_____________________________________________________________________________

Table of Contents

State/Territory Name: Florida

State Plan Amendment (SPA) #: FL-13-0001

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Florida consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES a

Centers for Medicare & Medicaid Services f “Cc M Ss aoe Security Boulevard, Mail Stop: $2-01-16 (CENTERS FOR MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Mr. Justin Senior Acting Deputy Secretary NOV 18 2013

Agency for Health Care Administration 2727 Mahan Drive, MS #20 Tallahassee, FL 32308-5403

Dear Mr. Senior:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPAs) numbered FL-13-0001 and FL-13-0002 submitted on September 13, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

In this SPA, page CS15 provides assurance that the state will apply methodologies based on MAGIT for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low-income children, including a special program for children with disabilities. Page CS10 allows the state to cover children who have access to public employee coverage and updates the supporting documentation. These pages are attached to this letter and should be incorporated into the current CHIP state plan according to the table below. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

New State Plan Page Impact on Current State Plan Section

CS15: MAGI-Based Income Methodologies Section 4.3: Add new subsection and supersede information on income eligibility and methods

CS7: Targeted Low-Income Children (except Sections 4.1.1, 4.1.2, 4.1.3: Supersede all Children with Disabilities)

CS7: Special Program for Children with Sections 3.1, 3.2, 4.1.6, 4.1.9, 4.3 and 4.4.1:

Disabilities Supersede information on Children’s Medical Services Network

CS10: Children Who Have Access to Public Section 4.4.1: Supersede information on

Employee Coverage dependents of employees of a public agency

CS10: Maintenance of Agency Contribution Appendix: Supersede current documentation

Page 2 — Mr. Justin Senior

XXI Medicaid Expansion:

SPA number FL-13-0002 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your Title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to

Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Ms. Jackie Glaze, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosures ce: Jackie Glaze, ARA, CMS Region IV Gail Hansen, MediKids Program, Agency for Health Care Administration

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility FL.0314.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Florida State Funds: $ Federal Funds: $ Submitted By: Gail Hansen Last Revision Date: Nov 5, 2013 Submit Date: Sep 13, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. FL-13-0001 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation CSY - 2102(b)(1)(B)(v) of the Social Security Act and 42 CFR 457.310, 315 and 320 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:628 out of 2000 CS7, CS10 and CS15 establish the MAGI income standards for all covered groups in the separate CHIP program. CS7 establishes eligibility for the targeted low-income children in the separate CHIP program and describes Title XXI Children's Medicaid Services for children with special health care needs. CS10 provides i f ti f th hild h h t bli l Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/07/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/07/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Cems CHIP Eligibility

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

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) 1 192 206 19 112 133

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

NOV 18 vis

SPA # FL-13-0002 Approval Date: Effective Date:

Page 1 of 1

ccmMs. CHIP Eligibility

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

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later.

If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just 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 for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: [J Include a prorated portion of the reasonably predictable increase in future income and/or family size. (Z Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

- An attachment is submitted:

PRA Disclosure Statement

SPA # FL-13-0001 Approval Date: NOV { 8 2013 Effective Date: January 1, 2014 Page 1 of 2

coms. CHIP Eligibility

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

SPA # FL-13-0001 Approval Date: NOV 1 8 2013 Effective Date: January 1, 2014 Page 2 of 2

ccmMs CHIP Eligibility

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

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

Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

@ The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL) ath 6 140 210 x 6 19 133 210 ee

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

Is the program available to all eligible targeted low-income children? | Yes

Program Description

NOV 18 2013

Effective Date: January 1, 2014 Page 1 of 3

SPA # FL-13-0001 Approval Date:

Cems CHIP Eligibility

Describe disability criteria used.

Children's Medical Services Network (CMSN) offers a broad range of medical, therapeutic and supportive services for Title XXI eligible children with special health care needs. CMSN services focus on helping the child grow up healthier and includes prevention and early intervention services, primary care, medical and therapeutic specialty care, and long term care. Services are coordinated through nurses and social workers who help organize their child's care. Children enrolled in the CMSN receive the same benefits as those offered through the Medicaid program, including EPSDT services.

State law defines children with special health care needs as “those children younger than 21 years of age who have chronic and serious physical, developmental, behavioral, or emotional conditions and who require health care and related services of a type or amount beyond that which is generally required by children.” (s. 391.021(2), F.S.)

The Florida KidCare application contains questions to identify a child has a special health care need. Such children are referred to CMSN for a clinical eligibility determination. CMSN uses a four level Clinical Eligibility Screening Guide. Except for levels three and four, screening is done by telephone with the parent. Ifa parent declines or cannot be located the child is reported as not clinically eligible. Level I identifies medical, developmental and behavioral health conditions that have lasted or are expected to last 12 months or longer. If clinical eligibility cannot be determined at the first level, the screener proceeds to Level IT, which includes disability screening questions from the National Survey of Children with Special Health Care Needs. If clinical eligibility cannot be determined at Level IL, Level III involves a medical record review. If clinical eligibility still cannot be determined, Level IV is a physical exam with the CMS medical director or designee.

Describe program, including additional benefits offered.

A child with a physical, developmental or behavioral special health care need receives the standard Medicaid benefit package, including the behavioral health services package, through the CMSN. Early intervention services, respite services, genetic testing, genetic and nutritional counseling, and parent support services may be offered, if such services are determined to be medically necessary. Effective July 1, 2009, CMSN clinically eligible children may elect to opt out of CMSN and enroll in MediKids or Healthy Kids, depending on their age.

Children who have serious emotional disturbance or substance dependence problems will be referred to the Department of Children and Families (DCF) for specialized behavioral health care services. DCF provides specialized behavioral health services for CMSN enrolled school-age children with serious emotional disturbance or substance abuse problems. These children receive their physical health care through CMSN.

The CMSN delivery system is a private provider network that includes local, regional and tertiary facilities and private health care providers. The delivery system incorporates a continuum of care that includes early intervention programs, primary and specialty care, and long term care. The specialty care providers are primarily Medicaid providers and meet additional credentialing criteria. The CMSN has a series of standards that are used to designate specialty components of the network. CMSN also has standards for the designation of hospital facilities in the network.

CMSN maintains physician-credentialing standards that exceed the standards of the National Committee for Quality Assurance. Specifically, primary care physicians must be Board Certified Pediatricians or Family Practitioners. There is a standard waiver process to grant exceptions to the standard under special circumstances and when in the best interests of the CMSN participants.

PRA Disclosure Statement

SPA # FL-13-0001 Approval vaNOV { 8 2013 Effective Date: January 1, 2014 Page 2 of 3

coms CHIP Eligibility

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

V.20130709

SPA # FL-13-0001 Approval ate NOV L 8 2013

Effective Date: January 1, 2014 Page 3 of 3

ccmMs CHIP Eligibility

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

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

rl Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment. The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: @ Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. C: Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act. Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children (@ The same as the standards for Targeted Low-Income Children C Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage, or only certain children:

@ All children who have access to public employee coverage

C: Certain children who have access to public employee coverage:

[li] Attach methodology the state has used to calculate maintenance of agency contribution.

An attachment is submitted.

The state provides assurance that the state will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance effort condition continues to be met.

Children who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

NOV 18 2013

SPA # FL-13-0001 Approval Date: Effective Date: January 1, 2014

V.20130917

Page | of |

Dependents of State Employee Coverage Maintenance of Agency Contribution

The charts below show the total monthly and annual premium for career service and payall (payalls includes executive, legislative and judicial branch agencies for employees with enhanced benefits) state employee family coverage, broken out by the family’s premium and the state’s expenditure. The Consumer Price Index for medical expenses (CPI- Medical) rate is shown for each year and the inflation column represents the previous year’s state expenditure multiplied by the CPI-Medical for that year. The result is the last column entitled “1997 Annual State Expenditure Increased by CPI”. In order to meet the maintenance of agency contribution requirement to cover state employees using Title XXI funding, the actual state expenditures need to exceed the annual state expenditure increased by the CPI. The charts below show that the State of Florida meets the maintenance of agency contribution requirement with the state annual expenditure exceeding the annual state expenditure increased by the CPI for each year since 1997. Going forward, each year will be computed to ensure continued compliance with the maintenance of agency contribution requirement.

Career Service State Employees State Employee Health Insurance State Employee Health Insurance : Employee 1997 Annual State Year | Total Family) ent State | Total Family | Employee | te Aniual | CP-Medical | Inflation Expenditure - Monthly set ¥ Monthly Annual Annual Family Expendi increased by CPI Premium arally Expenditure} = Premium Premium penditure Premium.

1997 $361.72 $93.58 $268.14 $4,340.64 $1,122.96 $3,217.68 $3,217.68 1998 $456.20 $93.58 $362.62 $5,474.40 $1,122.96 $4,351.44 3.2% $102.97 $3,320.65 1999 $470.23 $107.61 $362.62 $5,642.76 $1,291.32 $4,351.44 3.5% $116.22 $3,436.87 2000 $507.80 $116.20 $391.60 $6,093.60 $1,394.40 $4,699.20 4.1% $140.91 $3,577.78 2001 $583.96 $133.62 $450.34 $7,007.52 $1,394.00 $4,699.00 4.6% $164.58 $3,742.36 2002 $659.83 $151.00 $508.83 $7,918.00 $1,812.00 $6,106.00 4.7% $175.89 $3,918.25 2003 $765.50, $175.17 $590.33 $9,186.00 $2,102.00 $7,084.00 4.0% $156.73 $4,074.98 2004 $842.00 $175.17 $666.83 $10,104.00 $2,102.00 $8,002.00 4.4% $179.30 $4,254.28 2005 $895.92 $180.00 $715.92 $10,751.00 $2,160.00 $8,591.00 4.2% $178.68 $4,432.96 2006 $967.58 $180.00 $787.58 $11,611.00 $2,160.00 $9,451.00 4.0% $177.32. $4,610.28 2007 _| $1,016.00 $180.00 $836.00 $12,192.00 $2,160.00 $10,032.00 4.4% $202.85. $4,813.13 2008 | $1,127.75 $180.00 $947.75 $13,533.00 $2,160.00 $11,373.00 3.7% $178.09 $4,991.21 2009 | $1,127.75 $180.00 $947.75 $13,533.00 $2,160.00 $11,373.00 3.2% $159.72, $5,150.93 2010 | $1,184.14 $180.00 $1,004.14 $14,209.68 $2,160.00 $12,050.00 3.4% $175.13 $5,326.06 2011 | $1,243.34 $180.00 $1,063.34 $14,920.08 $2,160.00 $12,760.00 3.0% $159.78 $5,485.85 2012 _| $1,243.34 $180.00 $1,063.34 $14,920.08 $2,160.00 $12,760.00 3.7% $202.98 $5,688.82 2013 | $1,243.34 $180.00 $1,063.34 $14,920.08 $2,160.00 $12,760.00

NOV 18 2013

SPA # FL-13-0001 Approval Date: Effective Date: January 1, 2014

Payall State Employees State Employee Health Insurance State Employee Health insurance 1997 Annual Employee Employee State Year Total Family Monthly State Total Family Annual | State Annual CPI Inflation Expenditure : Monthly. Monthly Annual Medical

Premium. Family Expenditure| Premium Family Expenditure Increased by

Premium Premium CPi 1997 $361.72 $0.00 $268.14 $4,340.64 $0.00 $4,340.64 $3,217.68 1998 $456.20 $0.00 $362.62 $5,474.40 $0.00 $5,474.40 3.2% $102.97 $3,320.65 1999 | $470.23 $0.00 $362.62 $5,642.76 $0.00 $5,642.76 | 3.5% $116.22 $3,436.87 2000 $507.80 $0.00 $391.60 $6,093.60 $0.00 $6,093.60 4.1% $140.91 $3,577.78 2001 $583.96 $0.00 $450.34 $7,007.52 $0.00 $7,007.52 4.6% $164.58 $3,742.36 2002 $508.83 $0.00 $508.83 $6,106.00 $0.00 $6,106.00 4.7% $175.89 $3,918.25 2003 $590.33 $0.00 $590.33 $7,084.00 $0.00 $7,084.00 4.0% $156.73 $4,074.98 2004_| $666.83 $0.00 $666.83 $8,002.00 $0.00 $8,002.00 | 4.4% $179.30 $4,254.28 2005 $715.92 $0.00 $715.92 $8,591.00 $0.00 $8,591.00 4.2% $178.68 $4,432.96 2006 $787.58 $0.00 $787.58 $9,451.00 $0.00 $9,451.00 4.0% $177.32 $4,610.28 2007 $836.00 $0.00 $836.00 __| $10,032.00 $0.00 $10,032.00 | 4.4% $202.85 $4,813.13 2008 $947.75 $0.00 $947.75 $11,373.00 $0.00 $11,373.00 3.7% $178.09 $4,991.21 2009 _|$1,127.75 $0.00 $947.75 _| $13,533.00 $0.00__| $13,533.00 | 3.2% $159.72 $5,150.93 2010 _|$1,184.14 $30.00 $1,004.14 | $14,209.68 $360.00 $13,849.68 3.4% $175.13 $5,326.06 2011 _|$1,243.34 $30.00 $1,063.34 _| $14,920.08 $360.00 $14,560.08 3.0% $159.78 $5,485.85 2012 _|$1,243.34 $30.00 $1,063.34 _| $14,920.08 $360.00 $14,560.08 3.7% $202.98 $5,688.82 2013 [$1,243.34 _| $30.00 . | $1,063.34 _| $14,920.08 $360.00__| $14,560.08

NOV 18 2013

SPA # FL-13-0001 Approval Date: Effective Date: January 1, 2014

_____________________________________________________________________________

Table of Contents

State/Territory Name: Florida

State Plan Amendment (SPA) #: FL-13-0002

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Florida consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES a

Centers for Medicare & Medicaid Services f “Cc M Ss aoe Security Boulevard, Mail Stop: $2-01-16 (CENTERS FOR MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Mr. Justin Senior Acting Deputy Secretary NOV 18 2013

Agency for Health Care Administration 2727 Mahan Drive, MS #20 Tallahassee, FL 32308-5403

Dear Mr. Senior:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPAs) numbered FL-13-0001 and FL-13-0002 submitted on September 13, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

In this SPA, page CS15 provides assurance that the state will apply methodologies based on MAGIT for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low-income children, including a special program for children with disabilities. Page CS10 allows the state to cover children who have access to public employee coverage and updates the supporting documentation. These pages are attached to this letter and should be incorporated into the current CHIP state plan according to the table below. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

New State Plan Page Impact on Current State Plan Section

CS15: MAGI-Based Income Methodologies Section 4.3: Add new subsection and supersede information on income eligibility and methods

CS7: Targeted Low-Income Children (except Sections 4.1.1, 4.1.2, 4.1.3: Supersede all Children with Disabilities)

CS7: Special Program for Children with Sections 3.1, 3.2, 4.1.6, 4.1.9, 4.3 and 4.4.1:

Disabilities Supersede information on Children’s Medical Services Network

CS10: Children Who Have Access to Public Section 4.4.1: Supersede information on

Employee Coverage dependents of employees of a public agency

CS10: Maintenance of Agency Contribution Appendix: Supersede current documentation

Page 2 — Mr. Justin Senior

XXI Medicaid Expansion:

SPA number FL-13-0002 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your Title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to

Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Ms. Jackie Glaze, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosures ce: Jackie Glaze, ARA, CMS Region IV Gail Hansen, MediKids Program, Agency for Health Care Administration

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility FL.0315.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Florida State Funds: $ Federal Funds: $ Submitted By: Gail Hansen Last Revision Date: Oct 29, 2013 Submit Date: Sep 13, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. FL-13-0002 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:303 out of 2000 SPA CS3 establishes a new Medicaid eligibility group for 6 through 18 year olds with incomes between 100% and 133% of the federal poverty level. Florida has an existing Medicaid Expansion eligibility group of infants under one year of age with income between 185% and 200% of the federal poverty level. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/07/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/07/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

January 1, 2014 November 18, 2013

ccmMs. CHIP Eligibility

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

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later.

If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just 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 for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: [J Include a prorated portion of the reasonably predictable increase in future income and/or family size. (Z Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

- An attachment is submitted:

PRA Disclosure Statement

SPA # FL-13-0001 Approval Date: NOV { 8 2013 Effective Date: January 1, 2014 Page 1 of 2

coms. CHIP Eligibility

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

SPA # FL-13-0001 Approval Date: NOV 1 8 2013 Effective Date: January 1, 2014 Page 2 of 2

ccmMs CHIP Eligibility

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

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

Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

@ The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL) ath 6 140 210 x 6 19 133 210 ee

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

Is the program available to all eligible targeted low-income children? | Yes

Program Description

NOV 18 2013

Effective Date: January 1, 2014 Page 1 of 3

SPA # FL-13-0001 Approval Date:

Cems CHIP Eligibility

Describe disability criteria used.

Children's Medical Services Network (CMSN) offers a broad range of medical, therapeutic and supportive services for Title XXI eligible children with special health care needs. CMSN services focus on helping the child grow up healthier and includes prevention and early intervention services, primary care, medical and therapeutic specialty care, and long term care. Services are coordinated through nurses and social workers who help organize their child's care. Children enrolled in the CMSN receive the same benefits as those offered through the Medicaid program, including EPSDT services.

State law defines children with special health care needs as “those children younger than 21 years of age who have chronic and serious physical, developmental, behavioral, or emotional conditions and who require health care and related services of a type or amount beyond that which is generally required by children.” (s. 391.021(2), F.S.)

The Florida KidCare application contains questions to identify a child has a special health care need. Such children are referred to CMSN for a clinical eligibility determination. CMSN uses a four level Clinical Eligibility Screening Guide. Except for levels three and four, screening is done by telephone with the parent. Ifa parent declines or cannot be located the child is reported as not clinically eligible. Level I identifies medical, developmental and behavioral health conditions that have lasted or are expected to last 12 months or longer. If clinical eligibility cannot be determined at the first level, the screener proceeds to Level IT, which includes disability screening questions from the National Survey of Children with Special Health Care Needs. If clinical eligibility cannot be determined at Level IL, Level III involves a medical record review. If clinical eligibility still cannot be determined, Level IV is a physical exam with the CMS medical director or designee.

Describe program, including additional benefits offered.

A child with a physical, developmental or behavioral special health care need receives the standard Medicaid benefit package, including the behavioral health services package, through the CMSN. Early intervention services, respite services, genetic testing, genetic and nutritional counseling, and parent support services may be offered, if such services are determined to be medically necessary. Effective July 1, 2009, CMSN clinically eligible children may elect to opt out of CMSN and enroll in MediKids or Healthy Kids, depending on their age.

Children who have serious emotional disturbance or substance dependence problems will be referred to the Department of Children and Families (DCF) for specialized behavioral health care services. DCF provides specialized behavioral health services for CMSN enrolled school-age children with serious emotional disturbance or substance abuse problems. These children receive their physical health care through CMSN.

The CMSN delivery system is a private provider network that includes local, regional and tertiary facilities and private health care providers. The delivery system incorporates a continuum of care that includes early intervention programs, primary and specialty care, and long term care. The specialty care providers are primarily Medicaid providers and meet additional credentialing criteria. The CMSN has a series of standards that are used to designate specialty components of the network. CMSN also has standards for the designation of hospital facilities in the network.

CMSN maintains physician-credentialing standards that exceed the standards of the National Committee for Quality Assurance. Specifically, primary care physicians must be Board Certified Pediatricians or Family Practitioners. There is a standard waiver process to grant exceptions to the standard under special circumstances and when in the best interests of the CMSN participants.

PRA Disclosure Statement

SPA # FL-13-0001 Approval vaNOV { 8 2013 Effective Date: January 1, 2014 Page 2 of 3

coms CHIP Eligibility

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

V.20130709

SPA # FL-13-0001 Approval ate NOV L 8 2013

Effective Date: January 1, 2014 Page 3 of 3

ccmMs CHIP Eligibility

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

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

rl Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment. The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: @ Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. C: Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act. Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children (@ The same as the standards for Targeted Low-Income Children C Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage, or only certain children:

@ All children who have access to public employee coverage

C: Certain children who have access to public employee coverage:

[li] Attach methodology the state has used to calculate maintenance of agency contribution.

An attachment is submitted.

The state provides assurance that the state will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance effort condition continues to be met.

Children who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

NOV 18 2013

SPA # FL-13-0001 Approval Date: Effective Date: January 1, 2014

V.20130917

Page | of |

Dependents of State Employee Coverage Maintenance of Agency Contribution

The charts below show the total monthly and annual premium for career service and payall (payalls includes executive, legislative and judicial branch agencies for employees with enhanced benefits) state employee family coverage, broken out by the family’s premium and the state’s expenditure. The Consumer Price Index for medical expenses (CPI- Medical) rate is shown for each year and the inflation column represents the previous year’s state expenditure multiplied by the CPI-Medical for that year. The result is the last column entitled “1997 Annual State Expenditure Increased by CPI”. In order to meet the maintenance of agency contribution requirement to cover state employees using Title XXI funding, the actual state expenditures need to exceed the annual state expenditure increased by the CPI. The charts below show that the State of Florida meets the maintenance of agency contribution requirement with the state annual expenditure exceeding the annual state expenditure increased by the CPI for each year since 1997. Going forward, each year will be computed to ensure continued compliance with the maintenance of agency contribution requirement.

Career Service State Employees State Employee Health Insurance State Employee Health Insurance : Employee 1997 Annual State Year | Total Family) ent State | Total Family | Employee | te Aniual | CP-Medical | Inflation Expenditure - Monthly set ¥ Monthly Annual Annual Family Expendi increased by CPI Premium arally Expenditure} = Premium Premium penditure Premium.

