GENCY OFFICIAL 15. RETURN TO Andrew Wilson Andrew Wilson, Director, DMMA, P.O. Box 906 New Castle, --------------------DE19720 13. TITLE Director 14. DATE SUBMITTED 3/20/2025 I 10:29 AM EDT 16. DATE RECEIVED 03/20/2025 FOR CMS USE ONLY 17. DATE APPROVED 12/08/2025 PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 01/01/2025 20. TYPED NAME OF APPROVING OFFICIAL Wendy E. Hill Petras 22. REMARKS 21. TITLE OF APPROVING OFFICIAL Acting Director, Division of Program Operations 7/14/25-state approved pen and ink change to update Box 5, Box 7 and Box 8. FORM CMS-179 (09/24) Instructions on Back

Attachment 3.1-M Page 1

TN: 25-0001

Supersedes TN: NEW

Approval Date: 12/08/25 Effective Date: 01/01/25

Mandatory Coverage for Eligible Juveniles who are Inmates of a Public Institution Post Adjudication of Charges

State/Territory: Delaware

General assurances. State must indicate compliance with all four items below with a check. ցIn accordance with section 1902(a)(84)(D) of the Social Security Act, the state has an internal operational plan and, in accordance with such plan, provides for the following for eligible juveniles as defined in 1902(nn) (individuals who are under 21 years of age and determined eligible for any Medicaid eligibility group, or individuals determined eligible for the mandatory eligibility group for former foster care children age 18 up to age 26, immediately before becoming an inmate of a public institution or while an inmate of a public institution) who are within 30 days of their scheduled date of release from a public institution following adjudication: ցIn the 30 days prior to release (or not later than one week, or as soon as practicable, after release from the public institution), and in coordination with the public institution, any screenings and diagnostic services which meet reasonable standards of medical and dental practice, as determined by the state, or as otherwise indicated as medically necessary, in accordance with the Early and Periodic Screening, Diagnostic, and Treatment requirements, including a behavioral health screening or diagnostic service. ցIn the 30 days prior to release and for at least 30 days following release, targeted case management services, including referrals to appropriate care and services available in the geographic region of the home or residence of the eligible juvenile, where feasible, under the Medicaid state plan (or waiver of such plan). ցThe state acknowledges that a correctional institution is considered a public institution and may include prisons, jails, detention facilities, or other penal settings (e.g., boot camps or wilderness camps).

PRA Disclosure Statement - This use of this form is mandatory and the information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 5121 of the Consolidated Appropriations Act, 2023. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 #85). Public burden for all of the collection of information requirements under this control number is estimated to take about 50 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Attachment 3.1-M Page 2

TN: 25-0001

Supersedes TN: NEW

Approval Date: 12/08/25 Effective Date: 01/01/25

Additional information provided (optional):

܆No

܈Yes [provide below]

The authority to provide for mandatory coverage for eligible juveniles who are inmates of a public institution post adjudication of charges will sunset on December 31, 2026.

The state may determine that it is not feasible to provide the required services during the pre-release period in certain carceral facilities (e.g., identified local jails, youth correctional facilities, and state prisons) and/or certain circumstances (e.g. unexpected release or short-term stays). The state will maintain clear documentation in its internal operational plan regarding each facility and/or circumstances where the state determines that it is not feasible to provide for the required services during the pre-release period. This information is available to CMS upon request. Services will be provided post-release, including the mandatory 30-days of targeted case management, screening, and diagnostic services.

PRA Disclosure Statement - This use of this form is mandatory and the information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 5121 of the Consolidated Appropriations Act, 2023. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 #85). Public burden for all of the collection of information requirements under this control number is estimated to take about 50 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Table of Contents State/Territory Name: Delaware State Plan Amendment (SPA) #: 25-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) Form CMS-179 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group June 13, 2025 Andrew Wilson Medicaid Director Division of Medicaid and Medical Assistance Delaware Health and Social Services P.O. Box 906 New Castle, DE 19720-0906 Re: Delaware State Plan Amendment (SPA) 25-0004 Dear Medicaid Director \\Tilson: CMS CENTERS FOR MEDICARE & MEDICAID Sl:RVICIS CENTER FOR MEDICAID & CHIP SERVICES The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 25-0004. This amendment proposes to support the Delaware Division of Medicaid and Medical Assistance (DMMA) goal of expanding access to coverage, including coverage for those who need immediate care while applying for Medicaid. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act. This letter infonns you that Delaware's Medicaid SPA TN 25-0004 was approved on June 12, 2025, effective January 1, 2025. Enclosed are copies of the Form CMS-179 and approved SPA page to be incorporated into the Delaware State Plan. If you have any questions, please contact Talbatha Myatt at (215) 861-4259, or via email at Talbatha.Myatt@cms.hhs.gov. Enclosures Sincerely, Ruth A. Hughes, Acting Director Division of Program Operations