1997 $361.72 $93.58 $268.14 $4,340.64 $1,122.96 $3,217.68 $3,217.68 1998 $456.20 $93.58 $362.62 $5,474.40 $1,122.96 $4,351.44 3.2% $102.97 $3,320.65 1999 $470.23 $107.61 $362.62 $5,642.76 $1,291.32 $4,351.44 3.5% $116.22 $3,436.87 2000 $507.80 $116.20 $391.60 $6,093.60 $1,394.40 $4,699.20 4.1% $140.91 $3,577.78 2001 $583.96 $133.62 $450.34 $7,007.52 $1,394.00 $4,699.00 4.6% $164.58 $3,742.36 2002 $659.83 $151.00 $508.83 $7,918.00 $1,812.00 $6,106.00 4.7% $175.89 $3,918.25 2003 $765.50, $175.17 $590.33 $9,186.00 $2,102.00 $7,084.00 4.0% $156.73 $4,074.98 2004 $842.00 $175.17 $666.83 $10,104.00 $2,102.00 $8,002.00 4.4% $179.30 $4,254.28 2005 $895.92 $180.00 $715.92 $10,751.00 $2,160.00 $8,591.00 4.2% $178.68 $4,432.96 2006 $967.58 $180.00 $787.58 $11,611.00 $2,160.00 $9,451.00 4.0% $177.32. $4,610.28 2007 _| $1,016.00 $180.00 $836.00 $12,192.00 $2,160.00 $10,032.00 4.4% $202.85. $4,813.13 2008 | $1,127.75 $180.00 $947.75 $13,533.00 $2,160.00 $11,373.00 3.7% $178.09 $4,991.21 2009 | $1,127.75 $180.00 $947.75 $13,533.00 $2,160.00 $11,373.00 3.2% $159.72, $5,150.93 2010 | $1,184.14 $180.00 $1,004.14 $14,209.68 $2,160.00 $12,050.00 3.4% $175.13 $5,326.06 2011 | $1,243.34 $180.00 $1,063.34 $14,920.08 $2,160.00 $12,760.00 3.0% $159.78 $5,485.85 2012 _| $1,243.34 $180.00 $1,063.34 $14,920.08 $2,160.00 $12,760.00 3.7% $202.98 $5,688.82 2013 | $1,243.34 $180.00 $1,063.34 $14,920.08 $2,160.00 $12,760.00

NOV 18 2013

SPA # FL-13-0001 Approval Date: Effective Date: January 1, 2014

Payall State Employees State Employee Health Insurance State Employee Health insurance 1997 Annual Employee Employee State Year Total Family Monthly State Total Family Annual | State Annual CPI Inflation Expenditure : Monthly. Monthly Annual Medical

Premium. Family Expenditure| Premium Family Expenditure Increased by

Premium Premium CPi 1997 $361.72 $0.00 $268.14 $4,340.64 $0.00 $4,340.64 $3,217.68 1998 $456.20 $0.00 $362.62 $5,474.40 $0.00 $5,474.40 3.2% $102.97 $3,320.65 1999 | $470.23 $0.00 $362.62 $5,642.76 $0.00 $5,642.76 | 3.5% $116.22 $3,436.87 2000 $507.80 $0.00 $391.60 $6,093.60 $0.00 $6,093.60 4.1% $140.91 $3,577.78 2001 $583.96 $0.00 $450.34 $7,007.52 $0.00 $7,007.52 4.6% $164.58 $3,742.36 2002 $508.83 $0.00 $508.83 $6,106.00 $0.00 $6,106.00 4.7% $175.89 $3,918.25 2003 $590.33 $0.00 $590.33 $7,084.00 $0.00 $7,084.00 4.0% $156.73 $4,074.98 2004_| $666.83 $0.00 $666.83 $8,002.00 $0.00 $8,002.00 | 4.4% $179.30 $4,254.28 2005 $715.92 $0.00 $715.92 $8,591.00 $0.00 $8,591.00 4.2% $178.68 $4,432.96 2006 $787.58 $0.00 $787.58 $9,451.00 $0.00 $9,451.00 4.0% $177.32 $4,610.28 2007 $836.00 $0.00 $836.00 __| $10,032.00 $0.00 $10,032.00 | 4.4% $202.85 $4,813.13 2008 $947.75 $0.00 $947.75 $11,373.00 $0.00 $11,373.00 3.7% $178.09 $4,991.21 2009 _|$1,127.75 $0.00 $947.75 _| $13,533.00 $0.00__| $13,533.00 | 3.2% $159.72 $5,150.93 2010 _|$1,184.14 $30.00 $1,004.14 | $14,209.68 $360.00 $13,849.68 3.4% $175.13 $5,326.06 2011 _|$1,243.34 $30.00 $1,063.34 _| $14,920.08 $360.00 $14,560.08 3.0% $159.78 $5,485.85 2012 _|$1,243.34 $30.00 $1,063.34 _| $14,920.08 $360.00 $14,560.08 3.7% $202.98 $5,688.82 2013 [$1,243.34 _| $30.00 . | $1,063.34 _| $14,920.08 $360.00__| $14,560.08

NOV 18 2013

SPA # FL-13-0001 Approval Date: Effective Date: January 1, 2014

_____________________________________________________________________________

Table of Contents

State/Territory Name: Florida

State Plan Amendment (SPA) #: FL-13-0004

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Florida consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES ae Centers for Medicare & Medicaid Services Cc M S 7500 Security Boulevard, Mail Stop: S2-01-16 . (CENTERS FOR MEDICARE & MEDICAID SERVICES: Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

.7 204 Mr. Justin Senior JAN 07 2

Acting Deputy Secretary

Agency for Health Care Administration 2727 Mahan Drive, MS #20 Tallahassee, FL 32308-5403

Dear Mr. Senior:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number FL-13-0004 submitted on December 6, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

SPA number FL-13-0004 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, non-payment of premiums, and continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Florida’s current state plan as detailed below:

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility - Residency Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR

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

Number

C820: Non-Financial Eligibility — Substitution of | Section 4.4.4 Coverage

CS21: Non-Payment of Premiums Section 8.7

C827: General Eligibility — Continuous Eligibility | Section 4.1.8

Your Title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Page 2 — Mr. Justin Senior

Telephone: (410) 786-5480 Facsimile: (410) 786-5882 E-mail: Lavern.Baty@cms.hbhs.gov

Official communications regarding program matters should be sent simultaneously to

Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4 Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosures ce: Jackie Glaze, ARA, CMS Region IV Gail Hansen, MediKids Program, Agency for Health Care Administration

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility FL.0566.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Florida State Funds: $ Federal Funds: $ Submitted By: Gail Hansen Last Revision Date: Dec 31, 2013 Submit Date: Dec 6, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. FL-13-0004 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:685 out of 2000 CS17, CS18, CS19, CS20, CS21 and CS27 establish non-financial eligibility for all covered groups in the separate CHIP program. CS17 establishes our residency requirements, CS18 establishes our citizenship requirements, CS19 establishes our social security number requirements, CS20 establishes our substitution of coverage i t CS21 t bli h t f i Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/07/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/07/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CEmMs. CHIP Eligibility

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

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

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

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

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i] A non-institutionalized pregnant woman who is living in the state and:

1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed.

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

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

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

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

Approval Date: JAN 0 1 2014

SPA# FL-13-0004

Effective Date: January 1, 2014

Page | of 2

CCMs CHIP Eligibility

One or more interstate agreement(s). No

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

PRA Disclosure Statement

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

V.20130917

SPA# FL-13-0004 Approval Date: JAN 0 7 2014 Effective Date: January 1, 2014 Page 2 of 2

Cems CHIP Eligibility

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

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

Citizenship

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

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

Who are citizens or nationals of the United States; or

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

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

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

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

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

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date

earlier than the date the notice is received by the individual. °

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing

in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). No

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

No

PRA Disclosure Statement

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

JAN 0 7 2014 V.20130917

SPA# FL-13-0004 Approval Date: Effective Date: January 1, 2014

Page 1 of |

CCMs CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

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

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

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205

and 1137 of the Social Security Act and the Privacy Act of 1974.

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

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

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

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

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

PRA Disclosure Statement

JAN 07 2014

SPA# FL-13-0004 Approval Date: Effective Date: January 1, 2014 Page | of 2

ccmMs. CHIP Eligibility

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

V.20130917

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SPA# FL-13-0004 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

Separate Child Health Insurance Program 8 igibility - Substitution of Coverage

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Substitution of Coverage

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

[ll] Substitution of coverage prevention strategy:

Name of policy Description

Waiting Period A child is not eligible for CHIP coverage when employer-sponsored or private health care coverage + has been voluntarily canceled within 60 days prior to xX the date of application, unless the cancellation meets an acceptable good cause reason.

A waiting period during which an individual is ineligible due to having dropped group health coverage. Yes

How long is the waiting period?

C One month @ Two months C 90 days

C Other

[li] The state allows exemptions from the waiting period for the following reasons:

i The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP [mM] through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B-2(c)(3)(v).

[lM] The cost of family coverage that includes the child exceeded 9.5 percent of the household income.

TI The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan.

iw A change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

[M] The child has special health care needs.

[i] The child lost coverage due to the death or divorce of a parent.

SPA# FL-13-0004 Approval Date: JAN 07 2014

Effective Date: January 1, 2014 Page 1 of 2

CcMS CHIP Eligibility

Does the state allow other exemptions in addition to those listed above? | Yes

Describe

1. Domestic violence led to the loss of coverage.

2. The health benefits coverage does not cover the child's health care | needs xX 3. The child has exhausted coverage under COBRA continuation provision.

([] If the state covers pregnant women, the waiting period does not apply to pregnant women.

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

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

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

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

V.20130917

JAN 0 7 2014

SPA# FL-13-0004 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems CHIP Eligibility

CNHs tend ott Aid 8 Oe OE ABET ONT

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

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes Please describe the lock-out period: Florida has a one month lock-out period due to premium non-payment. Florida does not require the payment of past due premiums nor does Florida charge enrollment fees. A CHIP eligible child’s coverage is reinstated beginning on the first day of the month after the advance premium for that upcoming month has been paid. What is the length of the time premium lock-out period? Select a length of time: @ One month C Two months C 90 days C Other (not to exceed 90 days) Are there exceptions to the required lock-out period? No

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

V.20130917

JAN 07 2014

SPA# FL-13-0004 Approval Date: Effective Date: January 1, 2014

Page | of 1

ccmMs CHIP Eligibility

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

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. | Yes

(@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[Ml] Attheendofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [MH The child attains the age specified by the state Agency or age 19. : [BH The child or child's representative requests voluntary disenrollment. [ii] The child is no longer a resident of the state.

iw The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[i] The child dies. [Mi] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

(7) Other

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

V.20130917

JAN 0 7 2014

SPA# FL-13-0004 Approval Date: . Effective Date: January 1, 2014 Page 1 of |

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Florida FL-18-0029-CHIP

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

March 19, 2021 Beth Kidder Deputy Secretary for Medicaid Agency for Health Care Administration, State of Florida 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308 Dear Ms. Kidder: Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) FL- 18-0029-CHIP, submitted on June 28, 2018, has been approved. FL-18-0029-CHIP implements mental health parity regulations at 42 CFR 457.496 to ensure that treatment limitations and financial requirements applied to mental health and substance use disorder benefits are no more restrictive than those applied to medical/surgical benefits. This SPA has an effective date of October 1, 2017, with the exception of the changes noted below. Through this SPA, Florida conducted a full parity analysis for the Healthy Kids population and requested deemed compliance for the MediKids and Children’s Medical Services populations.

Florida Healthy Kids Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), require states to ensure that financial requirements and treatment limitations applied to Mental Health/Substance Use Disorder (MH/SUD) benefits covered under the state child health plan are consistent with the mental health parity requirements of 2705(a) of the Public Health Service Act, in the same manner in which such requirements apply to a group health plan. To the extent that a state provides both M/S and MH/SUD benefits, it must demonstrate that financial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan comply with these requirements. Florida demonstrated compliance by providing the necessary assurances and supporting documentation that the state's application of non-quantitative treatment limitations and financial requirements to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act.

MediKids and Children’s Medical Services Plan Section 2103(c)(7)(B) of the Act, as implemented through regulations at 42 CFR 457.496(b), provides that if CHIP coverage includes Early, Periodic Screening, Diagnostic and Treatment (EPSDT) as defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the state plan will be deemed to satisfy parity requirements. Florida has provided the necessary assurances and supporting documentation that EPSDT is covered under Florida’s CHIP program and provided in accordance with sections 1905(r) and 1902(a)(43) of the Act.

Page 2 – Ms. Kidder

During our review of this SPA, the Centers for Medicare & Medicaid Services (CMS) identified areas of Florida health plan member handbooks that could be modified to better describe EPSDT coverage. As part of this SPA approval, Florida completed modifications to the MediKids and Children’s Medical Services managed care plan member handbooks on February 2, 2019. This update ensures that the member handbooks align with the requirements of 42 CFR 457.496(b), which cross reference to informing and administrative requirements in section 1902(a)(43) of the Act.

This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately.

Your title XXI project officer is Jack Mirabella. They are available to answer questions concerning this amendment and other CHIP-related issues. Their contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-2424 E-mail: jack.mirabella@cms.hhs.gov

If you have any questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Amy Lutzky Deputy Director /Signed Amy Lutzky/

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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:____State of Florida____________________________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

____________________________________ _______________________________ Beth Kidder, Deputy Secretary for Medicaid Date

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Beth Kidder Position/Title: Deputy Secretary for Medicaid Name: Position/Title: Name: Position/Title:

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 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

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SPA FL-17-0029-CHIP (Mental Health Parity and Addiction Equity Act (MHPAEA) - To implement the requirements of the Mental Health Parity and Addiction Equity Act of 2008 preventing group health plans and health insurance issuers from imposing less favorable benefit limitations on mental health or substance use disorder benefits.

Effective Date:

July 1, 2018

Proposed Implementation Date: July 1, 2018

1.4- TC Tribal Consultation (section 2107(e)(1)(C) Describe the consultation process that occurred specifically for the development and submission of the State Plan Amendment, when it occurred and who was involved.

SPA #21 – Proposed Effective Date: September 1, 2011 In accordance with out tribal consultation process described in Section 2.3-TC, letters were sent to the Seminole and Miccosukee Tribes on 9/7/2011 outlining the SPA changes. The letters ask that comments or questions be directed to Gail Hansen at the Agency for Health Care Administration.

SPA #22 –Effective Date:

July 1, 2012 In accordance with our approved tribal consultation process described in Section 2.3-TC, the tribal notification letters were sent to the Seminole and Miccousukee Tribes on June 21, 2012, listing the SPA changes. The letters asked that comments be directed to Gail Hansen at the Agency for Health Care Administration. The letters advised the tribes that no response would be interpreted as they had no comments. No response was received from either tribe.

SPA #23 – Effective Date:

October 1, 2012 In accordance with our approved tribal consultation process described in Section 2.3-TC, the tribal notification letters were sent to the Seminole and Miccosukee Tribes on August 13, 2012, listing the SPA changes. The letters asked that comments be directed to Gail Hansen at the Agency for Health Care Administration. The letters advised the tribes that no response would be interpreted as they had no comments. No response was received from either tribe.

SPA #24 – Effective Date:

August 1, 2014 In accordance with our approved tribal consultation process described in Section 2.3-TC, the tribal notification letters were sent to the Seminole and Miccosukee Tribes on June 18, 2014, describing the SPA changes, The letters asked that comments be directed to Gail Hansen at the Agency for Health Care Administration. The letters advised the tribes that no response would be interpreted as they had no comments. No response was received from either tribe.

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Section 6. Coverage Requirements for Children’s Health Insurance

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42 CFR 457.410(a))

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

6.1.1.

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

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

6.1.1.1.

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

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

6.1.1.2.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

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Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:  the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

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

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

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under such coverage. (Section 2103(a)(2))

6.1.2.

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

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state-based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state- based coverage.

Healthy Kids Benefits Package was grandfathered in.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive

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services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1.

Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

Benefits for the MediKids program and for the Children’s Medical Services Managed Care Plan (CMS Plan)are the same as for Medicaid, which includes EPSDT.

The Healthy Kids program does not provide EPSDT benefits.

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population.

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in §457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage.

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverage applicable only in New York, Pennsylvania or Florida. (under 42 CFR 457.440)

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

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6.1.4.6.

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

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

6.1.4.7.

Other. (Describe)

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

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

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

MediKids, CMS Plan (including children enrolled through the CMS Plan Enrollment Exception Process), Florida Healthy Kids

6.2.1.

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

6.2.2.

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

6.2.3.

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

6.2.4.

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

6.2.5.

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

6.2.6.

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

Healthy Kids: Covers all prescriptions in the same manner in which the Florida Medicaid program provides. Participant is limited to the generic drug unless a generic is not

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available, or the prescriber indicates that the brand name is medically necessary

6.2.7.

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

6.2.8.

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

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

6.2.10.

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

Healthy Kids inpatient mental health benefits include 30 inpatient/residential days per contract year. If residential services are used then at least 10 days must be reserved for inpatient services. Effective October 1, 2009, the days limits have been removed from this benefit.

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

Healthy Kids: Outpatient behavioral health benefits are limited to 40 outpatient visits per contract year. Effective October 1, 2009, the visit limits have been removed from this benefit.

6.2.12.

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

6.2.13.

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

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

6.2.14.

Home and community-based health care services (Section 2110(a)(14))

Healthy Kids: Home health services are limited to skilled nursing services only. The benefit is intended to provide services on a limited, part-time intermittent basis and excludes meals, housekeeping and personal comfort items.

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Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.15.

Nursing care services (Section 2110(a)(15))

Healthy Kids: Nursing services in Healthy Kids are limited to skilled nursing only.

6.2.16.

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

6.2.17.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

Children enrolled in MediKids and the CMS Plan receive Medicaid dental benefits from Medicaid-enrolled providers. Healthy Kids: Healthy Kids enrollees also receive the Medicaid dental benefit package. See Section 6.2.-D

Effective July 1, 2010, Healthy Kids dental benefits are provided statewide by two (2) commercially licensed dental insurers. The annual dental benefit limit was eliminated to comply with CHIPRA legislation. If a child needs oral surgery due to an accident or injury to the mouth or jaw, this coverage would still be provided under the child’s medical services contractor and not the dental contractor.

6.2.18.

Vision screenings and services (Section 2110(a)(24))

6.2.19.

Hearing screenings and services (Section 2110(a)(24))

6.2.20.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Healthy Kids: Inpatient behavioral health services are limited to not more than 7 inpatient days per contract year for medical detoxification only and 30 residential days. Effective October 1, 2009, the day limits on inpatient and residential services have been removed. 6.2.21.

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

Healthy Kids: Outpatient visits are limited to 40 outpatient days per contract year.

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Effective October 1, 2009, the visit limit on outpatient services has been removed. 6.2.22.

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

6.2.23.

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

Care coordination services is limited to CMS Plan Title XXI enrolled children.

6.2.24.

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

Healthy Kids: Therapy services are limited to 24 treatment sessions within 60-day period and are intended for short-term rehabilitation only. 6.2.25.

Hospice care (Section 2110(a)(23))

Healthy Kids: Once a family elects hospice care for an enrollee, other services that treat that terminal condition will not be covered. Guidance: See guidance for Section 6.1.4.1 for guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check the box below.

6.2.26.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

The provision of EPSDT benefits only applies to MediKids and CMS Plan. The Healthy Kids program does not provide EPSDT benefits.

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.27.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24))

6.2.28.

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

6.2.29.

Medical transportation (Section 2110(a)(26))

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Healthy Kids covers emergency medical transportation only.

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.30.

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

Enabling services are provided for the MediKids and CMS Plan populations.

6.2.31.

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

For Children’s Medical Services network only, additional benefits for early intervention services, respite services, genetic testing, genetic and nutritional counseling, and parent support services may be offered, if such services are determined to be medically necessary.

6.2-DC Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) codes are included in the dental benefits:

1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200- D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

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

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Children enrolled in the MediKids and Children’s Medical Services Network receive the Medicaid dental benefit package, including EPSDT benefits. Children enrolled in Healthy Kids also receive the Medicaid dental benefit package, but do not receive EPSDT benefits.

The services included in the benefits listed above may be limited to services approved through a prior authorization process. Please see Appendix D for information about services that require a prior authorization. The prior authorization requirements are not established based on the dollar value of a service but are designated specialty services or for services that tend to be over-used, abused or need special oversight or care management by the plan. There is a prior authorization exception process in place for emergency situations.

In Appendix D, there are prior authorization guidelines for general dentists to follow when providing endodontic and periodontal procedures. Prior authorizations are required for referrals and treatment provided by Endodontists, Periodontists, Oral Surgeons and Orthodontists. Depending on the plan and the age of the child, prior authorizations may be required for procedures provided by Pediatric Dentists. Routine care provided by General Dentists does not require prior authorization.

Florida Healthy Kids Corporation requires their contracted dental plans to process all prior authorizations requests within fourteen (14) days of the request.

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

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific - MediKids and CMS Plan American Academy of Pediatric Dentistry - Healthy Kids enrollees follow the American Academy of Pediatric Dentistry periodicity schedule. Other Nationally recognized periodicity schedule Other (description attached)

Florida Healthy Kids requires that the Healthy Kids dental plans include specific standards for the delivery of services, including standards for access to appointments and geographic requirements for primary care and specialty care providers. Plans are also required to submit quarterly claims data on which annual quality measures are scored, including the number of enrollees who received a dental visit and any dental services during the year. Low scores on these measures are often a pre-cursor to network or service issues.

Families contact the KidCare Call Center with concerns when there is immediate access to care issues. Florida Healthy Kids Corporation staff can trouble-shoot these issues as they arise and also tracks them on a long term basis in order to

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identify systematic problems. Contract provisions provide for Healthy Kids to send children to any willing provider if the Plan is not able to meet contract standards at the Plan’s expense. Corrective action plans can also be implemented when necessary.

Both Healthy Kids dental plans have a grievance process in place for enrollees to dispute any denial of services. These processes have also been vetted by Healthy Kids. The processes include informal resolution of issues, as well as formal procedures for when the other avenues have not provided the family the relief being sought. Both plans also have an expedited process for emergency or urgent issues.

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

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

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

6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health

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

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coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) ICD-10 Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)).

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Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements. MediKids Program – children ages 1 through 4 years Children’s Medical Services Managed Care Plan (CMS Plan) – for children ages 1 through 18 years, with special health care needs The MediKids Program and CMS Plan enrollees receive Medicaid benefits, including EPSDT services.

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Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

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The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

The Florida Healthy Kids Program serves children ages 5 through 18 years, but does not offer this population EPSDT benefits. The program does offer comprehensive health benefits and contracts with licensed health plans. The following identified sections apply to the Florida Healthy Kids Program.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

Mental Health and Substance Use Disorder Parity Category Definitions

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Inpatient: covered services provided for the medical care and treatment of an enrollee who is admitted as an inpatient to a hospital licensed under Part I of Chapter 395, Florida Statutes, including enrollees admitted as inpatient to a hospital with the expectation of remaining at least overnight and occupying a bed even though the recipient may be discharged or transferred to another hospital and may not use the hospital bed overnight. • Part I of Chapter 395, Florida Statutes, defines a hospital as any establishment that: o Offers services more intensive than those required for room, board, personal services, and general nursing care, and offers facilities and beds for use beyond 24 hours by individuals requiring diagnosis, treatment, or care for illness, injury, deformity, infirmity, abnormality, disease, or pregnancy o Regularly makes available at least clinical laboratory services, diagnostic X-ray services, and treatment facilities for surgery or obstetrical care, or other definitive medical treatment of similar extent, except that a critical access hospital, as defined in s. 408.07, Florida Statutes, shall not be required to make available treatment facilities for surgery, obstetrical care, or similar services as long as it maintains its critical access hospital designation and shall be required to make such facilities available only if it ceases to be designated as a critical access hospital o Excludes any institution conducted by or for the adherents of any well-recognized church or religious denomination that depends exclusively upon prayer or spiritual means to heal, care for, or treat any person. • Includes “general hospitals” defined as any facility which meets the provisions of the requirements of a “hospital” and which regularly makes its facilities and services available to the general population. • Includes “specialty hospitals” defined as any facility which meets the provisions of the requirements of a “hospital” and which regularly makes available either: o The range of medical services offered by general hospitals, but restricted to a defined age or gender group of the population o A restricted range of services appropriate to the diagnosis, care, and treatment of patients with specific categories of medical or psychiatric illnesses or disorders o Intensive residential treatment programs for children and adolescents as defined in s. 395.002, Florida Statutes Outpatient: covered services provided to an enrollee: • In the outpatient portion of a health facility licensed under Chapter 395, Florida Statutes • Admitted as outpatient to a health care facility as defined by s. 408.07, Florida Statutes • At the service location of an office-based provider • By telemedicine • Excludes emergency care

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Emergency Care: Visits to an emergency room or other licensed facility within the U.S. if needed immediately due to an injury or illness and delay means risk of death or permanent damage to the enrollee’s health, including: • Services by a qualified provider that are needed to evaluate or stabilize an emergency medical condition • Emergency transportation required in response to an emergency medical condition situation Prescription Drugs: Drugs prescribed for the treatment of illness or injury, including those prescribed by an enrollee’s dental provider under Florida Healthy Kids and excluding drugs provided in an inpatient setting or administered in an outpatient setting.

Covered benefits were categorized based on ICD-10.

6.2.3.1.1 MHPAEA The State assures that:

The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub- classifications to distinguish between outpatient office visits from other outpatient services.

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6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied There is no aggregate lifetime or annual dollar limits on any mental health or substance disorder benefits for the Healthy Kids population. Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: No

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Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all

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medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5- MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits.

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Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non- quantitative treatment limitations.

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E))

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Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one- half threshold, the State may combine levels within a type of QTL such that

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the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5))

6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

NQTL Analysis Summary and supporting documentation provided as a separate electronic file.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers?

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

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6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information

6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other

Guidance: If other is selected, please specify the entity.

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State Managed Care entities Both

Other

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

8.2.1.

Premiums:

All Florida KidCare program components, except Medicaid, adhere to the same monthly premium provisions. The maximum monthly premium per household is $20 beginning with the payment due July 1, 2003, regardless of the number of children in the family. Effective with the premium payment due January 1, 2004, the monthly premium per household is $15 for families with income less than or equal to 150% of the federal poverty level and $20 for families with income above 150% to 200% of the federal poverty level. Effective January 1, 2004, for families at or below 150% of the federal poverty level, Florida Healthy Kids is applying $5.00 credits per month for every month the $20.00 premium was paid for coverage during August through December 2003. Effective January 1, 2014, the income levels for the monthly family premiums changed due to MAGI conversion. The upper income level for the $15 monthly family premium changed from 150% of the federal poverty level (FPL) to 158% FPL. Families with income above 158% FPL to 210% FPL will be charged a $20 monthly family premium. Families with children at different premium levels will be charged the lesser rate for their family premium. This conversion will be implemented effective April 1, 2015 and made retroactive to January 1, 2014. Families will receive correspondence advising them of their new premium payment.

The following table shows the changes in premium levels.

Florida KidCare Family Premiums Age Time Period $15 Premium $20 Premium Minimum Maximum Minimum Maximum 1 through 5 Effective 1/1/14 140% FPL 158% FPL Above 158% FPL 210% FPL Prior to MAGI 133% FPL 150% FPL Above 150% FPL 200% FPL 6 through 18 Effective 1/1/14 133% FPL 158% FPL Above 158% FPL 210% FPL Prior to MAGI 100% FPL 150% FPL Above 150% FPL 200% FPL

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For Healthy Kids and MediKids enrollees with family incomes above 210% (200% FPL prior to MAGI conversion) of the federal poverty level, and therefore not eligible under Title XXI, the family pays a non-subsidized monthly premium on a per child basis. Families who do not make their monthly premium payments on time will be disenrolled from coverage and will not be eligible for reinstatement for a minimum of 30 days, in accordance with state law. Premium payments are due on the first day of the month prior to the month of coverage. Families receive a coupon book upon enrollment that indicates the amount of the monthly premium and the day the premium is due for each month. Families that do not make a premium payment are sent a letter on the 7th of the month informing them that coverage will be cancelled if payment is not received. These letters are followed be a series of automated reminder calls and email reminders. If payment is not received by the 20th of the month a termination letter is issued effective the last day of the month. Families that make payment within the 30-days are issued a reinstatement letter informing them that coverage is still in effect. Premiums are considered late if not received by the first of the month prior to coverage. A 30 day grace period is given to families to make a payment prior to cancellation of coverage.

The late notice is generated by the TPA and also reminds the family that if the premium is not received during the grace period, the child’s coverage will be canceled for the next month and a minimum of a 30 day wait before reinstatement would be imposed as required by state law. On October 7, 2004, the Governor announced temporary changes to the KidCare program to assist families affected by the four hurricanes that impacted the state. The Governor announced that no children would be cancelled due to failure to pay premiums in the aftermath of the storms. The KidCare program adopted a temporary measure to reduce premium payments to $0 for the months of August (for September coverage), September (for October coverage) and October 2004 (for November coverage), for all children enrolled in Title XXI. Any payments received during this period are credited to future months. Once a month, the TPA sends electronic enrollment files to the Healthy Kids health and dental plans for Healthy Kids enrollees and electronic enrollment files for MediKids to the Agency for Health Care Administration and for the CMSN to the Department of Health. The files include all eligible children who have also made a premium payment by that date. Families who have not paid by this date will receive a second letter indicating that the child’s coverage will be canceled at the end of the month and that a minimum 30 day wait will be imposed before coverage can be reinstated if canceled. A supplemental file is prepared and distributed the first week of the coverage

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month that will include the children for whom payment had not been received prior to the previous file but was received within the 30 day grace period. Additionally, families also have the option of making their monthly family premium payment by credit card. Automated telephone payments were implemented on October 20, 2003, and web payments were implemented effective November 20, 2003. Families may make credit card payments 24 hours a day, seven days a week, either by phone or by accessing the Healthy Kids web site. Families may also arrange to have payment automatically withdrawn (ACH) from their accounts on an ongoing basis. Beginning in 2010, families have the option of paying their monthly premium by cash. The vendor selected to accept cash payments has hundreds of locations throughout Florida. Families can make their premium payment in person by providing their family account number and their cash payment. The payment is electronically transferred to Florida Healthy Kids Corporation’s third party administrator. Another payment option starting in 2011 is for families to pay by text message. Families choosing this payment method are provided an online link to sign up for the service. During the sign up process the family identifies the cell phone number they will be using and the account from which the funds will be deducted and select a personal identification number (PIN). Once enrolled, the family will receive a text message at the beginning of each month reminding them that a payment is due. To make a payment, the family provides their PIN authorizing the payment and deduction from their account. The funds will be automatically withdrawn from their account and the family will receive a text message confirming the payment has been made.

Disaster Relief Provisions At the State’s discretion, working collaboratively, and with the agreement of FHKC and/or CMS Plan, the premium due date may be extended or premiums may be waived for a specific period of time for CHIP enrollees who meet income and other eligibility requirements and who reside and/or work in Governor or FEMA declared disaster areas. 8.2.2.

Deductibles:

None of the Florida KidCare components charge deductibles.

8.2.3.

Coinsurance or copayments:

Healthy Kids Healthy Kids charges minimal co-payments for some managed care services. Services that require co-payments are listed in the chart below.

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8.2.4.

Other:

MediKids and CMS: No other cost sharing will be applied. Healthy Kids: All services are provided by managed care organizations and the following co-payments are applicable.

Florida Healthy Kids Co-payments Service Co-payment Amount Behavioral Health Outpatient Visits *$5.00 per visit Emergency Room, Inappropriate Use

$10.00 (waived if admitted) Emergency Transportation

$10.00 (waived if admitted) Eyeglasses, Prescription

$10.00 Office Visits, Primary Care

*$5.00 per visit Office Visits, Specialty Care

*$5.00 per visit Prescribed Medicine

*$5.00 per prescription Therapy Services (PT, OT, ST) *$5.00 per session Hospice and Home Health Services *$5.00 per visit * increases effective October 1, 2003

8.2-DS

Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) For children enrolled in the dental-only supplemental coverage, describe the amount of cost- sharing, specifying any sliding scale based on income. Also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, 6.2- DS, and 9.10 when electing this option.

8.2.1-DS Premiums:

8.2.2-DS Deductibles:

8.2.3-DS Coinsurance or copayments:

8.2.4-DS Other:

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any

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differences based on income. (Section 2103(e)(1)(A)) (42 CFR 457.505(b))

Florida KidCare Application In 1998, the original Florida Healthy Kids application was modified to become the first joint Florida KidCare/Medicaid application. Since then, the application has gone through several modifications and is now known as the Florida KidCare application. It includes necessary information for Title XIX eligibility determination as well as the KidCare components (MediKids, Healthy Kids and the Children’s Medical Services Network). Families will be informed through a separate brochure that is attached to the application packet that, except for Medicaid, monthly premium payments are required. Schedules of the co-payments for the Healthy Kids program are also included on the Healthy Kids web page, in member materials produced by the participating Healthy Kids health plans and through correspondence sent to families who have begun the application process. The Florida KidCare application has undergone significant revisions and was distributed beginning March 17, 2003. The application was field-tested with target audiences and includes additional data fields that were not captured on the previous application. Effective with the January 1, 2004 change to a two-tiered premium of $15 and $20, enrollees received correspondence advising them if their premium changed. The Florida KidCare and Healthy Kids websites were updated to reflect low cost premiums based on family income. The Florida KidCare Information Line also advised families applying that they would be advised of their premium at the time their eligibility is determined. The KidCare application was revised again in the summer of 2004 in order to address legislative changes with regard to eligibility and verification of income and accessibility to employer-based health insurance coverage. The Florida KidCare application is reviewed and revised, as necessary, on a regular basis and in order to accommodate legislative and administrative changes to the program. The most recent application revision occurred in 2009 and, as with all major application changes, focus groups were held to review the application for ease of completion and for public input. Employee Training The Departments of Health and Children and Families, the Agency for Health Care Administration, and the Florida Healthy Kids Corporation conduct ongoing training sessions for their respective employees to inform them about all of the requirements of the Florida KidCare program, including family cost-sharing and in response to any legislative or administrative change to the program.

Guidance: The State should be able to demonstrate upon request its rationale and justification regarding these assurances. This section also addresses limitations on payments for certain expenditures and requirements for maintenance of effort.

8.4. The State assures that it has made the following findings with respect to the cost sharing

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in its plan: (Section 2103(e))

8.4.1.

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

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

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

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify:) No Effective January 1, 2021, there will be no costing sharing for outpatient behavioral health and substance abuse services. Guidance: For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any

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medical/surgical benefits?

Yes No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results of the parity analysis as an attachment to the State child health plan.

Florida Healthy Kids identified all services to which financial requirements (copayments) apply. Services were categorized into inpatient, outpatient, prescription drugs, and emergency services categories. The $10 copayment requirement for corrective lenses was removed from the analysis as inapplicable.

Florida Healthy Kids applies the listed copayments to the following services without distinction between whether services are for mental health/substance use disorder services or medical/surgical services. The copayments apply to emergency services, outpatient services and prescription drugs only; preventive office visits do not have a copay.

• Emergency services - $10 • Outpatient services o Preventive care - $0 o All other outpatient services - $5 • Prescription drugs - $5 No financial requirements apply to inpatient services. Results: Financial requirements applied to mental health/substance use disorder services are the same as the financial requirements applied to medical/surgical services under the Healthy Kids program.

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Effective January 1, 2021, there will be no costing sharing for outpatient behavioral health and substance abuse services.

8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

_____________________________________________________________________________ Table of Contents State/Territory Name: Florida State Plan Amendments (SPA) #: FL-19-0030-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENTOF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-16 Baltimorg Maryland 21244-1850 Children and Adults Health Programs Group crvts cÊNtflas fon MtDtcARÉ & MEDtCAtD S[nVrctS CENTEI f0n n'tEDlCAlD & CHIP SEnVICtS ¡\u0 I Û 20ß Beth Kidder Deputy Secretary for Medicaid 2727 Mahan Drive, MS #20 Tallahassee, FL 32308 -5403 Dear Ms. Kidder: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), FL-19-0030-CHIP, has been approved. FL-19-0030-CHIP demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L for utilization of a managed care delivery system. This SPA has an effective date of July 1,2018. Sections 2101(a),2i03(Ð(3), 2107(b), and2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpafi L, describe the application of managed care requirements to CHIP. Florida has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan as of July l, 2018. This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on or afler July l, 2018 must comply with the CHIP managed care regulations and be submitted for CMS review. Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer questions concerning this amendment and other CHlP-related issues. Her contact information is as follows: Centers f-or Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, MD 21244- 1 850 Telephone: (41 0) 786-4554 E-mail : Cassandra.Lagorio@cms.hhs. gov Official communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Shantrina Roberts, Deputy Director, Division of Medicaid Field Operations South. Ms. Roberts's address is:

Page 2 - Ms. Beth Kidder Centers for Medicare & Medicaid Services Division of Medicaid Field Operations South 61 Forsyth Street, SW, Suite 4T20 Atla¡ta, GA 30303-8909 We look forward to continuing to work with you and your staff. Marie Costello Director cc: Ms. Shantrina Roberts, Deputy Director, Division of Medicaid Field Operations South /signed Anne Marie Costello/

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:____Florida __________________________________________________

(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

_______________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Beth Kidder

Position/Title: Deputy Secretary for Medicaid Name: ____________

Position/Title: ______________

Name: ____________

Position/Title: ______________

*Disclosure. In accordance with 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

This template outlines the information that must be included in the state plans and the State plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. • Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016) States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42

3 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based

4 coverage; and/or Secretary-approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or

5 through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State plan amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States

6 wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Where the state’s assurance is requested in this document for compliance with a particular requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in compliance no later than the applicable compliance date.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

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

1.3.

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

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date

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

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

Original Plan Effective Date: July 1, 2018

Implementation Date: July 1, 2018

SPA #FL-19-0030 Purpose of SPA: Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care and Revisions Related to Third Party Liability Final Rule – To demonstrate compliance with the CHIP Managed Care final regulations reflecting changes in the usage of managed care delivery systems.

Proposed effective date:July 1, 2018

Proposed implementation date: July 1, 2018

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. The tribal notification letters were sent to the Seminole and Miccosukee Tribes on June 4, 2019, describing the State Plan Amendment changes. The letters asked that comments be directed to Cole Giering at the Agency for Health Care Administration. The letters advised the Tribes that no response would be interpreted as the Tribes having no comments.

On June 11, 2019, the Seminole Tribe requested further clarification. The Agency provided clarification on June 18, 2019. No further comments or requests were received.

TN No: Approval Date Effective Date

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

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

9

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

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

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

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

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State

10 Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system.

11 If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system?

12 No Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others.

The following services are not provided by the Managed Care Plan, but are available to eligible Medicaid recipients through the Medicaid FFS delivery system (MediKids does not provide any waiver services):

1. Medical and Behavioral Services 2. Hemophilia Factor-related Drugs 3. School-based services provided by school districts 4. Newborn Hearing services 5. Prescribed Pediatric Extended Care services

3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Describe population served: Children ages 1-4 enrolled in the MediKids program. Children 5-18 enrolled in the Florida Healthy Kids program, Children with special health care needs, ages 1-18, enrolled in the Children’s Medical Services Plan.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

13

Describe population served: Children 5-18 enrolled in the Florida Healthy Kids program (dental services)

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross- referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs

14 Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non-emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e))

15 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs,

16 PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross- referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race,

17 color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider- beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least

18 annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross- referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR

19 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and

20 potential enrollees in accordance with the terms of 42 CFR 457.1207, cross- referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and • Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent

21 non-English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for

22 coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services; • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the

23 benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of- network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State- approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and • Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4))

24 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross-referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2))

25 Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260)

3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross-referencing 42 CFR 438.68(e)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered

26 care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross- referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of- network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207)

27 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross- referencing to 42 CFR 438.210(c))

28 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; • Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; • Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs; • Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(b)) Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care

29 services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross-referencing 42 CFR 438.12 and 438.214, including that:

30 Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3).

31 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p))

32 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is: • At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and

33 • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review. • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and

34 services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross- referencing to 42 CFR 42 CFR 438.408(b) and (c))

35 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)) 3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)) 3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so.

36 o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review: • The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process; • The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414) 3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner

37 accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross- referencing to 42 CFR 438.424(a))

3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data

38 submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the

39 overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)) 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

40

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a))

41 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)). 3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a))

42 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250. 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of

43 any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; • The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); • Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR- related activities; • Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2))

44 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS: • A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will: • Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2);

45 • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1))

Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4)

46 (related to dual eligibles) do not apply. The assessment and program must include: • Standard performance measures specified by the State; • Mechanisms to detect both underutilization and overutilization of services; and • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3.

47 3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)) 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)) Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register.

3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR)

48 for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR- related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review). 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340)

49 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing

50 the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)) 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness,

51 and access to health care services furnished to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)) 3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)) 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10 The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d))

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Florida FL-20-0032

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

August 7, 2020

Beth Kidder Deputy Secretary for Medicaid Agency for Health Care Administration, State of Florida 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Dear Ms. Kidder:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) FL- 20-0032, submitted on June 30, 2020, has been approved. This amendment has an effective date of March 9, 2020.

This amendment provides temporary adjustments to the state’s cost sharing requirements in response to disaster events. This amendment, as it applies to the COVID-19 public health emergency (PHE), waives all cost-sharing for CHIP services effective March 9, 2020 through the duration of the state or federally-declared PHE, or at state discretion, a shorter period of time. We note that the waiver of cost-sharing for services related to COVID-19 testing will apply for the duration of the federal emergency declaration, as required by Section 6004 of the Families First Coronavirus Response Act.

In the event of a future disaster, this SPA provides Florida with the authority to implement the approved, temporary policy adjustments by simply notifying CMS of its intent, the effective date and duration of the provision, and a list of applicable Governor or federally-declared disaster or emergency areas. While the state must provide notice to CMS, this option provides an administratively streamlined pathway for the state to effectively respond to an evolving disaster event.

Your title XXI project officer is Jack Mirabella. They are available to answer questions concerning this amendment and other CHIP-related issues. Their contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-2424

E-mail: jack.mirabella@cms.hhs.gov

Page 2 – Ms. Kidder

If you have any questions, please contact Meg Barry, Acting Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Amy Lutzky

Acting Deputy Director

/Signed by Amy Lutzky/

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:____Florida __________________________________________________

(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

_______________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Beth Kidder

Position/Title: Deputy Secretary for Medicaid Name: ____________

Position/Title: ______________

Name: ____________

Position/Title: ______________

*Disclosure. In accordance with 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

This template outlines the information that must be included in the state plans and the State plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. • Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016) States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42

3 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based

4 coverage; and/or Secretary-approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or

5 through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State plan amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States

6 wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Where the state’s assurance is requested in this document for compliance with a particular requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in compliance no later than the applicable compliance date.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

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

1.3.

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

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date

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

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

Original Plan Effective Date: March 9, 2020

Implementation Date: March 9, 2020

SPA #FL-20-0032 Purpose of SPA: The state is revising the CHIP State Plan to include Disaster Relief Provisions for co-payments during a declared emergency. .

Proposed effective date: March 9, 2020

Proposed implementation date: March 9, 2020

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

According to Florida’s Tribal Consultation Policy, the state does not need to provide tribal consultation in the event that a SPA is not restrictive. This SPA provides the state with an option to waive cost sharing during a state of emergency. The SPA is not restrictive, and therefore did not require Tribal consultation.”

TN No: Approval Date Effective Date N/A

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

Disaster Relief Provisions At the State’s discretion, working collaboratively, and with the agreement of FHKC and/or CMS Plan, the State may take any/or all of the following actions for a specified period of time for enrollees living and/or working in a Governor or Federally declared disaster areas or state of emergency (i.e. pandemic):

• Waive premium payments. • Allow additional time to:

9 − Complete the renewal process. − Make premium payments. • Waive or lower copayments

The AHCA will notify the CMS in the event of a declared disaster or state of emergency and Florida’s intent to implement any or all of the policy modifications. The CMS notification will include the intent to implement modifications, the areas affected by the disaster and the effective dates of the policy modifications.