Docusign Envelope ID: 6F305180-88F0-4E51-95EC-CC03C10ED096 UCr'l"'\n ltV1CI"& I vr nc.,·H •. I n l"'\l'fUnVIVll"'\1'4 .:::,cf'\VI\JC..:> CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 5 _Q 0 0 4 DE -- ---- -- 3. PROGRAM IDENTIFICATION TITLE OF THE SOCIAL SECURITY ACT @ XIX 0 XXI 4. PROPOSED EFFECTIVE DATE 01/01/2025 FORM APPROVED 0MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) 42 CFR 435.915, 42 CFR 45.916 a FFY 2025 $ 9,222,326 b. FFY 2026 $ 9,249,269 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Mtashment 4 .17 1 Page e Attachment 4.17-A Page 5 9. SUBJECT OF AMENDMENT Retroactive Eligibility 10. GOVERNOR'S REVIEW (Check One) @GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL GENCY OFFICIAL OR ATTACHMENT (If Applicable) Mtashment 4 .17 1 Page e Attachment 4.17-A Page 5 0 OTHER, AS SPECIFIED: 15. RETURN TO 1udrew Wilson Andrew Wilson, Director, DMMA, P.O. Box 906 New Castle, ---------------------DE19720 13. TITLE Director 14. DATE SUBMITTED 3/26/2025 I 11:48 AM EDT 16. DATE RECEIVED 03/26/2025 FOR CMS USE ONLY 17. DATE APPROVED 06/12/2025 PLAN APPROVED- ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 01/01/2025 20. TYPED NAME OF APPROVING OFFICIAL Ruth A Hughes 22. REMARKS 19. SIGNATUR 21. TITLE OF APPROVING OFFICIAL Acting Director, Division of Program Operations 6 -1 2 -25-state authorized pen and ink change to update SPA pages in Box 7 and Box 8. FORM CMS-179 (09/24) Instructions on Back

Revision: HCFA-PM 95-3 (MB) May 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE LIENS AND ADJUSTMENTS OR RECOVERIES CONTINUED Specifies which Medicaid payments DHSS will seek to recover: and, Attachment 4.17-A Page 5 Notifies the applicant, guardian, and/or responsible party of appeal procedures, specifically stating, "If you are dissatisfied with any decision made by the Division of Medicaid and Medical Assistance (DMMA), you have the right to request an appeal of the decision by requesting a fair hearing. You must submit a written request to the local DHSS office within 90 days of the action". DHSS exempts from estate recovery all Medicare Savings Program cost sharing benefits with dates of service on or after January 1, 2010 for qualified dual eligibles age 55 and over, but otherwise DHSS shall seek estate recovery after the client's death of the maximum recoverable amount to be defined as the total of funds disbursed or incurred by DHSS (including Federal matching dollars) during the time an individual, age 55 and over, receives covered Medicaid services paid for by DHSS including the total capitation payments for the period the beneficiary was enrolled in the managed care organization (MCO), and for any medical assistance payments made for nursing facility services, home and community- based services, and related hospital and prescription drug services paid during a period of retroactive eligibility. When the beneficiary enrolls in the MCO, the State provides a separate notice to the beneficiary, explaining premium payments made to the MCO are included in the claim against the estate. Collections efforts will include written notification to the executor, guardian, and/or responsible party of the client's long-term care balance owed via a claim summary report. If a lien was placed on the client's property upon entry to the long-term care institution, DHSS will place a recovery claim against the proceeds from the sale of the property. DHSS will also pursue obtaining any residual funds remaining in a trust to offset any balance owed DHSS. Upon request, DHSS will work with heirs of the estate who voluntarily wish to satisfy the recovery claim on a case-by-case basis offering mutually agreed upon payment schedules if necessary. Additionally, when the maximum recoverable amount cannot be collected DHSS may agree to accept partial recoveries. TN No. SPA# 25-0004 Supersedes TN No. SPA# 1 2-008 Approval Date June 12. 2025 Effective Date January 1, 2025