The next twelve-month continuous eligibility period begins the month after the renewal completion date.

Section 8. Cost Sharing and Payment (Section 2103(e))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

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

8.2.1. Coinsurance or co-payments: Healthy Kids Healthy Kids charges minimal co-payments for some managed care services. Services that require co-payments are listed in the chart below. Disaster Relief Provisions

At the State’s discretion, working collaboratively, and with the agreement of FHKC and/or CMS Plan, the premium due date may be extended or premiums may be waived, in addition, the State may waive or lower copayments for a specific period of time for CHIP enrollees who meet income and other eligibility requirements and who reside and/or work in Governor or Federally declared disaster areas or state of emergency areas (i.e. pandemic).

8.2.2. Other: MediKids and CMS : No other cost sharing will be applied. Healthy Kids: All services are provided by managed care organizations and the following co-payments are applicable.

10

8.2.3. Coinsurance or co-payments: Healthy Kids Healthy Kids charges minimal co-payments for some managed care services. Services that require co-payments are listed in the chart below. 8.2.4. Other: MediKids and CMS : No other cost sharing will be applied. Healthy Kids: All services are provided by managed care organizations and the following co-payments are applicable Florida Healthy Kids Co-payments Service Co-payment Amount Behavioral Health Outpatient Visits *$5.00 per visit Emergency Room, Inappropriate Use

$10.00 (waived if admitted) Emergency Transportation

$10.00 (waived if admitted) Eyeglasses, Prescription

$10.00 Office Visits, Primary Care

*$5.00 per visit Office Visits, Specialty Care

*$5.00 per visit Prescribed Medicine

*$5.00 per prescription Therapy Services (PT, OT, ST) *$5.00 per session Hospice and Home Health Services *$5.00 per visit * increases effective October 1, 2003

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

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

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages FL-21-0033 Florida

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

November 15, 2021

Tom Wallace Deputy Secretary for Medicaid 2727 Mahan Drive, MA #8 Tallahassee, FL 32308-5403

Dear Mr. Wallace:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number FL 21-0033, submitted on June 30, 2021, with additional information received on October 18, 2021 and November 3, 2021, has been approved. Through this SPA, Florida has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. This SPA has an effective date of July 1, 2020.

Section 5022 of the SUPPORT Act added Section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Florida demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner.

Your Project Officer is Joshua Bougie. He is available to answer your questions concerning this amendment and other CHIP-related matters. His contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-8117 E-mail: joshua.bougie@cms.hhs.gov

Page 2 — Mr. Tom Wallace

If you have additional questions, please contact Emily King, Division Deputy Director, Division of State Coverage Programs, at (443) 478-6811. We look forward to continuing to work with you and your staff.

Sincerely,

/Signed by Amy Lutzky/

Amy Lutzky Deputy Director

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM (Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b))) State/Territory:______________________________________________________ (Name of State/Territory) As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))_______________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: ____________ Position/Title: ______________ Name: ____________ Position/Title: ______________ Name: ____________ Position/Title: ______________ Disclosure Statement This information is being collected to pursuant to 42 U.S.C. 1397aa, which requires states to submit a State Child Health Plan in order to receive federal funding. This mandatory information collection will be used to demonstrate compliance with all requirements of title XXI of the Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of information requirements under this control number is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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. Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program Florida

2 (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

This template outlines the information that must be included in the state plans and the State plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. • Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016) States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

3

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of

4 any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR

5 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State plan amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program

6 and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Where the state’s assurance is requested in this document for compliance with a particular requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in compliance no later than the applicable compliance date.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

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

1.3.

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

8

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

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

Original Plan Effective Date: July 1, 2020

Implementation Date: July 1,2020

SPA #FL-2021-0033 Purpose of SPA: To demonstrate compliance with section 5022 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT Act) in areas related to coverage of behavioral health screening prevention and treatment services, strategies to facilitate use of appropriate screening and assessment tools and the requirement that these services be provided in a culturally and linguistically appropriate manner. Proposed effective date: July 1, 2020

Proposed implementation date: July 1, 2020

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. N/A TN No: Approval Date Effective Date

The State issued Tribal Correspondence to the Seminole and Miccosukee Tribes of Florida on May 28, 2021, describing the amendment. The State received no feedback regarding this amendment.

6.2.22. EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

6.2.22.1 The state assures that any limitations applied to the amount, duration,

9 and scope of benefits described in Sections 6.2 and 6.3- BH of the CHIP state plan can be exceeded as medically necessary.

Florida’s separate Children’s Health Insurance Program provides behavioral health and substance abuse services to children ages one through eighteen years. The CHIP enrollees receive an array of age-appropriate behavioral health services through Florida Healthy Kids, the Behavioral Health Network (BNet), MediKids, and Children’s Medical Services (CMS) Health Plan.

Healthy Kids: The Florida KidCare Act, outlines the benchmark health care benefits Florida Healthy Kids must include as medically necessary. The Florida Healthy Kids program serving children ages 5 to 19 does not provide Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. Behavioral health and substance use disorder services in excess of those specified in the Florida KidCare Act may be obtained through the Behavioral Health Network (BNet) via CMS Health Plan enrollment. Florida Healthy Kids refers children and families in need of behavioral health and substance use disorder services to CMS Health Plan for clinical assessment. MediKids: Children ages 1 through 4 eligible for CHIP services are enrolled in MediKids and receive EPSDT services. The program enrollees receive behavioral health services through Florida Medicaid’s Managed Medical Assistance (MMA) Program health plans. MediKids enrollees are also age appropriate for medically necessary early intervention services provided through the Healthy Start and Early Steps programs.

Children’s Medical Services Health Plan: The CMS Health Plan is a KidCare Title XXI program serving children and adolescents ages 1 through 18 years with special health care needs. Children enrolled in the CMS Health Plan are eligible for EPSDT services and are clinically eligible to receive medically necessary behavioral and developmental health services.

BNet is a statewide network of behavioral health service providers serving children ages 5 to 19 years of age with serious emotional disturbance, serious mental health disorder, or substance use disorders, eligible for the Florida KidCare Title XXI program and enrolled in the CMS Health Plan. A child enrolled in BNet receives medical health services from the CMS Health Plan, behavioral health services, and related medication through BNet.

BNet providers address enrollee’s behavioral health needs through: • In-home and outpatient individual and family counseling. • In-home and outpatient targeted case management.

10 • Psychiatry services and medication management including direct access to the network service provider’s pharmacy with no co-pays; and • Advocacy and provision for wrap-around services to meet each child’s social, educational, nutritional, and physical activity needs.

Pregnant Women: Florida has not elected to cover pregnant women under the CHIP option offered in section 2112 of the Social Security Act. Medically necessary mental health and substance use disorders services are offered to pregnant women through the Florida Medicaid (Title XIX) program.

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.23.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24))

6.2.24.

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

6.2.25.

Medical transportation (Section 2110(a)(26))

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.26.

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

6.2.27.

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

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn children.

11 Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related coverage, please describe the recommendations being followed for those services.

6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any covered CHIP populations:

State-developed schedule American Academy of Pediatrics/ Bright Futures Other Nationally recognized periodicity schedule (please specify: ) Other (please describe: )

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders. If there are differences in benefits based on the population or type of condition being treated, please specify those differences.

Children enrolled in the Children’s Medical Services Health Plan are eligible for EPSDT services and are clinically eligible to receive medically necessary behavioral and developmental health services. MediKids enrollees receive behavioral health services through Florida Medicaid’s Managed Medical Assistance (MMA) Program providers. MediKids enrollees are also age appropriate for medically necessary early intervention services provided through the Healthy Start and Early Steps programs. The BNet program is available to children enrolled in the Children’s Medical Services Health Plan, ages 5 through 18 who have mental health or substance use concerns. The BNet program is also available to children enrolled in the Title XXI Florida Healthy Kids program. If found clincally eligible for the CMS Health Plan program, the child is disenrolled from the Florida Healthy Kids Program as they can not be dually enrolled in both programs.

If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit.

Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1-BH.

6.3.1- BH Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

The amount, scope and duration of Florida Healthy Kids behavioral health screenings and assessment services, including substance use disorder evaluations, are provided as determined medically necessary.

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6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age-appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools.

Beginning in 2021, Florida Healthy Kids requires its managed care organizations (MCOs) to report the child core set measure, CDF-CH, “screening for depression and follow-up plan: ages 12-17”. Florida Healthy Kids requires the MCOs to implement performance improvement projects to improve the rate of enrollees who have been screened for depression using a standardized tool and who had a documented follow-up plan for those enrollees with a positive screening. In addition, the Florida Healthy Kids Corporation (FHKC) requires the MCOs to make information about using age-appropriate, validated behavioral health screening tools available to providers on their provider-facing websites, provider manuals, and provider toolkits. The MCOs review and update websites, provider manuals, and provider toolkits annually or as needed. Providers are educated on where the tools are located during onboarding as a new network provider and as part of ad hoc/on- demand provider training.

The Agency for Health Care Administration and the University of South Florida collaborate to disseminate updates regarding behavioral health policy to Florida Medicaid health plans and medical providers in the form of Florida Medicaid Policy Transmittals and Policy Alerts as necessary through the Florida Behavioral Health Center website, which is updated every two weeks.

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

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6.3.2.1- BH Psychosocial treatment Provided for: Mental Health Substance Use Disorder

The amount, scope and duration of psychosocial treatment services provided by MediKids, Florida Healthy Kids, and CMS Health Plan, including outpatient treatment and counseling services for behavioral health and substance use disorder conditions, are provided as determined medically necessary.

6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

The amount, scope and duration of tobacco cessation services provided by MediKids, Florida Healthy Kids, and CMS Health Plan, including therapy/counseling services and drugs prescribed for the purpose of tobacco cessation, are provided as determined medically necessary. Medically necessary services are rendered to recipients in lieu of service limits.

Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the Act, MAT benefits are required for the treatment of opioid use disorders. However, if the state provides MAT for other SUD conditions, please include a description of those benefits below at section 6.3.2.3- BH.

6.3.2.3- BH Medication Assisted Treatment Provided for: Substance Use Disorder

The State covers all formulations of MAT drugs and biologicals for OUD that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262).

The amount, scope and duration of Florida Healthy Kids Medication Assisted Treatment services, including inpatient and outpatient services for psychological or psychiatric evaluation, diagnosis, and treatment, are provided as determined medically necessary. This applies to all subsections of 6.3.2.3.

6.3.2.3.1- BH Opioid Use Disorder

6.3.2.3.2- BH Alcohol Use Disorder

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6.3.2.3.3- BH Other

6.3.2.4- BH Peer Support Provided for: Mental Health Substance Use Disorder

Florida Healthy Kids does not provide Peer Support Services as a covered benefit. Medically necessary Peer Support Services unavailable through Florida Healthy Kids coverage may be obtained through the BNet program.

6.3.2.5- BH Caregiver Support Provided for: Mental Health Substance Use Disorder

Florida Healthy Kids does not provide Caregiver Support Services as a covered benefit. Medically necessary Caregiver Support Services unavailable through Florida Healthy Kids coverage may be obtained through the BNet program.

6.3.2.6- BH Respite Care Provided for: Mental Health Substance Use Disorder

Florida Healthy Kids does not provide respite care services as a covered benefit. Respite care services unavailable through Florida Healthy Kids coverage may be obtained through the BNet program.

6.3.2.7- BH Intensive in-home services Provided for: Mental Health Substance Use Disorder

Florida Healthy Kids does not provide intensive in-home services as a covered benefit. Intensive in-home services unavailable through Florida Healthy Kids coverage may be obtained through the BNet program.

6.3.2.8- BH Intensive outpatient Provided for: Mental Health Substance Use Disorder

The amount, scope and duration of Florida Healthy Kids intensive outpatient services are provided as determined medically necessary.

The State defines intensive outpatient services as “outpatient” in Ch. 65E 14.021(4), F.A.C for BNet Services. The definition can be found below.

“Outpatient:

15 Outpatient services provide a therapeutic environment, which is designed to improve the functioning or prevent further deterioration of persons with mental health and/or substance abuse problems. These services are usually provided on a regularly scheduled basis by appointment, with arrangements made for non-scheduled visits during times of increased stress or crisis. Outpatient services may be provided to an individual or in a group setting. The group size limitations applicable to the Medicaid program shall apply to all Outpatient services provided by a SAMH-Funded Entity. This covered service shall include clinical supervision provided to a service provider’s personnel by a professional qualified by degree, licensure, certification, or specialized training in the implementation of this service.”

6.3.2.9- BH Psychosocial rehabilitation Provided for: Mental Health Substance Use Disorder

Florida Healthy Kids does not provide psychosocial rehabilitation services as a covered benefit. Psychosocial rehabilitation services unavailable through Florida Healthy Kids coverage may be obtained through the Title XXI CMS Heath Plan or the BNet program.

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit, please indicate that in the benefit description. If there are differences between these benefits, such as the staffing or intensity of the setting, please specify those in the description of the benefit’s amount, duration, and scope.

6.3.3- BH Day Treatment Provided for: Mental Health Substance Use Disorder

The State defines day treatment and partial hospitalization to be the same benefit. See description provided in subsection 6.3.3.1 - BH.

Florida Healthy Kids does not cover day treatment services that are outside regular outpatient services. Title XXI CMS Health Plan or the BNet provides medically necessary day treatment services.

6.3.3.1- BH Partial Hospitalization Provided for: Mental Health Substance Use Disorder

The State defines “partial hospitalization” as “Day Treatment” in Ch. 65E 12.021(4), F.A.C. The definition can be found below.

16 “Day Treatment: Day treatment services provide a structured schedule of non-residential services for four (4) or more consecutive hours per day. Activities for children and adult mental health programs are designed to assist individuals to attain skills and behaviors needed to function successfully in living, learning, work, and social environments. Activities for substance abuse programs emphasize rehabilitation, treatment, and education services, using multidisciplinary teams to provide integrated programs of academic therapeutic, and family services.”

6.3.4- BH

Inpatient services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18)) Provided for: Mental Health Substance Use Disorder

A child who is an inmate of a public institution or patient in an institution for mental diseases is not eligible for the Florida KidCare program.

Florida Healthy Kids covers inpatient and residential treatment services for behavioral health and substance use disorder conditions.

BNet provides a limited number of days of medically necessary mental health and substance use crisis stabilization, inpatient and outpatient hospital services, and residential services. A child assessed as needing more than 30 days residential mental health or seven days residential substance use treatment is not clinically eligible for the BNet program. The BNet provider responsibility for inpatient is limited to 10 days per year for mental health, seven days for substance use, and the first 30 days of residential care, after which payment responsibility shifts back to the CMS Health Plan.

Children enrolled in either MediKids or Title XXI CMS Health Plan receive medical services and benefits from Medicaid providers. Program age-appropriate recipients under age 21 requiring medically necessary Statewide Inpatient Psychiatric Program (SIPP) can receive treatment in a psychiatric residential setting due to a primary diagnosis of emotional disturbance or serious emotional disturbance. SIPP services provide extended psychiatric residential treatment with the goal of facilitating successful return to treatment in a community-based setting. SIPP services include individual plan of care, assessment, routine medical and dental care, certified educational programming, recreational, vocational, therapeutic group and behavior analysis services and therapeutic home assignment.

Guidance: If applicable, please clarify any differences within the residential treatment benefit (e.g. intensity of services, provider types, or settings in which the residential

17 treatment services are provided).

6.3.4.1- BH Residential Treatment Provided for: Mental Health Substance Use Disorder

The amount, scope and duration of Florida Healthy Kids residential treatment services are provided as determined medically necessary.

The State defines “Residential treatment” in Ch. 65E 12.021(4), F.A.C. The definition can be found below.

“Residential Level I. These licensed services provide a structured, live-in, non-hospital setting with supervision on a twenty-four hours per day, seven days per week basis. A nurse is on duty in these facilities at all times. For adult mental health, these services include group homes. Group homes are for longer-term residents. These facilities offer nursing supervision provided by, at a minimum, licensed practical nurses on a twenty-four hours per day, seven days per week basis. For children with serious emotional disturbances, Level 1 services are the most intensive and restrictive level of residential therapeutic intervention provided in a non- hospital or non-crisis support unit setting, including residential treatment centers. Medicaid Residential Treatment Centers and Residential Treatment Centers are reported under this Covered Service. On-call medical care shall be available for substance abuse programs. Level 1 provides a range of assessment, treatment, rehabilitation, and ancillary services in an intensive therapeutic environment, with an emphasis on treatment, and may include formal school and adult education programs.

Residential Level II. These facilities are licensed, structured rehabilitation-oriented group facilities that have twenty-four hours per day, seven days per week, supervision. Level II facilities house persons who have significant deficits in independent living skills and need extensive support and supervision. For children with serious emotional disturbances, Level II services are programs specifically designed for the purpose of providing intensive therapeutic behavioral and treatment interventions. Therapeutic Group Home, Specialized Therapeutic Foster Home – Level II, and Therapeutic Foster Home – Level 2 are reported under this Covered Service. For substance abuse, Level II services provide a range of assessment, treatment, rehabilitation, and ancillary services in a less intensive therapeutic environment with an emphasis on rehabilitation and may include formal school and adult educational programs.

Residential Level III. These licensed facilities provide twenty-four hours per day, seven days per week supervised residential alternatives to persons who have developed a moderate functional

18 capacity for independent living. For children with serious emotional disturbances, Level III services are specifically designed to provide sparse therapeutic behavioral and treatment interventions. Therapeutic Group Home, Specialized Therapeutic Foster Home – Level I, and Therapeutic Foster Home – Level 1 are reported under this Covered Service. For adults with serious mental illness, this Covered Service consists of supervised apartments. For substance abuse, Level III provides a range of assessment, rehabilitation, treatment and ancillary services on a long-term, continuing care basis where, depending upon the characteristics of the individuals served, the emphasis is on rehabilitation or treatment.

Residential Level IV. This type of facility may have less than twenty-four hours per day, seven days per week on-premises supervision. It is primarily a support service and, as such, treatment services are not included in this Covered Service, although such treatment services may be provided as needed through other Covered Services. Level IV includes satellite apartments, satellite group homes, and therapeutic foster homes. For children with serious emotional disturbances, Level IV services are the least intensive and restrictive level of residential care provided in group or foster home settings, therapeutic foster homes, and group care. Regular therapeutic foster care can be provided either through Residential Level IV “Day of Care: Therapeutic Foster Home” or by billing in-home/non-provider setting for a child in a foster home.”

6.3.4.2- BH Detoxification Provided for: Substance Use Disorder

The amount, scope and duration of Florida Healthy Kids detoxification services are provided as determined medically necessary.

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or short term residential or other facility-based services in order to avoid inpatient hospitalization.

6.3.5- BH Emergency services Provided for: Mental Health Substance Use Disorder

The amount, scope and duration of Florida Healthy Kids emergency services are provided as determined medically necessary. 6.3.5.1- BH Crisis Intervention and Stabilization Provided for: Mental Health Substance Use Disorder

The amount, scope and duration of Florida Healthy Kids crisis intervention and stabilization services are provided as determined medically necessary.

The State distinguishes Crisis Stabilization from Crisis Support/Emergency services in Ch.

19 65E-14.021(4), F.A.C. The definitions can be found below.

“Crisis Stabilization. These acute care services offered twenty-four hours per day, seven days per week, provide brief, intensive mental health residential treatment services. These services meet the needs of individuals who are experiencing an acute crisis and who, in the absence of a suitable alternative, would require hospitalization.”

“Crisis Support/Emergency. This non-residential care is generally available twenty-four hours per day, seven days per week, or some other specific time period, to intervene in a crisis or provide emergency care. Examples include mobile crisis, crisis support, crisis/emergency screening, crisis telephone, and emergency walk-in.”

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

6.3.7- BH Care Coordination Provided for: Mental Health Substance Use Disorder

Florida Healthy Kids does not cover care coordination services. Medically necessary Mental Health and Substance Use Disorder Care Coordination unavailable through Florida Healthy Kids coverage may be obtained through the BNet program.

CMS Health Plan and MediKids define Care Coordination in conjunction with the delivery of Case Management. The goal of this service is to assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet health needs using communication and all available resources to promote quality outcomes.

In accordance with section 394.4573(1)(a), F.S. BNet utilizes the definition of “Care Coordination” to mean “the implementation of deliberate and planned organizational relationships and service procedures that improve the effectiveness and efficiency of the behavioral health system by engaging in purposeful interactions with individuals who are not yet effectively connected with services to ensure service linkage”. The purpose of the BNet program Care Coordination is to enhance the delivery of treatment services and recovery supports and to improve outcomes among Title XXI children and adolescents. Care Coordination is not an independent service, but rather a collaborative effort to efficiently target an individual’s treatment resource needs, effectively manage and reduce risk, and promote accurate diagnosis and treatment.

6.3.7.1- BH Intensive wraparound

20 Provided for: Mental Health Substance Use Disorder

Florida Healthy Kids does not cover intensive wraparound services. Medically necessary Intensive Wraparound services unavailable through Florida Healthy Kids coverage may be obtained through the BNet program.

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

Florida Healthy Kids does not cover care transition services. Medically necessary care transition services unavailable through Florida Healthy Kids coverage may be obtained through the Title XXI CMS Health Plan or the BNet program.

The state references “care transition” services as comprehensive discharge planning ( i.e., aftercare, post discharge and follow-up services). These services are provided in accordance with Title 42, CFR, section 441, Subpart D (for providers licensed under the state Rule Chapter 65E-9, F.A.C.). The services are designed to facilitate the successful, therapeutic movement of a child from one setting or set of services to another. The state requires the Statewide Inpatient Psychiatric Program (SIPP) provider to ensure community supports and aftercare treatment are in place prior to discharge. The monitoring of aftercare services is required to determine the appropriateness of the post discharge plan of care and to ensure the discharge plan is correctly implemented. Comprehensive discharge planning includes, but is not limited to:

1. Services recommended by the child/adolescent’s treatment team consistent family’s strengths and needs. 2. Therapeutic services for the child/adolescent and family or caregiver to prepare for change outside of inpatient treatment. 3. Inclusion of the child/adolescent’s assigned targeted case manager in treatment team meetings prior to discharge. 4. Assisting the child/adolescent and family or caregiver locate appropriate provider for delivery of aftercare services and document participation of planning for post- SIPP services. 5. Referral and coordination to providers of recommended services, including liaison with the receiving school setting and primary medical care provider.

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

As required by federal law, the state provides services to eligible children if such services are medically necessary to correct or ameliorate a defect, a condition, or a physical or mental illness. Child Health Services Targeted Case Management services are available

21 as medically necessary. Case management services are provided through the state CHIP managed care plans. Prior authorization may be required once a member exceeds plan limits/units.

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder

6.4- BH Assessment Tools

6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use

The state Managed Medical Assistance Plan may utilize a national standardized set of criteria (e.g. InterQual, MCG Guidelines) or other evidence-based guidelines approved by the Agency to approve services. Such criteria and guidelines shall not solely be used to deny, reduce, suspend or terminate a good or service, but may be used as evidence of generally accepted medical practices that support the basis of a medical necessity determination.

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders

State-specific criteria (e.g. state law or policies) (please describe) Mental Health Substance Use Disorders

22 The Behavioral Health Network (BNet) provider agencies are contractually required to use the state prescribed Children’s Global Assessment Scale (CGAS). Additionally, all BNet provider agencies use biopsychosocial assessments.

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Other (please describe) Mental Health Substance Use Disorders

No specific criteria or tools are required Mental Health Substance Use Disorders

Florida Healthy Kids requires the MCOs to adopt evidence-based practice guidelines and encourages the use of validated screening and assessment tools but does not require any specific criteria or tool.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools to determine possible treatments or plans of care, providing education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

Florida Healthy Kids requires the MCOs to make information about using validated assessment tools available to providers using the same facilitation strategies as described in section 6.3.1.2- BH.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex or serious conditions.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Florida FL-22-0034

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group June 30, 2022 Tom Wallace Deputy Secretary for Medicaid 2727 Mahan Drive, MA #8 Tallahassee, FL 32308-5403 Dear Mr. Wallace: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number FL-22-0034, submitted on June 22, 2022, has been approved. Through this SPA, Florida has demonstrated compliance with the American Rescue Plan Act of 2021 (ARP). This SPA has an effective date of March 11, 2021 and extends through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period, as described in section 1135(g)(1)(B) of the Social Security Act (the Act). Section 9821 of the ARP amended sections 2103(c)(11)(B) and 2103(e)(2) of the Act to mandate coverage of COVID-19 testing, treatment, and vaccines and their administration without cost- sharing or amount, duration, or scope limitations. Sections 2103(c)(11)(B) and 2103(e)(2) of the Act also require states to cover, without cost sharing, the treatment of conditions that may seriously complicate COVID-19 treatment, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19. The state provided the necessary assurances to demonstrate compliance with the ARP in accordance with the requirements of sections 2103(c)(11)(B) and 2103(e)(2) of the Act. 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. 457.65 that the state submit SPAs that are related to the COVID-19 public health emergency by the end of the state fiscal year in which they take effect. CMS is allowing states that submit SPAs after the last day of the state fiscal year to have an effective date in the prior state fiscal year, but no earlier than the effective date of the public health emergency. Florida requested a waiver to obtain an earlier effective date and this letter approves Florida’s request for an effective date of March 11, 2021. Your Project Officer is Joshua Bougie. He is available to answer your questions concerning this amendment and other CHIP-related matters. His contact information is as follows:

Page 2 – Mr. Tom Wallace Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-8117 E-mail: joshua.bougie@cms.hhs.gov If you have additional questions, please contact Ms. Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff. Sincerely, Amy Lutzky Deputy Director On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services cc: Courtney Miller, Director, Medicaid and CHIP Operations Group Jackie Glaze, Deputy Director, Medicaid and CHIP Operations Group /Signed by Amy Lutzky/

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:______________Florida________________________________________

(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))_______________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: ____________

Position/Title: ______________ Name: ____________

Position/Title: ______________

Name: ____________

Position/Title: ______________

Disclosure Statement This information is being collected to pursuant to 42 U.S.C. 1397aa, which requires states to submit a State Child Health Plan in order to receive federal funding. This mandatory information collection will be used to demonstrate compliance with all requirements of title XXI of the Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of information requirements under this control number is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

This template outlines the information that must be included in the state plans and the State plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. • Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016)

States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

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When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary-

4 approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a

5 combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State plan amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create

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

Where the state’s assurance is requested in this document for compliance with a particular requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in compliance no later than the applicable compliance date.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

7

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

SPA number: FL-2022-0034

Purpose of SPA: The purpose of this SPA is to demonstrate compliance with the American Rescue Plan Act provisions that require states to cover treatment (including treatment of a condition that may seriously complicate COVID-19 treatment), testing, and vaccinations for COVID-19 without cost sharing in CHIP.

Proposed effective date: March 11, 2021

Proposed implementation date: March 11, 2021

1.4-TC Tribal Consultation. (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

SPA #34 - Effective Date:

March 11, 2021

According to Florida’s Tribal Consultation Policy, the state does not need to provide tribal consultation in the event that a SPA is not restrictive. This SPA demonstrates compliance with the American Rescue Plan Act provisions that require states to cover treatment (including treatment of a condition that may seriously complicate COVID-19 treatment), testing, and vaccinations for COVID-19 without cost sharing in CHIP.

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

Effective March 11, 2021, and through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period described in section 1135(g)(1)(B) of the Act, and for all populations covered in the CHIP state child health plan:

COVID-19 Vaccine: • The state provides coverage of COVID-19 vaccines and their administration, in accordance with the requirements of section 2103(c)(11)(A) of the Act.

COVID-19 Testing:

8 • The state provides coverage of COVID-19 testing, in accordance with the requirements of section 2103(c)(11)(B) of the Act. • The state assures that coverage of COVID-19 testing is consistent with the Centers for Disease Control and Prevention (CDC) definitions of diagnostic and screening testing for COVID-19 and its recommendations for who should receive diagnostic and screening tests for COVID-19. • The state assures that coverage includes all types of FDA authorized COVID-19 tests.

COVID-19 Treatment: • The state assures that the following coverage of treatments for COVID-19 are provided without amount, duration, or scope limitations, in accordance with requirements of section 2103(c)(11)(B) of the Act: o The state provides coverage of treatments for COVID-19 including specialized equipment and therapies (including preventive therapies); o The state provides coverage of any non-pharmacological item or service described in section 2110(a) of the Act, that is medically necessary for treatment of COVID-19; and o The state provides coverage of any drug or biological that is approved (or licensed) by the U.S. Food & Drug Administration (FDA) or authorized by the FDA under an Emergency Use Authorization (EUA) to treat or prevent COVID-19, consistent with the applicable authorizations. Coverage for a Condition That May Seriously Complicate the Treatment of COVID-19: • The state provides coverage for treatment of a condition that may seriously complicate COVID-19 treatment without amount, duration, or scope limitations, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19, in accordance with the requirements of section 2103(c)(11)(B) of the Act.

8.2.3 Coinsurance or Copayments:

Effective March 11, 2021 and through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period described in section 1135(g)(1)(B) of the Act, and for all populations covered in the CHIP state child health plan, the state assures the following:

COVID-19 Vaccine: • The state provides coverage of COVID-19 vaccines and their administration without cost sharing, in accordance with the requirements of section 2103(c)(11)(A) and 2013(e)(2) of the Act.

9 COVID-19 Testing: • The state provides coverage of COVID-19 testing without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

COVID-19 Treatment: • The state provides coverage of COVID-19-related treatments without cost sharing, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.

Coverage for a Condition That May Seriously Complicate the Treatment of COVID-19: • The state provides coverage for treatment of a condition that may seriously complicate COVID-19 treatment without cost sharing, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19, in accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act. This coverage includes items and services, including drugs, that were covered by the state as of March 11, 2021.

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Center for Medicaid and State Operations, Family and Children’s Health Programs Group

April 1, 2010

Ms. Roberta K. Bradford Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, MS #8 Tallahassee, FL 32308

Dear Ms. Bradford:

We are pleased to inform you that your Children’s Health Insurance Program (CHIP) State plan amendment (SPA) submitted on September 29, 2009, has been approved.

This amendment reduces the period of uninsurance for the voluntary cancellation of group health insurance coverage from 6 months to 60 days and provides good cause exemptions to the waiting period; increases the dental benefit limit to $1000 per member per year; removes limitations for mental health and substance abuse services; utilizes electronic verification of income; provides clinically eligible children with the choice of enrolling in the Children’s Medical Services Network (CMSN) or MediKids or Healthy Kids. It also updates the outreach section of the State plan; reduces the nonpayment of premium grace period from 60 to 30 days; and clarifies the KidCare dispute and grievance process. This amendment has a retroactive effective date of July 1, 2009, for all provisions, with the exception of October 1, 2009, for the removal of limitations for mental health and substance abuse services.

It is our understanding that the State will be working through this upcoming legislative session to ensure that the dental benefits provided through the State plan meet the statutory requirements of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). CMS continues to be available, should you need technical assistance.

Your title XXI project officer is Ms. Crystal Francis. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Francis’ contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and State Operations

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-4626

Facsimile: (410) 786-5882 E-mail: Crystal.Francis@cms.hhs.gov

Page 2 – Ms. Bradford

Official communications regarding program matters should be sent simultaneously to Ms. Francis and to Ms. Mary Kaye Justis, Acting Associate Regional Administrator for the Centers for Medicare & Medicaid Services, Region IV, Division of Medicaid and State Operations. Ms. Justis’ address is:

Centers for Medicare & Medicaid Services Division of Medicaid and State Operations Atlanta Federal Center – 4th Floor 61 Forsyth Street, SW Suite 4T20 Atlanta, GA 30303-8909

If you have additional questions, please contact Ms. Victoria Wachino, Director, Family and Children’s Health Programs Group, Center for Medicaid and State Operations, at (410) 786-5647. We look forward to continuing to work with you and your staff.

Sincerely,

/s/

Cindy Mann Director cc: Ms. Mary Kaye Justis, Acting Associate Regional Administrator, CMS Region IV Office

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Center for Medicaid, CHIP and Survey & Certification

May 5, 2011

Roberta K. Bradford Deputy Secretary for Medicaid 2727 Mahan Drive, MS #8 Tallahassee, FL 32308

Dear Ms. Bradford:

Your title XXI Children’s Health Insurance Program (CHIP) State plan amendment (SPA) number 19, submitted on September 29, 2010, has been approved. Through this SPA, the State comes into compliance with the dental requirements in section 501 of the Children’s Health Insurance Program Reauthorization Act (CHIPRA). The State has elected to meet CHIPRA’s dental requirements through a State specific dental benefit package. Florida’s CHIP SPA number 19 has a retroactive effective date of July 1, 2010.

Your title XXI project officer is Ms. Amy Lutzky. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Lutzky’s contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid, CHIP and Survey & Certification

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-0721

Facsimile: (410) 786-5943

E-mail: Amy.lutzky@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Lutzky and to Ms. Jackie Glaze, Associate Regional Administrator in our Atlanta Regional Office. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid and Children’s Health Operations 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909

If you have additional questions, please contact Ms. Victoria Wachino, Director, Children and Adults Health Programs Group at (410) 786-5647.

Page 2 – Ms. Roberta Bradford

We look forward to continuing to work with you and your staff.

Sincerely,

/s/

Cindy Mann

Director

cc: Jackie Glaze, ARA, CMS Region IV

State of Florida

Florida KidCare Program

Amendment to Florida’s Title XXI Child Health Insurance Plan Submitted to the Centers for Medicare and Medicaid Services

Amendment #19 July 1, 2010

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 1 Table of Contents

Section 1 General Description and Purpose of the State Child Health Plans and State

Child Health Plan Requirements ....................................................................... 4 Section 2 General Background and Description of State Approach to Child Health

Coverage and Coordination.............................................................................. 9 Section 3 Methods of Delivery and Utilization Controls ................................................ 29 Section 4 Eligibility Standards and Methodology .......................................................... 37 Section 5 Outreach .......................................................................................................... 61 Section 6 Coverage Requirements for Children’s Health Insurance .............................. 72 Section 7 Quality and Appropriateness of Care .............................................................. 84 Section 8 Cost Sharing and Payment .............................................................................. 92 Section 9 Strategic Objectives and Performance Goals and Plan Administration ........ 101 Section 10 Annual Reports and Evaluations ................................................................... 115 Section 11 Program Integrity…………………………………………………………... 116 Section 12 Applicant and Enrollee Protections………………………………………….117 Tables and Charts Florida KidCare Eligibility ....................................................................................................... 5 Florida Medicaid Child Eligibility .......................................................................................... 17 Overview of FHKC Administrative Functions ....................................................................... 22 Florida KidCare Application Process...................................................................................... 26 Florida Medicaid/MediKids Managed Care Coverage ........................................................... 29 Title XXI Transfer Policy…………………………………………………………………………………...54

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 2 Non-Payment Waiting Period………………………………………………………………..55 Florida Healthy Kids Co-payments .................................................................................... .…94 Title XXI Billing Methodology ....................................................................................... ….112 SCHIP Budget Plan Template .......................................................................................... ….114 Review Processes for Florida KidCare ................................................................................ .119 Appendix A…KidCare Medicaid Screening Criteria ………………………….…………...124

Appendix B …Dispute Review Process…………………………………………………….127

Appendix C …Florida KidCare Grievance Procedure.……………………………………..134

Appendix D…Healthy Kids Dental Prior Authorization Process…………………………..139

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 3 STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:____State of Florida____________________________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

____________________________________ _______________________________ Roberta K. Bradford, Deputy Secretary for Medicaid Date

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Roberta K. Bradford

Position/Title: Deputy Secretary for Medicaid Name:

Position/Title: Name:

Position/Title:

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 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 4 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1 

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.  Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3. X A combination of both of the above.

Major elements of Florida’s Title XXI plan, known as the Florida KidCare Program, include: Phase 1 (effective April 1, 1998) • Extending Medicaid coverage for children ages 15 to 19 in families with incomes up to 100% of the Federal Poverty Level; • Expanding the Florida Healthy Kids program, modified to meet the requirements of Title XXI; Phase 2 (effective July 1, 1998) • Implementing the Florida KidCare program for children in families with incomes up to 200% of the federal poverty level, except for Medicaid. The components of the Florida KidCare program include: − MediKids, ages 1 to 5; − Florida Healthy Kids, ages 5 to 19; − the Children’s Medical Services Network for children with special health care needs, ages 0 to 19; and − Medicaid for children under age 19. • Initiating preventive dental coverage for selected sites for Florida Healthy Kids enrollees • Converting children under the age of 1 in families with income up to 200% of the federal poverty level, to Title XIX Medicaid. • Expanding comprehensive dental coverage for the Florida Healthy Kids program.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 5 Florida KidCare Eligibility

MediKids Full Pay >200% 200 Ages 0 to 1 Ages 1 through 4 Age 5 Florida Healthy Kids (Title XXI Administration/Enrollment, 3rd Party Administrator Contract) 133% 100% MediKids (AHCA) 185% Ages 6 through 18 Medicaid for Children (DCF, Eligibility; AHCA, Program Administration) CMS Network Title XIX and Title XXI (Dept. of Health) Title XXI-Funded Title XIX-Funded Medicaid: Florida Healthy Kids Full Pay > 200% Federal Poverty Level

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 6 1.2  Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

Florida assures CMS that it will not claim expenditures for child health insurance prior to obtaining legislative authority to operate the CMS-approved plan amendment.

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

The state assures that it complies with all applicable civil rights requirements.

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

SPA #1 (MediKids and CMSN Expansion)

Effective date: July 1, 1998

Implementation date: October 1998

SPA #2 (Employer-sponsored Insurance)

Disapproved: November 5, 1999

SPA #3 (Healthy Kids Dental Pilot)

Effective date: October 1, 1999

Implementation date: October 1, 1999

SPA #4 (Expands Medicaid <1, MediKids Mandatory Assignment)

Effective date: July 1, 2000

Implementation date: July 1, 2000

SPA #5 (Expands Healthy Kids Dental Coverage)

Effective date: February 1, 2001

Implementation date: February 1, 2001

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 7 SPA #6 (School-based Health Services)

Effective date: July 1, 2002

Implementation date: July 1, 2002

SPA #7 (Employer-Sponsored Coverage) SPA Withdrawn

SPA #8 (Compliance)

Effective date: February 7, 2003

Implementation date: July 1, 2002

SPA #9 (Legislative Changes)

Effective date: July 1, 2003 & December 1, 2003

Implementation date: July 1, 2003

SPA#10 (PIC Services) Effective date: March 11, 2004 Implementation date: March 11, 2004

SPA#11 (Change in Source of State Funding) Withdrawn: April 10, 2006

SPA#12 (Legislative Changes) Effective date: April 1, 2004 and July 1, 2004 Implementation date: April 1, 2004 and July 1, 2004

SPA#13 (KidCare Policy Changes)

Effective date: September 14, 2004

Implementation date: September 14, 2004 and March 12, 2004

SPA#14 (Hurricane Premium Credits)

Effective date: September 1, 2004

Implementation date: September 1, 2004

SPA#15 (Legislative Changes)

Effective date: December 21, 2004

Implementation date: December 21, 2004

SPA #16 (Legislative Changes)

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 8

Effective date: June 1, 2005

Implementation date: June 10, 2005

SPA #17 (Policy Clarifications)

Effective Date: October 1, 2006

Implementation Date: October 1, 2006

SPA #18 (Legislative Changes) Effective Date: July 1, 2009

Implementation Date: July 1, 2009 and October 1, 2009 (for removal of

limitations for mental health and substance abuse services)

SPA #19 (CHIPRA Dental Compliance)

Effective Date: July 1, 2010

Implementation Date: July 1, 2010

Section 2. General Background and Description of State Approach to Child Health

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 9 Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a)) Insured Children Almost 2.8 million of Florida’s 3.6 million children under age 19 are insured. Females represent 49 percent of insured children and males represent 51 percent. White children account for 80.4 percent of insured children under age 19, and non- whites account for 19.6 percent. At the inception of the Florida KidCare Program, the state lacked sufficient information about the distribution of the insured by geographic region. However, the 1998 Legislature authorized funding for a comprehensive health care study, the primary goal of which was to update the estimates of Florida’s insured and uninsured populations. This study included information on insurance and uninsurance status by geographic region, race and ethnicity, employment and income level, the extent of dependent coverage, and type of coverage employees select. (See updated information from the insurance study, on page 10) Uninsured Children Florida has one of the nation’s largest uninsured populations. An estimated 12.1 percent of Florida’s 4.4 million children under age 19 are uninsured. Of the approximately 646,430 uninsured children, males represent slightly more than one half (53 percent). Whites account for 42.1 percent, African Americans account for 19.3 percent, Hispanics account for 36.3 percent, Asian and Pacific Islanders account for 2.2 percent, and Native Americans account for less than 0.1 percent. As a consequence, uninsured children are typically treated for urgent or emergent conditions in inappropriate settings and do not share the continuity of care enjoyed by their insured peers. Most of Florida’s uninsured children — 42 percent — reside in the southern part of the state. Thirty-six percent reside in Central Florida counties, and 22 percent reside in North Florida. Estimates of the uninsured children by geographic region were obtained by assuming that the statewide uninsurance rate of 23 percent is equally

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 10 distributed among all 67 Florida counties. These estimates were derived from the 1993 RAND survey and updated by population estimates from Florida’s Joint Legislative Management Committee, Division of Economic and Demographic Research, the 1997 Florida Statistical Abstract, and the Urban Institute’s State-Level Data Book on Health Care Access and Financing. Part of Florida’s high uninsurance rate can be attributed to the characteristics of the state’s business economy. Larger firms are more likely to offer health insurance as a benefit than small firms. More than 95 percent of Florida’s businesses employ fewer than 25 individuals. Health Insurance and Access to Care Access to health care is crucial to a child’s development. Children who have health insurance are more likely to receive preventive care — care that helps keep them in good health. Children who lack affordable access to a doctor are less likely to seek treatment for minor illnesses, suffering until the body heals itself or the condition becomes too severe for home treatments. For many children, the emergency room is their primary source of care. The Centers for Disease Control in 1991 reported that, for 13 percent of children ages 15 and under, hospital outpatient departments were their primary contact for health care services. Another study found that uninsured children under the age of 19 are eight times more likely to receive care in an emergency room than children with insurance. This type of care is devastating to the child. The severe outcomes of these medical conditions reduce the child’s ability to attend school and participate in the activities of a normal childhood. The costs associated with this level of care are not limited to the child, but affect the community as a whole. Emergency room services are expensive, especially when they are used to treat illnesses that could have been prevented by an earlier visit to a physician. According to the Journal of the American Medical Association, lack of health care coverage is an important factor in the delay of seeking preventive and acute care. Children with health insurance are more likely to be fully immunized, have more preventive care visits, fewer physician office visits for illnesses and fewer emergency room visits. For children with a regular source of care, total health care costs are lowered by 25%. Prior to the inception of Florida KidCare, the structure of health insurance programs left more than 823,000 Florida children uninsured. This problem was partly a result of the system of employment-based health insurance. Although no single approach can solve the problems, Title XXI funding for the Florida KidCare program significantly reduced the number of uninsured children. The Institute for Child Health Policy released their Statewide Children’s Health

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 11 Insurance Survey dated June 2002. The results show that approximately 15% of Florida’s children are currently uninsured. The figures varied by federal poverty level (FPL) and have increased in both the less than 100% FPL category and the greater than 200% FPL category. The Urban Institute and Kaiser Commission on Medicaid and the Uninsured, based on estimates from the March 2002 and 2003 Current Population Surveys, determined that 16% of Florida’s children are currently uninsured. Florida KidCare Law The 1998 Legislature enacted the Florida KidCare Act, which dramatically enhances child health insurance options under Florida’s Title XXI child health insurance plan. Florida KidCare consists of the following components: • MediKids, a Medicaid “look-alike” program for children ages 1 to 5; • Healthy Kids for children ages 5 to 19; • The Children’s Medical Services Network (CMSN) for children ages 0 to 19 who have a special health care need; and • Medicaid for children under age 19. Except for Medicaid, financial eligibility for the Florida KidCare program is 200 percent of the federal poverty level. Except for Medicaid, the Florida KidCare program is not an entitlement and participants contribute to the cost of their monthly premiums. The KidCare law also provides for six months of continuous eligibility for coverage. The 2000 Florida Legislature authorized the following changes affecting the Title XXI Florida KidCare Program: • Funding for 102,000 additional children in KidCare • Mandatory Assignment for MediKids: This is a vehicle that is not intended to restrict enrollee choices. It is a measure to speed up the actual enrollment process by assuring a provider choice is made. • Medicaid Expansion for Children Under Age 1: This is an expanded Medicaid eligibility for children under the age of 1 to 200% of poverty ($37,700 for a family of four). Children under the age of 1 between 185% and 200% FPL in MediKids and in Title XXI CMSN are enrolled in Medicaid and funded with Title XXI (like the Medicaid for Teens expansion group). • Expedited eligibility for KidCare program components: This authorized each

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 12 of the KidCare partners to seek innovative measures to speed up the eligibility process. • Implementing a comprehensive dental benefit program for the Florida Healthy Kids Corporation for counties that contribute at least $4,000 annually in local match funds, effective February 1, 2001. The Corporation began a staggered implementation of this program to eligible counties on February 1, 2001. The 2001 Florida Legislature further amended the Florida KidCare program in the following areas: • Removed the $4,000 local match requirement in order to have a comprehensive dental program in the Healthy Kids program. Healthy Kids was then required to expand this benefit statewide by June 30, 2002. • Waived any local match requirements for the Healthy Kids program for the 2001-2002 state fiscal year. The 2002 Florida Legislature amended the Healthy Kids’ enabling statute, the Florida Healthy Kids Corporation Act, in order to address the issue of local match and to prescribe a specific formula for the calculation of match only on Healthy Kids’ non- Title XXI enrollees. The 2002 Legislature also provided $33.8 million in additional state funds to meet projected enrollment needs during the 2002-2003 state fiscal year.