Table of Contents

State/Territory Name: Delaware State Plan Amendment (SPA) #: 25-0009 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

!! "#$%&'%()*+*,- +++./0*,+++123 ( 3 45 

6
7
 
8

9 
   :
; 

<  69=9
 >??@ABCDFGHHG@ I 9  < =

9
9   JKLMNOPKQOSTUKMVOUWUXPMQYKNZ[\KY \]^_]`abc`P]defg`]WP]defgedY]`hef]a P]defgedg^d\U[LSi]`g_ec^aj`cki lmnKonp_qY_`]]_rNccstuu vg^aga\e_wrP[lxnml yz{|z}€}z‚ƒ„ ƒ‚†y‡ˆ‰Šz}‹ƒ„zŒ J]f]s]`mŽrpmpu M^d`]e‘ac^ Je`]f_c`rJPPM Jeheaec^cbP]defgedg^dP]defg‘Maaea_g^f] n’mnQoJkLc^_Ue“qgw LoSo”c•’ml Q]\ga_‘]rJKn’–pm N]—Mii`chg‘cbY_g_]L‘g^Ms]^ds]^_JK˜pu˜mmm’ J]g`M^d`]e‘ac^r S^Y]i_]s]`nmrpmpur_q]\]^_]`abc`P]defg`]g^dP]defgedY]`hef]a™\PYš`]f]eh]dJ]‘gg`]Y_g_]L‘g^Ms]^ds]^_™YLMšJK˜pu˜mmm’re^qefq_q]a_g_] i`cica]d_cdea`]“g`dg_`]^]g‘e^f`]ga]ae^`]ack`f]a_qg_]`]d]_]`se^]dfck^_g‘]g_gP]defged]^]›feg`wœasca_`]f]^_P]defgedgii‘efg_ec^o ]gii`ch]J]‘gg`]Y_g_]L‘g^Ms]^ds]^_™YLMšJK˜pu˜mmm’e_qg^]]f_eh]dg_]™ašcbžk‘wmnrpmpuo [bwckqgh]g^wŸk]a_ec^a`]“g`de^“_qeags]^ds]^_ri‘]ga]fc^_gf_Og^] gNeh]`gg_Og^] goNeh]`g¡fsaoqqao“cho Ye^f]`]‘wr ]^dwKoUe‘‘L]_`ga Mf_e^“Je`]f_c`rJeheaec^cbL`c“`gs Si]`g_ec^a \]^_]`bc`P]defgedW\U[LY]`hef]a ctr-ITT RS FOR MEDICARE &· MEOfCAJO SCfl\flCCS

Records / Submission Packages - View All DE - Submission Package - DE2025MS0001O - (DE-25-0009) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 CMS-10434 OMB 0938-1188 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID N/A SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date N/A State Information State/Territory Name: Delaware Medicaid Agency Name: Division of Medicaid and Medical Assistance Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID N/A SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date N/A SPA ID and Eſective Date SPA ID DE-25-0009 Reviewable Unit Proposed Eſective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 7/1/2025 DE-17-0010 Optional Eligibility Groups 7/1/2025 DE-19-0008 Individuals Eligible for but Not Receiving Cash Assistance 7/1/2025 n/a Individuals Eligible for Cash Except for Institutionalization 7/1/2025 DE-19-0008 Individuals in Institutions Eligible under a Special Income Level 7/1/2025 DE-19-0008 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID N/A SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives The purpose of this amendment is to amend the permanent allowance for the resource test to be excluded at renewal for certain Medicaid groups subject to an asset test. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2025 $0 Second 2026 $0 Federal Statute / Regulation Citation 42 CFR §435.916 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID N/A SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date N/A Governor's OŰce Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/9/2025 2:12 PM EST No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All DE - Submission Package - DE2025MS0001O - (DE-25-0009) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 CMS-10434 OMB 0938-1188 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-17-0010 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneţciaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/9/2025 2:13 PM EST 1. SSA Eligibility Determination State (1634 State) 2. State Eligibility Determination (SSI Criteria State) 3. State Eligibility Determination (209(b) State) 0 0 0