The 2003 Florida Legislature made several statutory changes to the Florida KidCare Program’s enabling legislation and adjusted the funding for the Florida KidCare Program based on several program modifications including:

• Effective July 1, 2003, the family premium payment increased from $15 per family per month to $20 per family per month for all Florida KidCare Program components (non-Medicaid). Effective January 1, 2004, a tiered monthly premium system will be implemented as follows: the family premium will be $15 for families with income less than or equal to 150% of the federal poverty level and $20 for families with incomes above 150% to 200% of the federal poverty level ($5 credits were provided in January to those families whose incomes were less than or equal to 150% of the Federal Poverty Level for each month of coverage their children had received between August 2003 and December 2003);

• Effective July 1, 2003, dental benefits were capped at $750 per enrollee per year (July 1 – June 30) for children enrolled in the Florida Healthy Kids program; and,

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 13

• Effective October 1, 2003, co-payments are increased from $3 to $5 for certain health care services for children enrolled in the Florida Healthy Kids program.

In addition to the statutory changes, the 2003 Florida Legislature eliminated funding for outreach for the KidCare Program, and appropriated funds that will limit enrollment to the June 30, 2003 enrollment levels.

The 2004 Florida Legislature made several statutory changes to the Florida KidCare Act, as follows:

 Provides an interim appropriation for SFY 2003-2004 to fund the enrollment of children who were on the wait list on or before March 11, 2004;

 Restricts application processing and enrollment for the Florida KidCare Program to no more than two 30-day open enrollment periods per year, in September and January, subject to available funding;

 Applications for the KidCare program, except Medicaid, will be accepted and processed only during open enrollment periods; applications for Title XXI received outside of an open enrollment period will not be processed and no wait lists will be maintained;

 Requires verification and proof of income supported by copies of any federal income tax return for the prior year, any wages and earnings statements (W-2 forms), and any other appropriate document;

 Changes eligibility criteria to include accessibility to employer-based insurance coverage and provides an affordability test allowing families whose coverage would exceed 5% of the family’s income to continue to be eligible for KidCare;

 Excludes from eligibility any applicant who has voluntarily canceled employer-based coverage in the six months prior to application for Title XXI, provides an exception for children whose pre-existing condition would exclude them from their parents’ employer-sponsored health insurance;

 Requires disenrollment from Title XXI Florida KidCare when the program is over-enrolled, except for those children enrolled in CMSN;  Authorizes Children’s Medical Services Network (CMSN) to enroll up to 120

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 14 additional children outside of open enrollment periods annually, within existing resources, and based on emergency disability criteria outside the open enrollment periods. CMSN is exempt from disenrollment provisions. Children will not be required to disenroll from other components to support the 120 CMSN enrollment slots;

 Modifies the Healthy Kids dental benefit language to require dental benefits coverage for Healthy Kids enrollees and further provides that the benefit may include all services available to children under Medicaid. Effective July 1, 2004 the dental premium rate capped at $12 per member per month;

 Provides for the withhold of benefits and prosecution of fraud for applicants and enrollees who submit fraudulent information or fail to provide evidence of eligibility;

 Establishes a 12-month continuous eligibility period, effective January 1, 2005;

 Changes the standards for Healthy Kids insurer contracting process; and

 Eliminates the statutory references related to outreach functions.

During the 2004 December special session, the Florida Legislature made a statutory change to the Florida KidCare Act, revising the income documentation requirement, as follows:

 Effective December 21, 2004, families are required to provide proof of income, including a copy of the most recent federal income tax return. In the absence of a federal income tax return, the family may submit wages and earnings statements, W-2 forms, or other appropriate documents.

The 2005 Florida Legislature made several statutory changes to the Florida KidCare Act, as follows:

 Upon a determination from the Social Services Estimating Conference, applications for the Florida KidCare Program will be accepted at any time throughout the year for the purpose of enrolling children eligible for all Title XXI program components. Children will be enrolled on a first-come, first- served basis using the date the application is received. Enrollment will cease when the enrollment ceiling is reached. The enrollment ceiling is based on

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 15 available funding. Enrollment will resume when the Social Services Estimating Conference determines sufficient federal and state funds are available to finance the increased enrollment through federal fiscal year 2007.

 The Florida KidCare application will be valid for a period of 120 days after the date it was received. At the end of the 120-day period, if the applicant has not been enrolled in the program, the application shall be invalid and the applicant shall be notified. The applicant may resubmit another application, or request that a previously submitted application be reactivated.

 Eliminates the provision that Children’s Medical Services Network (CMSN) may enroll up to 120 additional children outside of open enrollment periods.

 Allocates up to $40,000 in state funds for the production and distribution of information about the Florida KidCare program through the school system. The materials are to be distributed on the first day of the 2005-2006 school year.

 Caps the dental premium rate for the Healthy Kids program at not more than $12 per member per month for the 2005/2006 state fiscal year.

The 2006 Florida Legislature made the following statutory changes to the Florida KidCare Act:

 Requires the Agency for Health Care Administration to implement a Full Pay buy-in program for MediKids-aged children by July 1, 2006.

 Allocates $1,000,000 in state funds for a KidCare community-based marketing and outreach matching grant program. No federal matching funds will be used. The 2009 Florida Legislature made the following statutory changes to the Florida KidCare:

 Requires the marketing of the program as “Florida KidCare”.

 Reduces the voluntary nonpayment of premium penalty from 60 days to 30 days.

 Allows children clinically eligible for Children’s Medical Services Network to opt out of the CMS Network and instead be enrolled in MediKids or Healthy

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 16 Kids, depending on the child’s age.

 Waives the waiting period for enrollees who cancelled employer sponsored health insurance coverage prior to application if the cost of the coverage was greater than five (5) percent of the family’s income.

 Reduces the waiting period from 6 months to 60 days, if health insurance is voluntarily canceled.

 Waives the waiting period for voluntary cancellation of health insurance coverage under certain good cause exceptions.

 Requires proof of income only if income cannot be determined or substantiated electronically.

 Allows 10 working days from an adverse action notice for enrollees to request reinstatement while pending a dispute resolution; clarifying that the timeline is working days rather than calendar days.

The 2010 Florida Legislature increased funding for the Florida Healthy Kids Corporation’s dental plans and eliminated the annual benefit limit on dental services.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for

uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance): Florida uses several programs to provide health care coverage to eligible low- income children: Medicaid The Agency for Health Care Administration is Florida’s designated single state agency for the Medicaid program. The Department of Children and Families is Florida’s designated Title IV-A agency and conducts Medicaid eligibility determination and enrollment functions.

Over half of Florida’s 2 million Medicaid patients are children — about 1.3

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 17 million. Florida Medicaid covers children at the following income levels:

Florida Medicaid Child Eligibility Age Federal Poverty Level 2009 Annual Income Family of 4 0 to 1 185% (Title XIX - effective 7/1/00) $40,792 0 to 1 185.01% - 200% (Title XXI Medicaid Expansion) $44,100 1 to 6 133% $29,327 6 to 15 100% $22.050 15 to 19 100% (effective 4/1/98) $22.050

Managed care is an integral part of the Florida Medicaid program. Medicaid beneficiaries have several types of managed care options available, including managed care organizations and MediPass, which is a primary care case management program. Children account for approximately two thirds (2/3) each of the populations eligible for MediPass and managed care organizations. Florida has a strong historical commitment to Medicaid outreach. Since the late 1980s, the state has out stationed eligibility staff with major health care providers to make eligibility services more accessible. Out posted sites have included hospitals serving large numbers of Medicaid patients, county health departments and Regional Perinatal Intensive Care Centers. Currently, almost 254 eligibility specialists are out posted. Florida has developed outreach brochures emphasizing Medicaid and other benefits for low-income working families and providing information on transitional benefits, including transitional Medicaid coverage for families leaving welfare for work. All materials are available in a variety of languages, reflecting the state’s multicultural environment. Florida was part of a 17-member group of states working with the Southern Institute for Children and Families. The Institute received a grant from the Robert Wood Johnson Foundation to provide technical assistance, hold

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 18 conferences, and prepare outreach materials to assist states in informing low- income families who may or may not be losing other public assistance eligibilities about other benefits that they may qualify for, including Title XIX or Title XXI benefits. Florida Healthy Kids Healthy Kids is another Florida KidCare component for uninsured children in Florida. As of July 1, 2005, this program provides coverage to more than 203,730 children, of which 177,721 are Title XXI eligible. Healthy Kids is authorized under section 624.91, Florida Statutes. Initially, The Florida Healthy Kids Corporation (FHKC) used school districts to create large health insurance risk pools to bring affordable, accessible, quality private sector health care to the population of uninsured children. • In the Healthy Kids program, the children themselves qualify for coverage. • It is a solution for parents who are not offered employer-based health insurance. • A child’s coverage is not dependent on parents remaining employed. With the implementation of Title XXI and the removal of the eligibility requirement that a child be enrolled in school in order to be eligible, Healthy Kids’ relationship with the school districts has evolved; however, they remain a valuable partner in identifying eligible children and assisting with outreach efforts. The problem of uninsured children is not exclusive to Florida — it is nationwide. Furthering its mission to assure that all Americans can acquire basic health care at a reasonable cost, from 1996 through 2001, the Robert Wood Johnson Foundation has made grant money available to replicate the Florida Healthy Kids program. The importance of Healthy Kids is evident not only in the number of children who now receive health care, but also in the well-deserved recognition it has received. In December 1996, the FHKC received an Innovations in American Government Award from the John F. Kennedy School of Government at Harvard University and the Ford Foundation. Selected from 1,560 applicants, Healthy Kids was honored for its outstanding example of creative problem solving in the public sector. Additionally in 2001, the Innovations Program celebrated its 15th Anniversary and as part of its celebrations, they named the top 15 programs ever recognized and the Healthy Kids program was one of

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 19 those distinguished programs. Children’s Medical Services Network The Children’s Medical Services Network (CMSN) and its area offices are located in the Department of Health. The CMSN is statutorily authorized (Chapter 391, Florida Statutes) to operate the CMSN, which is a managed system of care for low-income children with special health care needs. For Title XXI-funded enrollees, the CMSN receives a monthly premium from AHCA. The CMSN is also an approved Medicaid managed care option for children with special health care needs and is the state’s Title V agency for children with special health care needs. These children do not pay premiums. Staff in the CMSN area offices determine medical eligibility and enroll children with special health care needs into the CMSN . The CMSN delivery system is a private provider network that includes local, regional and tertiary facilities and private health care providers. The delivery system incorporates a continuum of care that includes early intervention programs, primary and specialty care, and long term care. Providers and families are supported through a case management system. The provider network includes approved Medicaid providers and pediatric primary care physicians enrolled in Healthy Kids plans. The CMSN enters into contracts with providers to participate in the CMSN.

Children’s Mental Health Services Florida’s Agency for Health Care Administration, the Department of Children and Families and the Department of Health work collaboratively to provide Medicaid-funded and state-funded mental health and substance abuse services for children through networks of contracted providers. There is also an array of substance abuse services funded by Medicaid and the Department of Children and Families for children and adolescents with serious alcohol or other drug addictions. Direct Health Services Direct health services are provided by county health departments, school-based health centers and voluntary practitioner programs. • Florida has 67 county health departments, which provide comprehensive primary care services, including care for acute and

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 20 chronic illness, injuries, family planning, prenatal care, diagnostic services and prescriptions. • County health departments are MediPass providers for Medicaid patients. Some county health departments have agreements with managed care organizations to provide other Medicaid services. • The county health departments furnish services on a sliding fee scale, according to family size and income. • Maternal and Child Health Block Grant (Title V of the Social Security Act) funds are passed through to the county health department where they are used to support a number of activities on behalf of women and children, particularly those of low income. State Title V staff provides oversight, consultation and standards to assure appropriate utilization of these funds. When families are ineligible for any insurance plan, or when there is not another provider of free or reduced price health care (i.e., community or rural health centers) available or accessible, many of these county health departments provide direct services to low- income children. Services provided in county health departments include comprehensive well child clinic services, including developmental and physical assessments, immunizations and parent education. Families under 100% of the Federal Poverty Level receive these services at no cost. Others pay on a sliding scale. • The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides nutritious foods to supplement the regular diet of pregnant women, breastfeeding women, infants and children under age five who are at or below 185% of the Federal Poverty Level and who meet nutritional/medical risk criteria for eligibility. WIC staff encourages pregnant women and parents and guardians of infants under 12 months of age to apply for Medicaid. • County health departments tell their clients about the Medicaid program and refer them to the local Department of Children and Families office for a full eligibility determination. County health departments also serve as presumptive eligibility sites for pregnant women and infants under age 1. Healthy Start Florida’s Healthy Start service delivery model has proven to be an effective strategy for targeting risk reduction resources to pregnant women and infants

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 21 most at risk for poor health and development outcomes. Prenatal and infant risk screening identify potential Healthy Start participants. Further in-depth risk assessment by trained staff and family support planning with clients ensures risk reduction services are targeted to at-risk pregnant women and infants. These services, which provide at-risk families with the information, encouragement and support needed to take control of their own health practices and choices, may be provided in the home, clinic, or other community settings. Universal Healthy Start risk screening takes place at the first prenatal visit and before a newborn leaves the hospital, providing a unique opportunity to reach out to the populations whom could most benefit from Healthy Start services. Other outreach sites include WIC and Work and Gain Economic Self- Sufficiency (TANF) offices for welfare-to-work participants, Head Start and day care sites, and teen pregnancy/parenting programs. Florida’s locally-based Healthy Start Coalitions have been very successful in reinforcing the delivery of quality services through involving community partners in local needs assessment, service delivery planning and implementation and monitoring service delivery. The Healthy Start Coalitions which do not provide health services are responsible for determining the allocation of state and federal maternal and child health funds for Healthy Start risk reduction services and for ensuring accountability for high-quality service at the local level, where monitoring and ongoing evaluation can best be accomplished. 2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

Healthy Kids has contract arrangements with many school districts in order to facilitate the distribution of applications and other marketing materials through the schools each year. Many of the original school districts that became involved in Healthy Kids prior to Title XXI continue their own local efforts as well.

For the 2005/2006 SFY, the Legislature appropriated $40,000 in state funds to provide KidCare program information to all school children. This information will be distributed statewide on the first day of the 2005/2006 school year. The following table indicates activities and the sharing of responsibilities in those counties with local efforts.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 22 Function FHKC or Its Third Party Administrator School Districts Health Plans Outreach X X

Participant Education X X X Enrollment X

Member Services X

X Outreach Enrollment forms and marketing materials are made available at participating county schools during open enrollment periods. The marketing activities, forms and associated materials are designed by the KidCare Partners and FHKC or provided by the Department of Health. Participant Education Healthy Kids’ contracted health and dental insurers also include activities such as: (1) basic education about accessing services and using the plan, and (2) innovative strategies for meeting wellness care and immunization standards, as well as health promotion and prevention. Enrollment The enrollment process is a function of the Corporation or its third party administrator, which conducts Medicaid eligibility screening and referral, determines financial eligibility for Title XXI and verifies lack of enrollment in Medicaid and access to state employee benefits. Member Services The health and dental plans provide identification cards and membership handbooks detailing program benefits and the grievance process. The third-party administrator (TPA) and the health plan each have member services staff that provide assistance to families regarding eligibility, benefits and how to access services. Customer service representatives that are bi-lingual and other language translation services are also available. In addition, Healthy Kids provides an auto-dialer process, where software

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 23 automatically calls families with recorded information in order to expedite processing and alert families that their payments are late.

Outbound telephone calls are also conducted for Healthy Kids families who are in the re- determination or renewal process for the program. Customer service representatives make phone calls to families reminding them of the importance of completing this process and providing assistance with the completion of the renewal document. The FHKC is responsible for coordinated marketing of the Healthy Kids program. FHKC does not use commissioned insurance agents for marketing and enrollment. One of the primary objectives of the marketing strategy is to keep the materials, both Healthy Kids specific information as well as general KidCare program information, simple to understand. As such, a goal for marketing materials is that they be written at a fifth grade reading level. For areas with a large concentration of non-English speaking populations, materials are prepared to fit their specific needs. Currently, the KidCare application and brochures are available in English, Spanish and Creole. In addition, FHKC’s TPA employs a multi-lingual staff. The school system is an integral component for the marketing of the program. As previously noted, most children attend school. The school systems already have in place an efficient distribution system. By sending brochures and applications home with the children, FHKC can be assured that it is reaching its target population.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as Title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

New Florida KidCare Program Applicants Applications received through the mail are usually received at a Post Office Box in Tallahassee, Florida. The program also offers families an online application process

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 24 as well. FHKC’s third party administrator retrieves the mail from the post office on a daily basis. Children who appear to be Title XIX eligible based on age, household and income indicators (after applying income disregards), according to the most recent Federal Poverty Guidelines, will be referred for full Medicaid eligibility determination. Department of Children and Families’ eligibility specialists are co-located at FHKC in Tallahassee. During open enrollment periods, children who are not eligible for Title XIX will be processed for enrollment in the appropriate Florida KidCare program component (MediKids, Healthy Kids, or the Children’s Medical Services Network). Applications received outside an open enrollment period will not be processed for Title XXI coverage. Applicants will receive a letter informing them of the closed enrollment period and will direct them to re-apply during the next open enrollment period. FHKC and/or its third party administrator conduct the following activities for all components of the Florida KidCare program (except Medicaid): • accepting and processing Florida KidCare applications; • conducting Title XIX screening of Florida KidCare applications; • electronically transmitting application data for children who appear to be eligible for Medicaid to the Department of Children and Families eligibility determination workers for a full Medicaid eligibility determination; • collecting monthly premiums from Title XXI families in accordance with the fee schedule, distributing coupon books to families, sending follow-up letters to families who have not made their monthly premium payments, and disenrolling children whose families do not make their monthly premium payment; • making referrals to the Children’s Medical Services Network (CMSN) of applicants or current enrollees who indicate their child has a special health care need; • transferring a data file of MediKids eligibles to the Agency for Health Care Administration for choice counseling once an application is received from a potential MediKids enrollee; and • notifying MediKids enrollees who attain the age of 5 that they will be enrolled in Healthy Kids at the first of the month following the month in which the child reached his fifth birthday, if space is available for such a transition.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 25 Enrollment in a Florida KidCare program component will not occur until the following conditions are met after ineligibility for and non-enrollment in Medicaid is determined and financial eligibility has been established: MediKids: (1) the FHKC receives the premium payment, and (2) the family has made a choice of a managed care plan or MediPass provider. Healthy Kids: FHKC receives the premium payment. CMSN: (1) the FHKC receives the premium payment, and (2) the Children’s Medical Services Network confirms that the child meets the clinical eligibility criteria for participation in the Children’s Medical Services Network.

PIC Services: Title XXI PIC services is an extension of the Medicaid 1115 waiver which established PIC services as a coordinated effort between the Department of Health, chiefly CMSN, the Agency for Health Care Administration and Florida Hospices and Palliative Care, Inc. The same criteria and referral process used in the 1115 waiver is used for Title XXI PIC services. After a child is determined eligible for Title XXI and enrolled in the CMSN, if the child meets the criteria for PIC services and the family chooses to receive PIC services, CMSN refers the child to hospice to evaluate the need for PIC services. The PIC services become an overlay to the child’s medical services. The CMSN care coordinator takes the lead in coordinating between hospice and CMSN. The CMSN care coordinator is responsible for developing and maintaining the child’s care plan. The care coordinator works in collaboration with the hospice care coordinator, making sure all of the PIC services are included in the care plan and that all services are provided and coordinated.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 26 Florida KidCare Application Process Initially Developed 12/14/98. Revised 2/12/99, 12/7/99,4/12/04 and 6/21/05. Families who leave TANF due to earned income may be eligible for KidCare or Medicaid Applications brought into Children & Families service centers Applications mailed to Florida Healthy Kids Corporation (FHKC) Unopened applications sent overnight to TPA and scanned by TPA and date stamped Uninsured children may be eligible for KidCare, including Medicaid Receipt of application acknowledged. Missing information letters sent to applicants if critical information is omitted Applications screened for potential Medicaid eligibility. Applications that may be CMS eligible are sent to CMS for medical eligibility determination concurrently with referrals to Children & Families for Medicaid eligibility determination. TPA processes other applications for Healthy Kids or MediKids Application status letters are sent to families Potentially Medicaid Eligible Electronically transmitted applications are sent to Tallahassee Children & Families KidCare/Medicaid application processing unit. Information from complete applications is entered into the FLORIDA system. Applications are distributed to one of the central processing units. Children & Families eligibility specialists use the simplified eligibility process to determine Medicaid eligibility Eligible for Medicaid Medicaid approvals authorized with code “144” to signify use of KidCare application Applications receive case numbers and transferred to local Children & Families service centers Post application verification of income occurs New eligibility determination occurs at the end of 6 or 12 months depending on the child’s age Potentially KidCare Eligible TPA conducts Medicaid and state employee matches Child is enrolled in Healthy Kids, the CMS Network, MediKids or denied Case status for applications received at FHKC only are communicated to TPA. Process must be completed within 45 days Ineligible for Medicaid Open enrollment Non-open enrollment period Letter sent - reapply at open enrollment

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 27 Department of Children and Families The Department of Children and Families has eligibility specialists out stationed at the Florida Healthy Kids Corporation (FHKC) and at three additional sites throughout the state. These specialists conduct Medicaid eligibility determinations on new applicants to the Florida KidCare program. The Department of Children and Families will also continue to conduct Medicaid eligibility determinations in its district offices . Families will have two ways to apply for Medicaid for their children: (1) using the traditional “Request for Assistance” form and process, or (2) using the Florida KidCare application. Request for Financial A family who chooses to apply for Medicaid for Assistance Application their children and other benefits, such as cash assistance, food stamps, and Medicaid eligibility for parents and other adults, will use the “Request for Financial Assistance” application form. Families who apply for multiple benefits will continue to make their applications through the local Department of Children and Families district offices. Florida KidCare A family who chooses to apply for children’s health Application insurance only, may complete the Florida KidCare application at the local Department of Children and Families district office. During an open enrollment period, the Florida KidCare application can also be mailed to FHKC in Tallahassee for processing. If a child is determined Medicaid eligible based on the Florida KidCare application or the Request for Financial Assistance application, the child will be enrolled in Medicaid. If the child is not Medicaid-eligible, the information is electronically transmitted to FHKC for Title XXI processing. The Department of Children and Families has modified its “loss of Medicaid eligibility” letters to families to inform them about the Florida KidCare program.

Children’s Medical Services Network and Children’s Mental Health Services Medical eligibility criteria for the CMSN include chronic physical and developmental conditions, and serious emotional disturbances, as identified by the Department of Children and Families, Children’s Mental Health program. Children enrolled in the CMSN will receive the same benefits as those offered through the Medicaid program.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 28 Medicaid Effective April 1, 1998, Florida extended Medicaid eligibility to children ages 15 to 19 with family incomes up to 100 percent of the federal poverty level. Eligibility is based solely on the child’s age, household size and family income, as reflected in the Federal Poverty Guidelines. No asset tests were applied. The children in this expansion group aged out of the program as of October 1, 2002. Effective July 1, 2000, Florida extended Medicaid eligibility as a Title XXI Medicaid Expansion program to children ages 0-1 with family incomes up to 200 percent of the federal poverty level. Eligibility is based solely on the child’s age, household size and family income, as reflected in the Federal Poverty Guidelines. No asset tests are applied. Effective July 1, 2004, the Department of Children and Families transfers to FHKC, a weekly file of children who are no longer eligible for Medicaid due to being over income or aging out. Families are mailed an EASY (Expedited Application Services for You) KidCare application. Families who return the EASY application along with the required documentation are processed for Title XXI coverage, regardless of whether or not the enrollment ceiling is reached. Effective July, 1, 2009, the Department of Children and Families will transfer to FHKC, a nightly file of children who were denied or are no longer eligible for Medicaid due to being over income or aging out, to facilitate the transfer of children from Medicaid to Title XXI. The nightly file includes all of the data elements used by the Department of Children and Families to determine eligibility. A Title XXI eligibility determination will be made using the Medicaid data elements and other documentation as needed.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 29 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

Walton Holmes Washington Wakulla Madison Leon Gadsden Jackson Bay Santa Rosa Okaloosa Calhoun Liberty Gulf Franklin Taylor Lafayette Hamilton Suwannee Baker Nassau Duval St. Johns Union Bradford Flagler Putnam Clay Dixie Alachua Levy Marion Volusia Citrus Lake Sumter Orange Seminole Hernando Indian River Osceola Polk Pasco Pinellas Manatee Hardee Highlands St. Lucie Sarasota De Soto Charlotte Glades Martin Lee Hendry Palm Beach Collier Broward Monroe Dade No Medicaid managed care organizations (34) One Medicaid managed care organization (10) Two or More Medicaid managed care organizations (23) Florida Medicaid/MediKids Managed Care Organizations Coverage Gilchrist Jefferson Columbia Hillsborough Brevard Okeechobee Escambia

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 30 MediKids Provider and health plan choice for children who are eligible for MediKids will be substantially the same as for children who are Medicaid-eligible. State law provides that a child who is eligible for MediKids will have a choice between Medicaid participating managed care organizations and MediPass, which is a primary care case management program.

To select a MediPass provider, a child must reside in a county that has fewer than two managed care organizations participating in Medicaid. The managed care organizations or MediPass provider will provide the same services to a MediKids- enrolled child that a Medicaid-enrolled child receives, except for Medicaid waiver services (e.g., AIDS waiver, and other home and community-based services waivers). The Agency for Health Care Administration will apply its Title XIX choice counseling process to MediKids enrollees, with two modifications. The 2000 Florida Legislature authorized the agency to make mandatory managed care organization assignments for those families who do not voluntarily choose a managed care provider. Families will have 10 days from the receipt of a choice-counseling letter to make a health care provider selection. State law explicitly prohibits MediKids from providing interim benefits to a MediKids-eligible child until the child is officially enrolled in a managed care organization or MediPass. Therefore, it is vital that families make a choice as quickly as possible. If families do not respond with their voluntary choice within 10 days, the MediKids Choice Counselors send a letter stating that since a voluntary choice was not made, a provider was selected for them. The letter offers the parents the option to change this choice, if unsatisfactory, by calling the toll-free MediKids Choice Helpline. If a family fails to make a health care provider choice, the child’s enrollment will not be complete and the child will not be eligible for benefits. The mandatory assignment process speeds up the enrollment process and ensures access to care. Healthy Kids FHKC contracts with commercially licensed health and dental plans. These plans are selected through a competitive bid process conducted by FHKC. Beginning in 2004, FHKC is required to contract in the most cost-effective manner consistent with the delivery of quality medical care. Previously, the contracting guidelines required FHKC to select plans based primarily on quality criteria. As part of the bid process, bidding insurers must submit a breakdown of the cost of the monthly premium by benefit categories, such as primary care physician office visits, specialist visits, inpatient care and pharmacy. The insurance rates are filed with the Office of Insurance Regulation at the Florida Department of Financial Services.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 31 The 2003 Florida Legislature prescribed in statute a minimum medical loss ratio and a maximum administrative cost for insurer contracts under Healthy Kids. The maximum medical loss ratio is 85% and the maximum administrative component of any premium rate is 15%. The state’s largest inpatient safety net providers (Jackson Memorial Hospital, Shands Teaching Hospital, Tampa General Hospital, Miami Children’s Hospital and All Children’s Hospital) are also providers for many of FHKC health plans. In most counties, Healthy Kids’ enrollees are enrolled into the single participating provider in a particular county. However, in the more urban counties, Healthy Kids does provide families with a choice of plans. Currently, there are seven heavily populated counties that offer more than one plan. Families make their selection upon enrollment and then are locked into this plan until the annual choice period that usually occurs each year in the late summer. The current policy is to consider multiple health plans where enrollment exceeds 10,000 enrollees. As of September 1, 2000, the Healthy Kids program became available statewide. Additionally, the 2000 Florida Legislature directed the Florida Healthy Kids Corporation to implement a comprehensive dental program in certain counties. Initially, state funds were appropriated for the enrollment of up to 160,000 children into this program and the Corporation was given until June 30, 2002 to complete its implementation. For the first year, only those counties that provided a minimum of $4,000 in local matching funds were eligible for implementation of the program. In the fall of 2000, Healthy Kids conducted a competitive bid process for a licensed dental insurer to provide services for children in eligible counties. The benefits mirror those offered to children enrolled in Florida’s Medicaid program and families had the ability to choose from among three insurers. The 2001 Florida Legislature removed the local match requirement for the dental program and Healthy Kids began expanding the benefit on a statewide basis. As of June 1, 2002, the comprehensive dental benefit was available in 67 Florida counties. As a result of legislation adopted by the 2003 Legislature, the dental benefit for the Healthy Kids program was modified. While the whole array of Medicaid dental benefits for children will still be available to Healthy Kids enrollees, an annual benefit cap of $750 per child per year was implemented effective July 1, 2003 through June 30, 2004. The benefit level was reduced to $600 effective July 1, 2004 through December 31, 2005 when the 2004 Legislature capped the dental premium rate to $12 per member per month. However, with the re-bid of the dental insurer contracts, the annual benefit cap was raised to $800 per member effective January 1, 2005. The $12 per member per month premium rate maximum remains in effect through June 30,

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 32 2006.

Effective July 1, 2009, contracts with four (4) statewide dental plans were executed and the dental benefit maximum was increased to $1,000 per year (measured July 1st through June 30th each year). Effective July 1, 2010, Florida Healthy Kids Corporation contracted with two (2) statewide dental plans and eliminated the annual dental benefit limit to comply with CHIPRA legislation. Additionally, effective October 1, 2003, the co-payments for certain health care services under Healthy Kids were increased from $3 to $5 per service. Children’s Medical Services The CMSN providers are the same providers as those who serve Medicaid children under the MediPass option for children with special health care needs. CMSN contracts with providers to offer a full range of services for these children. Families are offered a choice of primary care providers in the network. The CMSN provides the standard Medicaid benefit package to its enrollees. The specialty care providers are primarily Medicaid providers and meet additional credentialing criteria or standards to serve children with special health care needs. For example, CMSN only uses certain facilities to perform cardiac surgery on children with special health care needs. Those facilities are designated by CMSN based on the recommendations of a cardiac advisory panel. This panel is comprised of experts in the field of pediatric cardiology and designates facilities based on national and state standards. Contract providers are required to submit encounter level data to the CMSN. The encounter level data are used to determine the reimbursement rates based on Medicaid fee schedules. The Department of Children and Families contracts with local mental health providers to provide specialized behavioral health services for CMSN enrolled school-age children with serious emotional disturbance (mood, psychotic or anxiety disorders) or substance abuse problems, subject to the availability of enrollment slots. Children on the waiting list for an enrollment slot will be provided with the standard Medicaid behavioral health package through the CMSN until a slot becomes available. These children also receive their physical health care through the CMSN. A child with a physical, developmental or behavioral special health care need, but who does not have a serious emotional disturbance or substance abuse problem, will receive the standard Medicaid benefit package including the behavioral health services

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 33 package through the CMSN. Department of Health Comprehensive School Health Services Initiative Florida is a leader in providing comprehensive health services to low-income, at-risk school age children. The Florida Department of Health’s School Health Services Program promotes student health through prevention, early intervention and treatment or referral for acute or chronic health problems. Established by state law, the Department of Health’s Comprehensive School Health Services are available to schools where there is a high incidence of medically underserved high-risk children, low birth weight babies, infant mortality, or teenage pregnancy. The purpose is to promote the health of students, reduce teenage pregnancy and other risk-taking behaviors, and facilitate the educational process in developing healthy, self-sufficient adults who will become productive citizens independent of public support. The program does this by focusing on prevention of high-risk behaviors, keeping children in school, healthy and ready to learn, and by facilitating early return of students who are out of school because of serious illness, or for childbirth and parenting. Services rendered under the Department of Health’s Comprehensive School Health Services Program do not duplicate services provided under the Title XIX Medicaid Certified School Match Program. Two major differences are the target population served and the geographic scope of the programs.

Target Populations Unlike the Title XIX Medicaid Certified School Match Program, which finances health services for eligible children in Exceptional Student Education under IDEA, the Department of Health’s Comprehensive School Health Services Program targets more than a quarter of a million low-income, high-risk children in Kindergarten through 12th grade. In some of the schools with comprehensive projects, more than 70 percent of the students are on free or reduced lunch. Many of these students do not have health insurance.

Geographic Scope The Department of Health’s Comprehensive School Health Services Program is available in 334 selected schools in 47 of the state’s 67 counties.

Services Provided During the school year, children spend many of their waking hours at school. Without comprehensive school health services, students with minor injuries, acute illness, chronic conditions, mental and social problems may not be able to attend school. During a typical school day in Florida, there are nearly 100,000 visits to school health

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 34 rooms across the state and more than 80,000 doses of medication administered to school students. The school health nurse supports each student by implementing several strategies that promote student health and safety. Some of these strategies include:

• Providing direct health services and conducting screening, referral and clinical follow-up of suspected problems, including surveillance of high-risk behavioral health patterns, immunization status, diseases, and home and school safety practices; • Medical supervision and coordination for pregnant and parenting students to assure that students have access and utilize needed services, home visits, helping students and families find willing and affordable providers, assisting with transportation to health care or in applying for children’s health insurance programs such as Florida KidCare; • Treating students for minor emergencies and acute illnesses; • Providing clinical intervention services, which includes health room care, nursing assessments, social work evaluations and services, and home visits; • Providing health education within the school to reduce high-risk behaviors such as premature and unprotected sexual activity, smoking and other drug use, driver/passenger safety, violence prevention, and to promote healthy life styles such as healthy nutrition and increased physical activity to prevent obesity and related chronic diseases; • Identifying health and safety concerns in the school environment, and • Administering medications. The cost allocation includes paying nurses' salaries. However, the school health staff also includes health aides, who provide supportive services to the nurses.

Nurses provide services that range from sick room care, such as first aid, nursing interventions and medication. They also provide screening, referrals, and follow-up for counseling for students to assure that they are accessing and maximizing the services that will enable them to remain in school or, in the case of pregnant and parenting students, return to school after delivery.

Health Care Providers Services are provided by registered nurses, licensed practical nurses, social workers, health aides, and in some cases advanced registered nurse practitioners or physicians.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 35 The services are provided in schools and school health rooms.

Funding Sources Historically, Florida’s Comprehensive School Health Services Program has been funded primarily with state General Revenue funds. In some counties, program participants have entered into partnerships with other public and private organizations. The program funding also has been supplemented with TANF funding of approximately $1 million annually. The program does not receive any third-party insurance payments for services provided. A very small amount of Title XIX Medicaid funds, approximately $350,000 in calendar year 2001, have been billed under the County Health Department Certified Matching Program for school nursing services. This amounts to approximately 1% of the DOH funding for School Health Programs in Florida. These funds, however, were not reimbursed for comprehensive school health services since the vast majority of those three million services do not qualify for Medicaid billing.

Assurances The state will not use federal funds or TANF funds as the state matching share for receipt of Title XXI funds for the Department of Health’s Comprehensive School Health Services initiative. Only state funds or local funds will be used as the state matching requirement. The state will not use Title XXI funds for expenses that are billable to Medicaid under the County Health Department Medicaid Certified Match Program. Health room records and state data coding will be used to document services provided and to ensure that the federal programs are billed correctly.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

MediKids MediKids will be subject to the same utilization controls as the traditional Medicaid program. Examples include peer review, data analysis for over- or under-utilization of services, application of InterQual criteria to appropriateness of inpatient hospital stays, and case file review for outpatient ambulatory care. Healthy Kids Healthy Kids receives on a quarterly basis health care utilization reports from all of its

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 36 contracted health and dental plans that are analyzed by the University of Florida Institute for Child Health Policy (ICHP) and a schedule of special reports is agreed to between the FHKC and ICHP each year. The health plans also conduct internal utilization control programs. Additionally, FHKC contracts with an independent medical quality auditor who reviews medical records as well as conducts site visits on a random sample of providers. The auditor’s reports are presented to the Standards Workgroup of the FHKC Board of Directors for any necessary action. Plans are reviewed at least once every three years for compliance with FHKC’s appointment, access and credentialing standards. Children’s Medical Services Network The CMSN uses the same utilization controls employed by the Healthy Kids Corporation. In addition, CMSN uses teams of health care professionals to determine the medical necessity for certain services such as private duty nursing and skilled nursing facilities. Providers are expected to have internal and concurrent utilization management programs. In addition, CMSN is subjected to Medicaid’s peer review organization and other Medicaid reviews for Medicaid children with special health care needs. For specialized behavioral health benefits for SED children, the Department of Children and Families will use the same utilization controls that are currently in place to manage Medicaid mental health service utilization. Certain services (such as psychiatric hospitalization) will require pre-authorization. Other services will be reviewed on a selected basis for under- or over-utilization.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 37 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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

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

4.1.1.  Geographic area served by the Plan: MediKids: Statewide Healthy Kids: Statewide CMSN : Statewide Partners In Care (PIC) Services: PIC services will be limited to counties participating in the Program for All-Inclusive Care for Children (PACC) Demonstration. These counties are: Baker, Clay, Duval, Nassau, St. Johns, Pinellas, Glades, Hendry, Lee, Escambia, Okaloosa, Santa Rosa, Walton, Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, Union, Citrus, Hernando, Lake, Marion, Sumter, Dade, Monroe, Palm Beach, Orange, Osceola and Seminole. 4.1.2.  Age:

Medicaid Expansion: 0 to 1

MediKids: 1 to 5 Healthy Kids: 5 to 19 Initially, Healthy Kids allowed the younger siblings of its enrollees to elect Healthy Kids coverage. Beginning May 1, 2002, no counties currently offer this option. No new enrollees under the age of 5 were allowed after this date and only those who applied previously were grandfathered in with coverage.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 38 CMSN: 1 to 19 for children with special health care needs Effective July 1, 2000, the Florida Legislature increased the income eligibility in Title XIX Medicaid for children ages 0-1 to 200% of the federal poverty level. All children under the age of 1 enrolled in MediKids and CMSN for June 2000 were transferred to Medicaid with no interruption in coverage. PIC Services: Same as CMSN. 4.1.3.  Income:

In an effort to ensure Florida KidCare uses the most family friendly approach to application processing, we use a bi-level approach to applying review standards. Applications are initially processed using the same family size, income guidelines and disregards as Title XIX Medicaid. If the results are that the child is found ineligible for Title XIX then the application is refigured, based upon gross household size and gross income. For specific information, please see the Screening Tool in Attachment A. Florida uses no resource tests in determining eligibility. The 2004 State Legislature modified the Florida KidCare Act to require income documentation supported by copies of any federal income tax return for the prior year, any wages and earnings statements (W-2 forms), and any other appropriate document, beginning July 1, 2004. This requirement will apply to all new applicants after this date and to current enrollees at their redetermination date. During the 2004 December special session, the Florida Legislature made a statutory change to the Florida KidCare Act, revising the income documentation requirement. Effective December 21, 2004, families are required to provide proof of income, including a copy of the most recent federal income tax return. In the absence of a federal income tax return, the family may submit wages and earnings statements, W-2 forms, or other appropriate documents. Households are required to include income information on the KidCare application and provide documentation of income. If a household member is not listed in the income section of the KidCare application, it will be presumed that the unlisted person has no income. Application instructions state to write “none” if no household member has income.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 39 Effective July 1, 2009, income will be verified electronically first and only if electronic verification is not available or is not able to substantiate the income reported by the family, will a request be sent for written documentation. Electronic verification of income may be obtained from various sources including Medicaid. Wage, unemployment compensation and child support data may be received electronically from Florida’s Agency for Workforce Innovation and the Florida Department of Revenue. Private vendors may also be used to verify a family’s income. If income cannot be electronically verified, then the family will need to provide wages and earnings statements or pay stubs, W-2 forms, or a copy of their most recent federal income tax return. Effective July 1, 2009, the family’s attestation of income will be accepted for the MediKids and Healthy Kids Full Pay components. Effective July 1, 2004, a child must also not have access to and be eligible for employer-based coverage, unless the cost of such coverage exceeds 5% of the family’s income. Families will be required to provide a statement on the availability and cost of employer-based coverage. Effective July 1, 2009, access to employer-sponsored coverage is no longer a factor of eligibility based on changes to state law. Additionally, a child will not be eligible for the KidCare program if the child voluntarily cancelled employer-based coverage within six months prior to applying for Title XXI coverage. State law provides an exception for children whose pre-existing condition would exclude them from participation in their parents’ employer-sponsored coverage.

Effective July 1, 2009, a child will not be eligible if employer- sponsored or private coverage was voluntarily canceled within 60 days prior to applying for Title XXI funded coverage. Good cause exceptions to the 60 day wait are listed in Section 4.1.7. MediKids: There are no income limitations for participation. Premiums are subsidized through Title XXI for participants at or below 200% of the Federal Poverty Level with no asset tests. Children with income over 200% of the Federal Poverty Level may enroll in the MediKids Full pay program, paying the entire cost of

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 40 the premium. No state or federal funds are used. Healthy Kids: There are no income limitations for participation. Premiums are subsidized through Title XXI for participants at or below 200% of the Federal Poverty Level with no asset tests. Children with income over 200% of the Federal Poverty Level may enroll in the MediKids Full pay program, paying the entire cost of the premium. No state or federal funds are used. CMSN: 200% of the Federal Poverty Level with no asset tests for premium subsidies.

PIC Services: Same as CMSN Medicaid Expansion: For infants under 1 year old, enrolled in the Medicaid expansion program, from the current Medicaid Title XIX funded income limit of 185% of the Federal Poverty Level to 200% of the Federal Poverty Level. There are no premiums and no asset tests. For this population only, all wages paid by the Census Bureau for temporary employment related to Census activities are excluded. 4.1.4. Resources (including any standards relating to spend downs and disposition of resources):

Florida KidCare uses no resource tests in determining eligibility.