Records / Submission Packages - View All DE - Submission Package - DE2025MS0001O - (DE-25-0009) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 CMS-10434 OMB 0938-1188 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 NEW Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children NEW Individuals above 133% FPL under Age 65 APPROVED Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Yes No - • 0 ~ □ □ 0 ~ □ □ 0 ~ r.a □ 0 ~ □ □ 0 ~ □ □ 0 ~ r.a □ 0 ~ □ 0 ~ □ □ 0 ~ □ □ 0 ~ □ □ 0

Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization APPROVED Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneţciaries NEW Individuals in Institutions Eligible under a Special Income Level APPROVED PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic APPROVED Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW □ [!] [!] [!] r.a [!] □ [!] r.a [!] □ [!] □ [!] r.a [!] □ [!] □ [!] □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. Yes No 0 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: Individuals Eligible for but Not Receiving Cash Assistance PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/9/2025 2:14 PM EST

Records / Submission Packages - View All DE - Submission Package - DE2025MS0001O - (DE-25-0009) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Individuals who are eligible for but not receiving federal cash assistance or an optional state supplement. CMS-10434 OMB 0938-1188 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID n/a User-Entered SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 Group No Longer Covered Covered Through 6/30/2025 Terminated As Of 7/1/2025 PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/9/2025 2:16 PM EST

Records / Submission Packages - View All DE - Submission Package - DE2025MS0001O - (DE-25-0009) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Individuals who would be eligible for federal cash assistance or an optional state supplement, except for institutionalization. CMS-10434 OMB 0938-1188 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 The state covers the optional Individuals Eligible for Cash Except for Institutionalization eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are in a medical institution. 2. Would meet the eligibility requirements for at least one of the following cash assistance programs, but for the lower income standards used to determine eligibility for institutionalized individuals: a. SSI b. Optional State Supplement c. AFDC

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No 0 0

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. In calculating household income and resources for populations for which AFDC is the most closely related program, the following methodology(ies) are used: 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Census Bureau wages are discarded. 4. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of methodology: Description: Resources at Renewal Any increases in the total amount of resources determined available at an individual's most recent Medicaid application will be disregarded. a. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No Census Bureau wages are disregarded. Yes No The following less restrictive methodologies are used: • 0 • 0 0 •

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 D. Income Standard Used The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 F. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/9/2025 2:17 PM EST

Records / Submission Packages - View All DE - Submission Package - DE2025MS0001O - (DE-25-0009) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Individuals who are in medical institutions for at least 30 consecutive days who are eligible under a special income level. CMS-10434 OMB 0938-1188 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 The state covers Individuals in Institutions Eligible under a Special Income Level in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Have been in a medical institution for at least 30 consecutive days. 2. Have income at or below a standard described in section D.

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 B.Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No 0 0

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 C. Financial Methodologies 1. In calculating household income, the methodologies of the most closely related cash assistance program are used, except that disregards are not applied. 2. In calculating household resources, the methodologies of the most closely related cash assistance program are used Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of methodology: Description: Resources at Renewal Any increases in the total amount of resources determined available at an individual's most recent Medicaid application will be disregarded. Yes No A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy. The following less restrictive methodologies are used: 0 0

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 D. Income Standard Used The income standard for this group is: 250.00% 1. 300% of the SSI Federal Beneţt Rate (FBR) for an individual 2. Other lower income level a. Percent of the SSI FBR: b. Dollar amount: 0 • • 0

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 E.Resource Standard Used The resource standard for this group is the one used for the most closely-related cash assistance program.

Individuals in Institutions Eligible under a Special Income Level MEDICAID | Medicaid State Plan | Eligibility | DE2025MS0001O | DE-25-0009 Package Header Package ID DE2025MS0001O Submission Type OŰcial Approval Date 12/08/2025 Superseded SPA ID DE-19-0008 System-Derived SPA ID DE-25-0009 Initial Submission Date 9/10/2025 Eſective Date 7/1/2025 F.Additional Information (optional) Earned income of temporary census workers for purposes of eligibility will be excluded.

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/9/2025 2:18 PM EST

Table of Contents

State/Territory Name: Delaware State Plan Amendment (SPA) #: 25-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) Form CMS-179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group November 2 2025 Andrew Wilson Medicaid Director Division of Medicaid and Medical Assistance Delaware Health and Social Services P.O. Box 906 New Castle, DE 19720-0906 Re: Delaware State Plan Amendment (SPA) - 25-0010 Dear Medicaid Director Wilson: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 25-0010. This amendment proposes to update the Division of Medicaid and Medical Assistance (DMMA) Title XIX Medicaid State Plan regarding Buy-In, specifically, to provide clarity that DMMA accretes clients to the Buy-In for Part A, as needed, and Part B for all Medicaid programs where a client is dually eligible for Medicare and Medicaid. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act. This letter informs you that Delaware’s Medicaid SPA TN 25-0010 was approved on November 25, 2025, effective September 2, 2025. Enclosed are copies of Form CMS-179 and the approved SPA pages to be incorporated into the Delaware State Plan. If you have any questions, please contact Taneka Rivera at (410) 786-9502, or via email at Taneka.Rivera@cms.hhs.gov. Sincerely, Wendy E. Hill Petras, Acting Director Division of Program Operations Enclosures

Docusign Envelope ID: DE7CC77B-469E-45D2-BFAD-220D5636B6DF UCr-"1-\l"'tl lVICl't I ur ncML In 1-\l'CUnutV11·\1"4 .::,cl"'(VIVC.:t CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 5 -0 0 1 0 DE -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (e_) XIX 0 XXI 4. PROPOSED EFFECTIVE DATE 09/02/2025 FORM APPROVED 0MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2025 $ 0 42 CFR 407.40, 1843 & 1818(9) of the SSA 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT General Program Administration and Table of Contents pages 29 29b 29a-29b 9. SUBJECT OF AMENDMENT Buy-In 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL GENCY OFFICIAL b. FFY 2026 $ 0 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) General Program Administration and Table of Contents pages 29 29b 29a-29b 0 OTHER, AS SPECIFIED: 15. RETURN TO 1 vv• v·" wwvv•o,v ... Andrew Wilson Andrew Wilson, Director, DMMA, P.O. Box 906 New Castle, --------------------DE19720 13. TITLE Director 14. DATE SUBMITTED 9/2/2025 I 10:01 AM EDT 16. DATE RECEIVED 09/02/2025 FOR CMS USE ONLY 17. DATE APPROVED November 25, 2025 PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 09/02/2025 20. TYPED NAME OF APPROVING OFFICIAL Wendy E. Hill Petras 22. REMARKS 21. TITLE OF APPROVING OFFICIAL Acting Director, Division of Program Operations Box 7 and Box 8 Delaware authorized a pen and ink change on 11/25/2025. FORM CMS-179 (09/24) Instructions on Back

29a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE Citation

3.2 Coordination of Medicaid with Medicare and Other Insurance Sections 1843 and1818(g), of X__ The Medicaid agency has a buy-in agreement with CMS under the Act; 42 CFR 407.40(b)

which it agrees to cover Medicare premiums for Medicare-eligible individuals enrolled in certain Medicaid eligibility groups selected by the Medicaid agency below. The SPA pages that follow represent the entirety of the buy-in agreement and bind the state to follow federal regulations and guidance promulgated under these provisions. (a) Medicare premiums

(1) Medicare Part A premiums Sections 1902(a)(10)(E)(i)

(i) Qualified Medicare Beneficiary (QMB) Group: and 1905(p)(1) of the Act; 42 CFR 435.123 and 400.200 The Medicaid agency pays the Medicare Part A premiums (if applicable) for individuals in the QMB eligibility group as defined in the QMB pages of this plan using the following:

Section 1818(g) of the Act;

__X__ Buy-in agreement that pays the Part A premiums for individuals 42 CFR 406.26

entitled to Medicare Part A and/or enrolled in Part B.

42 CFR 406.32(g)

____Group payer arrangement Section 1902(a)(10)(E)(ii) of the Act; (ii) Qualified Disabled and Working Individuals (QDWI) Group 42 CFR 435.126 __X__ The Medicaid agency pays Part A premiums under a group payer arrangement, subject to any contribution required as described in the QDWI pages of this plan. Section 1843 of the Act;

(2) Medicare Part B Premiums 42 CFR 407.42 The Medicaid agency includes the following Medicaid eligibility groups in its buy-in group: __X__ Mandatory cash assistance and deemed recipients of cash assistance groups: 42 CFR 435.120, 435.121;

(i) Individuals who receive SSI or SSP or both and are covered under 435.130, 435.232; and

this plan as categorically needy. 435.234 TN No. SPA# 25-0010 Approval Date: November 25, 2025 Supersedes TN No. SP# 409 Effective Date: September 2, 2025

29b STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: DELAWARE Citation Sections 1619(b) and

(ii) Individuals who under the Act or any other provision of federal 1634(c) of the Act; 42 CFR Law are treated, for Medicaid eligibility purposes, as though they were 435.134, 435.135, 435.137, receiving SSI or SSP and are covered under this plan as categorically and 435.138

needy. Section 1931(b) of the Act; 42 CFR 435.145

__X__ Optional deemed recipients of cash assistance groups:

Individuals whom the State must consider to be recipients of AFDC, including those who receive adoption assistance, foster care or guardianship care under part E of title IV of the Act.

42 CFR 435.4

__X__ Medicare Savings Programs groups:

1902(a)(10)(E)(i) and

(i) Individuals in the QMB eligibility group as defined in the QMB 1905(p)(1) of the Act; 42 pages in this plan. CFR 435.123 and 400.200

Sections 1902(a)(10)(E)(iii) (ii) Individuals in the Specified Low-Income Medicare Beneficiary and 1905(p)(3)(A)(ii) of the (SLMB) eligibility group as defined in the SLMB pages in this plan. Act;42 CFR 435.124 Sections 1902(a)(10)(E)(iv) (i) Individuals in the Qualifying Individual (QI) eligibility group as and 1905(p)(3)(A)(i) of the

defined in the QI pages in this plan. Act, 42 CFR § 435.125 __X__ All other Medicaid eligibility groups. All other individuals eligible for Medicaid under Title 19 of the Act. (a) Other Health Insurance Section 1905(a) of the Act

The Medicaid agency pays insurance premiums for medical or any other type of remedial care to maintain a third-party resource for Medicaid covered services provided to eligible individuals (except individuals 65 years of age or older and disabled individuals, entitled to Medicare Part A but not enrolled in Medicare Part B). (See attachment 4.22-C for methods of determining cost-effectiveness.).

TN No. SPA# 25-0010 Approval Date: November 25, 2025 Supersedes TN No. SP# 409 Effective Date: September 2, 2025

This amendment proposes to request an extension of the exception from participation in the Recovery Audit Contractor’s (RAC) requirements under section 1902(a)(42)(B) of the Act.

Approval Document

This SPA amends the state plan to allow greater flexibility in covering select drugs when used for weight management, including weight loss and weight gain.

Approval Document

This amendment proposes to provide for mandatory coverage in accordance with section 1902(a)(84) as well as 1905(a)(19) and 42 CFR 440.169, authorizing Targeted Case Management for eligible juveniles who are incarcerated in a public institution post-adjudication of charges.

Approval Document

This amendment proposes to remove the September 30, 2025, sunset date for the Medication-Assisted Treatment (MAT) benefit, making the MAT benefit permanent under the Medicaid State Plan.

Approval Document

This amendment proposed to disregard at renewal increases in resources that were determined countable at a Medicaid beneficiary's most recent Medicaid application.

Approval Document

This amendment is to provide for mandatory coverage for eligible juveniles who are incarcerated in a public institution post-adjudication of charges.

Approval Document

This amendment proposes to update the Division of Medicaid and Medical Assistance (DMMA) Title XIX Medicaid State Plan regarding Buy-In, specifically, to provide clarity that DMMA accretes clients to the Buy-In for Part A, as needed, and Part B for all Medicaid programs where a client is dually eligible for Medicare and Medicaid.

Approval Document

This amendment proposes to provide additional postpartum visits with a recommendation by a practitioner or clinician licensed under Title 24 acting within their scope of practice.

Approval Document

This SPA updates the payment methodology for physician administered drugs and high investment medications.

Approval Document

This plan amendment adds language to the Medicaid State Plan regarding lactation counseling services for pregnant and postpartum individuals.

Approval Document

This plan amendment updates the methodology for pediatric nursing facility care pediatric facility care currently applies only for members up to age 21.

Approval Document

This amendment proposes to support the Delaware Division of Medicaid and Medical Assistance (DMMA) goal of expanding access to coverage, including coverage for those who need immediate care while applying for Medicaid.

Approval Document

This amendment proposes to request an extension of the exception from participation in the Recovery Audit Contractor’s (RAC) Program.

Approval Document

To modify the personal needs allowance amount for individuals residing in long-term care facilities.

Approval Document

This plan amendment modifies the reimbursement methodology for vaccines and vaccine administration.

Approval Document

This amendment is to update state plan assurances in accordance with federally mandated quality reporting requirements for the Child Core Set and the behavioral health quality measures on the Adult Core Set outlined in 42 CFR 431.16 and 437.10 through 437.15.

Approval Document

The purpose of this amendment is to renew Delaware's 1915 State Plan HCBS benefit. The effective date for this renewal is January 1, 2025. This SPA is approved for five years expiring December 31, 2029, in accordance with 1915(7) of the Social Security Act.

Approval Document

To add the role of pharmacist as a provider type.

Approval Document

This amendment proposes removing the premiums requirement for participation in the Medicaid Workers with Disabilities (MWD) Program.

Approval Document

This SPA amends the State Plan to add coverage of prescribed drugs when medically necessary during drug shortages.

Approval Document

To provide Doula services as separately reimbursed pregnancy-related services.

Approval Document

To comply with the current law and revise the Medicaid State Plan to align with the Consolidated Appropriations Act of 2022 and Senate Bill 220 of the 152nd Delaware General Assembly.

Approval Document

This amendment provides 12 months of continuous eligibility to children under age 19 enrolled in Medicaid.

Approval Document

This plan amendment revises the Medicaid reimbursement for ground emergency transportation services (GEMT).

Approval Document

This SPA amends the State Plan to allow the State to enter into value-based contract arrangements with drug manufacturers through supplemental rebate agreements.

Approval Document

This SPA updates language on the Delaware excluded drug coverage pages to reflect coverage of selective medications by referencing the state’s webpage and policy handbook resources instead of listing specific covered medications. Additionally, the SPA amends the Title XIX Medicaid State Plan regarding physician administered drug reimbursement rates.

Approval Document

This amendment proposes to remove the optional service, case management of high-risk pregnant women, from the Delaware Medicaid State Plan as these services will now be provided via an evidence-based home visiting model under 1115 waiver authority, effective January 1, 2023.

Approval Document

Ambulatory Surgical Center Services Rate

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

CMS is approving DE-19-0009 which amends the State Plan to allow Medicaid beneficiaries to request coverage from pharmacies of select FDA approved over-the-counter medications through an agreement with the Department of Public Health Medical Director for the purpose of generating a prescription and clarifies the coverage policy related to drugs indicated for the treatment of obesity.

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

This SPA updates Optional Eligibility Groups which includes Individuals Eligible for Cash Except for Institutionalization, Individuals in Institutions Eligible under a Special Income Level and Ticket to Work Basic.

Approval Document

Approval Document

Approval Document

Approval Document

Ensures individuals under 2l in qualified inpatient psychiatric residential treatment facilities are guaranteed access.

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

This amendment covers and reimburses all United States Preventive Services Task Force (USPSTF) grade A and B clinical preventive services and approved adult vaccines and their administration recommended by the Advisory Committee on Immunization Practices (ACIP), without cost sharing; and establishes a one percentage point increase in federal medical assistance percentage (FMAP) for these service expenditures whether they are provided in fee-for-service (FFS), managed care or under an alternate benefit plan.

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Allows the A1-A3 State Plan Pages to supersede the Current Attorney General Certification, Organizational Chart, Description of the Single State Agency, the Description of Medical and Support Staff, and Pages 2-8, the Organization of the State Agency.

Approval Document

Approval Document

Approval Document

Attachment

Form CMS-179

Coverage of barbiturates and benzodiazepines for dual eligibles as a Medicare Part D drug and update quantity limits for opiod analgesics.

Approval Document

Payment methodology for Outpatient hospital services specifically Partial hospital psychiatric services and PPEC services.

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Approval Document

Approval Document

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Approval Document

Attachment

Form CMS-179

Approval Document

Approval Document

Attachment

Form CMS-179