4.1.5.  Residency (so long as residency requirement is not based on length of time in state): A child must be a U.S. citizen or qualified alien for all of the Florida KidCare components (except emergency Medicaid services for illegal immigrants in compliance with Title XIX requirements). A child must be a resident of the state of Florida in order to be eligible. 4.1.6.  Disability Status (so long as any standard relating to disability status does not restrict eligibility): MediKids: None.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 41 Healthy Kids: None. CMSN: State law provides that a child with a special health care need be referred to the CMSN; however, effective July 1, 2009, CMSN clinically eligible children may opt out of CMSN and enroll in MediKids or Healthy Kids, depending on their age. CMSN care coordinators will explain the benefits of CMSN enrollment invite providers, if they meet CMSN’s credentialing requirements, to join the CMS Network, if opting out to keep a provider not in the CMS Network. Families opting out of CMSN will sign the Voluntary Opt Out form. There are no limits to the number of times a clinically eligible child can enroll in CMSN and opt out.

PIC Services: CMSN enrolled children who are or have been diagnosed with life threatening conditions, with or without complex psychosocial and familial problems, who are at risk of a death event prior to reaching 21 years of age will be eligible for participation in PIC. The CMS care coordinator will include in the medical, developmental, psychosocial assessments, additional assessment information to determine eligibility for PIC services. PIC services are only available to children enrolled in CMSN. Clinically eligible children opting out of CMSN cannot receive PIC services.

Since the CMSN is a PCCM model, each child has a primary care physician who provides or authorizes all services for the child. The CMSN care coordinator works in collaboration with the family/caregiver and the primary care physician as well as specialists. The CMSN care coordinator, after determining eligibility for PIC services, will contact the child’s physician for his/her medical determination that the child is at risk for a death event prior to age 21 and could benefit from PIC services. Families will be offered the choice of participating in PIC. Upon receiving physician approval, the family/caregiver will be contacted by professional hospice staff that work with PIC to assess the child’s needs for PIC services.

The enrollment goal for the Title XXI pilot program is to have approximately 150 children enrolled based on the following criteria: 50 will be newly diagnosed, 50 will be in the mid-stage of their life-threatening illness, and 50 will be at the end-of-their

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 42 life. The CMSN is responsible for referring children for PIC services through a coordinated effort that includes the child’s primary physician, specialist physicians and the family/caregiver. The child’s primary care physician must certify that the child’s condition could result in death prior to the age of 21 years and that the child/family/caregiver could benefit from PIC support services.

Possible diagnoses for children entering the PIC program may include: brain and spinal cord malformations, central nervous system degeneration and disease, infantile cerebral palsy, epilepsy, muscular dystrophies and myopathies, heart and great vessel malformations, cardiomyopathies, conduction disorders and dysrhythmias, respiratory malformations, chronic respiratory disease, cystic fibrosis, congenital anomalies, chronic renal failure, congenital liver disease and cirrhosis, inflammatory bowel disease, sickle cell anemias, hereditary anemias, hereditary immunodeficiency, human immunodeficiency virus disease, amino acid metabolism, carbohydrate metabolism, lipid metabolism, storage disorders, other metabolic disorders, chromosomal anomalies, bone and joint anomalies, diaphragm and abdominal wall anomalies, and other congenital anomalies.

4.1.7.  Access to or coverage under other health coverage:

A child must be uninsured at the time of application for the Florida KidCare program. Effective July 1, 2009, a child will not be eligible if employer- sponsored or private health care coverage was voluntarily canceled within 60 days prior to applying for Title XXI coverage. Claiming a good cause exception will be based on the parents’ attestation. Good cause exceptions to the 60 day wait are including, but not limited to, the following situations: 1. The cost of participation in an employer-sponsored health benefit plan is greater than 5 percent of the family’s gross

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 43 income; 2. The parent lost a job that provided an employer-sponsored health benefit plan for children; 3. The parent who had health benefits coverage for the child is deceased; 4. The child has a medical condition that, without medical care, would cause serious disability, loss of function, or death; 5. The employer of the parent canceled health benefits coverage for children; 6. The child’s health benefits coverage ended because the child reached the maximum lifetime coverage amount; 7. The child has exhausted coverage under a COBRA continuation provision; 8. The health benefits coverage does not cover the child’s health care needs; or 9. Domestic violence led to loss of coverage. State law provides an exception for children whose pre-existing condition would exclude them from participation in their parents’ employer-sponsored coverage. 4.1.8.  Duration of eligibility: Florida KidCare covers children up to age 19. Florida law provides for six months of continuous eligibility for the Florida KidCare program. Effective January 1, 2005, enrollees will receive twelve months of continuous eligibility. In addition: MediKids: A child is eligible for Title XXI subsidies until the end of the month of the child’s 5th birthday. The month following the child’s fifth birthday, the child, if still eligible is transferred to the Healthy Kids program. Healthy Kids: A child is eligible for Title XXI subsidies up to age 19. CMSN : A child is eligible for Title XXI subsidies up to age 19.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 44 4.1.9.  Other standards (identify and describe): All Partners: The Florida SCHIP requires social security numbers for applicants enrolling in Florida KidCare. This requirement is consistent with 42 CFR 457.340(b). CMSN : A child must meet criteria indicating that the child has a special health care need. However, CMSN clinically eligible children may opt out of CMSN and enroll in MediKids or Healthy Kids, depending on their age. Healthy Kids, MediKids and the CMSN :

Effective June 10, 2005, with the approval of year- round enrollment by the Social Services Estimating Conference, applications for Title XXI coverage are accepted continuously throughout the year. Year- round enrollment shall cease when the enrollment ceiling is reached. Enrollment may resume when the Social Services Estimating Conference determines sufficient federal and state funds are available to finance the increased enrollment through federal fiscal year 2007. Applications received during a closed enrollment period will be screened for Medicaid and referred to the Department of Children and Families if a child appears eligible. All other applicants will receive a letter informing them that enrollment is closed and to re-apply during the next open enrollment period. Healthy Kids and MediKids: Effective July 1, 2004, state law provides for mandatory disenrollments on a last-in, first-out basis, if the programs are over- enrolled or exceed budget limits. Children enrolled in the CMSN are exempt from mandatory disenrollments. Florida does not anticipate the need for mandatory disenrollments. Each program is required to maintain reserves to accommodate transfers between programs and these reserve estimates are monitored by the state’s Social Service Estimating Conference. There

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 45 are protections in place so that each program manages its budget. Each program calculates an average cost per member per month to project the maximum number of children that can be enrolled within appropriated funding. In the unlikely event that mandatory disenrollments are imminent, such activity shall not occur until Florida KidCare notifies the federal Centers for Medicare and Medicaid Services (CMS).

In the event that enrollment exceeds allocated funds and mandatory disenrollment becomes necessary, the public will be notified by means of press releases, public notices and information posted on the Florida KidCare and Healthy Kids web sites. Children affected by mandatory disenrollments will be notified in writing, providing a minimum 30-day notice before the effective date of the disenrollment. The families affected by mandatory disenrollment will have the same appeal rights offered to all applicants or enrollees.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.  These standards do not discriminate on the basis of diagnosis. 4.2.2.  Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.  These standards do not deny eligibility based on a child having a pre- existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

Florida KidCare General Requirements Florida’s KidCare law establishes the general eligibility requirements for all

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 46 components of the Florida KidCare program. To be eligible for premium assistance with Title XXI funds, a child must: (1) be uninsured; (2) be ineligible for Medicaid; (3) not be covered by group health insurance; (4) not have voluntary cancelled employer-sponsored coverage in the last 60 days; (5) not be the dependent of a state employee; (6) have family income at or below 200% of the federal poverty level; (7) be a U.S. citizen or qualified alien; (8) not be an inmate of a public institution or a patient in an institution for mental diseases; (11) be a Florida resident; and (12) be age-eligible. As of July 1, 2004, new verification requirements will be imposed on all applicants and enrollees (at time of reverification) who applied prior to March 11, 2004. Families will be required to provide proof of income and to attest to whether or not the child has access to employer-based dependant coverage. If the child has access to such coverage and the cost does not exceed 5% of the family’s income, the child will not be eligible for the non-Medicaid components of Florida KidCare coverage. Effective July 1, 2009, access to employer-sponsored coverage is no longer a factor of eligibility based on changes to state law. No face-to-face interviews are required. The Department of Children and Families will use its access to other state computer systems to verify income statements on the application form for the Medicaid eligibility determination process. If the child is not a U.S. citizen, additional information may be required from the family in order to determine whether the child meets the criteria to be considered a qualified alien for Title XXI coverage. An automated matching system will also verify that no applicant is currently enrolled in the Medicaid program prior to enrollment in a non-Medicaid component of the Florida KidCare program. A Third Party Administrator (TPA) under contract with FHKC conducts the determination of eligibility for non-Medicaid components of the Florida KidCare program. The TPA is responsible for the following services: system development; application processing; account maintenance; customer service and eligibility determination. The Title XXI and Title XIX programs use the same income disregards and family income definitions to determine eligibility to the extent shown in Attachment A, the Medicaid Screening Tool. As part of the application process, applicants will be required to provide a social security number for each child beginning with the distribution of the new KidCare application in the first quarter of 2003. For those children who do not yet have a social

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 47 security number, processes are in place to address those situations, to avoid any lag in processing time. An automated matching system has been established with Medicaid, the TPA, and the Florida State Employees Payroll System. Electronic matches are conducted on at least a monthly basis, if not more frequently, to identify the following conditions which may affect continued participation in the Florida KidCare program: (1) enrollment in Medicaid, and (2) the parent’s employment with a state agency. If the match indicates either or both of these conditions, the child’s coverage will be cancelled or the child’s application will be denied, whichever is appropriate. Starting April 1, 2006, all applications are matched weekly with the Florida State Employees Payroll System. This ensures that any child of a state employee will be identified before the eligibility determination is complete.

System Improvements Florida KidCare partners initiated several improvements to the processing system to streamline the program and to improve overall program efficiency. • The Medicaid screening process was revised to count Social Security Income. Previously, Social Security benefits were not counted in the initial screen process, and as many as one-third of all KidCare referrals to DCF were denied and sent back to DHACS in the disposition file. Many of these “false positive” referrals eventually resulted in enrollment in CMSN, MediKids, or Healthy Kids. Children who were unnecessarily referred to DCF took longer to complete the process and also represented additional work and cost at DCF. Revising the Medicaid screen within the KidCare processing system to count Social Security benefits eliminates more than half of the false positive DCF referrals without negatively affecting the screen’s basic integrity or accuracy. Reducing the number of false positives referrals lessens the time it takes to process applications and provides a more reliable basis for referring children to DCF for Medicaid evaluation. • The Florida KidCare application process makes the State employee match a pre-condition of eligibility. Federal law precludes Title XXI eligibility for dependents of workers who receive their insurance benefits from a state agency. In Florida, the State employee match is a critical step in the Title XXI eligibility determination process.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 48 All applications will be matched weekly with the Florida State Employees Payroll System. This ensures that any child of a state employee are identified before the eligibility determination is complete. • The Child’s Social Security Number (SSN) is now a Required Data Element. Making a child’s SSN a required element expedites the processing of applications, improves the efficiency of Medicaid referrals, and improves the feasibility of data interfaces. Those children who do not have an SSN, must provide the date they applied for the SSN in order to be considered for coverage. • Florida KidCare is aligning the Medicaid and Title XXI eligibility rules. An important consumer issue currently facing the Florida KidCare program is maintenance of coverage for a child moving from Medicaid to one of the non- Medicaid Title XXI programs. To improve this process, KidCare now assesses family size, countable income, and income disregards for each KidCare program using the Medicaid formulas as described in Appendix A, KidCare Medicaid Screening Criteria. The Florida Healthy Kids Corporation has also implemented an eligibility review process whereby applicants and enrollees are selected for review through a random audit process. This quality assurance activity ensures that applicants and enrollees are enrolled in the appropriate programs. Open Enrollment Processing and Time Frames All Florida KidCare applications are mailed to the Florida Healthy Kids Corporation (FHKC) for processing. The Florida KidCare application will be valid for a period of 120 days after the date it was received. At the end of the 120-day period, if the applicant has not been enrolled in the program, the application shall be invalid and the applicant shall be notified. The applicant may resubmit another application or request that a previously submitted application be reactivated. FHKC and/or its third party administrator (TPA) conducts a Title XIX pre-screening for all children who apply for Florida KidCare. Children who appear to be Title XIX eligible based on age, family size and income indicators (after applying income disregards), according to the most recent Federal Poverty Guidelines, are transmitted electronically to the Department of Children and Families and processed for full Medicaid eligibility determination. Some Department of Children and Families’ eligibility specialists are co-located at FHKC in Tallahassee and others are located in service offices throughout the state. Applications of children who are not eligible for

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 49 Medicaid are processed for enrollment in the appropriate Title XXI-financed Florida KidCare program component (MediKids, Healthy Kids, or the CMSN). The TPA screens and electronically transfers all applicable applications to either the Department of Children and Families staff or to its TPA on the same day the application arrives in the office.

Within 72 hours of receipt, the TPA will generate a letter to the families informing them that the application has been received and is being processed.

If any information is missing, the family is notified by letter at this time. There are two types of missing information: those that would not stop the application from being processed and those that would stop the application from being processed. An example of the types of information that would stop an application if missing includes the lack of a Social Security number (or date applied) for a child, the date of birth for a child, or an authorized signature allowing FHKC to conduct the eligibility determination. Any other minor missing information would result in a letter to the family requesting such information but would not delay the child getting coverage.

The TPA determines, based on age, income and special health care needs, the program for which each child in the family is eligible. The TPA sends a data file to the Agency for Health Care Administration (AHCA) of all children who are eligible for the MediKids program for choice selection and a data file to the CMSN of all children who have indicated a special health care need on the application. The CMSN further screens each applicant in order to determine whether or not the child is clinically eligible for the program. Families are notified of their effective date of coverage, if eligible, in approximately 4- 6 weeks after receipt of a completed application.

MediKids In addition to the general requirements, to be eligible for MediKids, children must be between the ages of 1 and 5 and not have a special health care need, which would make them eligible for the CMSN, unless the family has opted out of CMSN enrollment. Children’s Medical Services Network The Florida KidCare application contains questions to indicate whether a child has a special health care need. A family who indicates a child has a special health care need will be referred to the CMSN for a clinical eligibility determination. A child who meets the CMSN eligibility criteria will be enrolled in the CMSN provided they meet

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 50 all other Title XXI non-Medicaid eligibility criteria. A child who does not meet the CMSN eligibility criteria will be processed for enrollment in MediKids or Healthy Kids. In September 2002 the KidCare program field-tested a new Florida KidCare application that contains 3 questions related to each child applicant’s health care needs. The questions serve as a screening tool to determine if the children are clinically in need of CMSN enrollment. The new application was distributed in early 2003. Children who have serious emotional disturbance (mood, psychotic or anxiety disorders) or substance dependence problems will be referred to Children’s Medical Services and Children and Families’ local staff for a determination of eligibility for specialized behavioral health care services. Effective July 1, 2009, CMSN clinically eligible children may elect to opt out of CMSN and enroll in MediKids or Healthy Kids, depending on their age. Continuous Eligibility for the Florida KidCare Program Through December 31, 2004, Florida’s KidCare Act provided for six months of continuous eligibility. Before the six-month eligibility period ends, a family is asked to verify that their income status has not changed in order to continue the child’s eligibility. Families of children who remain eligible for the Florida KidCare program at the six-month redetermination are notified to continue making premium payments. Beginning July 1, 2004, at redetermination, families will be required to provide proof of income and an attestation regarding availability of employer-sponsored health insurance for their children in order to remain eligible for continued coverage.

Beginning January 1, 2005, children enrolled in the Title XXI programs will receive 12 months of continuous eligibility. Twelve months of continuous eligibility are provided as follows: • To qualify for the 12 months of continuous eligibility the child must have been determined eligible for a subsidized premium at the time of application or renewal. • For an applicant, the first month of coverage begins the 12 month continuous eligibility period. • For a renewing family, the month following the renewal completion date begins the 12 month continuous eligibility period. • When a family reports an income change that exceeds 200% of the federal poverty level, the child(ren) will receive the remainder of their 12 month continuous eligibility period with no change in their subsidized premium.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 51 Exceptions: Coverage is cancelled if the parent becomes a State employee. Six-month transition period is given if the child obtains access to employer- sponsored health insurance costing less than 5% of gross family income. • When a family reports a decrease in income, a Medicaid screening will be done and if potentially eligible, the account will be referred to the Department of Children and Families for a complete Medicaid determination, regardless of their 12 month continuous eligibility period. • The 12 month continuous eligibility period may be different for each family member if adding a new child. At the time of the next renewal cycle, all individuals will be placed on the same 12 month continuous eligibility period. • When a parent becomes a state employee during the 12 month continuous eligibility period, the family will have the option of transferring to the full pay program the next effective month for the remainder of their 12 month continuous eligibility period. If the family does not choose to transfer to full pay, the coverage is terminated. • When a parent is offered employer-sponsored health insurance at a cost less than 5% of the family’s gross monthly income, during the 12 month continuous eligibility period, the child(ren) will receive 6 months of subsidized premiums, regardless of their 12 month continuous eligibility period. At the end of their 6 month transition period, the family will have the option of transferring to the full pay program. If the family does not choose to transfer to full pay, the coverage is terminated. If access to employer-sponsored health insurance is timely reported, the 6 month transition period begins the following month. If not reported timely, the 6 month transition period is determined based on timely reporting and only the remaining months of the 6 month period are given. If no months remain, coverage is cancelled unless the family chooses to purchase full pay coverage. Renewal Process Each family must have their eligibility redetermined every 12 months. The renewal form is mailed to the family two months prior to the month of renewal. The deadline to return the renewal form and the required documentation is the 10th of the month prior to the renewal month. For example: Renewal is due October 1, the notice is mailed to the family the first week in August. The renewal form and documentation is due September 10th. A cancellation notice is mailed to the family the day after the renewal deadline if the renewal form and the documentation are not received. If neither the renewal form nor the documentation is received, coverage is terminated effective the next month. If the family returns at least one document, indicating their

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 52 intention to comply, the family is given a one month grace period and coverage continues. Coverage is cancelled effective the next month if the remaining documentation is not returned during the one month grace period. During this process, the family will also receive autodialer calls as reminders. The next twelve month continuous eligibility period begins the month after the renewal completion date. Time Frame for Changes When a change occurs that affects eligibility and/or the family premium, the family is notified by letter of the change and the effective date of the change. Premium and eligibility changes are handled as follows: • Changes that reduce the monthly premium are effective the next month, regardless of when in the month the change occurs. For example: a change occurs on August 5 that reduces the monthly premium. The reduced premium will be due September 1 for October coverage. A change occurring August 25 which reduces the monthly premium will also be effective with the premium due September 1 for October coverage. • Changes resulting in loss of eligibility, which are not subject to the 12 month continuous eligibility period, are effective the next month, unless the change occurs after the next month’s eligibility file run date. Changes occurring after the eligibility file run date will be effective the month following the next month, to allow for adequate notice. For example: a change occurs August 5 which results in a loss of eligibility. Coverage is terminated effective September 1. A change occurring August 25 which results in a loss of eligibility will cause coverage to be terminated October 1. • Changes resulting in a premium increase, which are not subject to the 12 month continuous eligibility period, are effective the next month, unless the change occurs after the next month’s eligibility file run date. Changes occurring after the eligibility file run date will be effective the month following the next month, to allow for adequate notice. For example: a change occurs August 5 which results in an increase in the monthly premium. The increased premium will be due September 1 for October coverage. A change occurring August 25 which results in an increase in the monthly premium will be effective with the premium due October 1 for November coverage. Fraud Provisions The 2004 State Legislation also added provisions to the Florida KidCare Act to

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 53 discourage fraud by applicants and enrollees in the program. The legislation allows the program to withhold benefits from any enrollee where evidence has been obtained indicating that incorrect or fraudulent information has been submitted, or the enrollee failed to provide information for verification of eligibility. Additional provisions are included for those found to have enrolled when the applicant knew or should have known that the child was not eligible, or for those who assist others in committing fraud against the program. For those accused of fraud, the Medicaid fraud provisions in state law are to be utilized for prosecution. 4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Effective July 1, 2003, each of the Florida KidCare components implemented a waiting list. The waiting list was eliminated as of March 11, 2004. Additional state funds were provided to extend coverage to those who entered the list on or before March 11, 2004. Applicants after that date were not processed for coverage and received a letter informing them to re-apply during the next open enrollment period. Effective June 10, 2005, the two annual open enrollment periods were eliminated by the Florida legislature and after approval by the state’s Social Services Estimating Conference, Florida KidCare resumed accepting applications on a year-round basis. Year-round enrollment shall cease when the enrollment ceiling is reached. The enrollment ceiling will be determined by the amount of funding available. Florida will notify the federal Centers for Medicare and Medicaid (CMS) in the event that the enrollment ceiling is reached and enrollment has ceased. Year-round enrollment may resume when the Social Services Estimating Conference determines sufficient federal and state funds are available to finance the increased enrollment through federal fiscal year 2007. No waiting list currently exists and no future waiting lists will be maintained. New legislation effective July 1, 2004, does allow for transfers among the KidCare program components so long as space and funding are available. The programs are directed to establish reserves so these transfers can be managed within existing funding. Florida will notify the federal Centers for Medicare and Medicaid (CMS) in the event that transfers are no longer allowed between programs. We do not anticipate the need for this to occur.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 54 Enrollee Status Transfer to Title XXI Coverage New Applicants – Enrollment ceiling not reached Yes New Applicants – Enrollment ceiling reached No Current Title XXI Enrollee Transferring to New Title XXI Component Yes Current Medicaid Expansion Under 1 Year Old – Turning 1 Year Old and Losing Medicaid Eligibility Yes Current Title XIX Under 1 Year Old – turning 1 Year Old and Losing Title XIX Eligibility Yes Current Title XIX losing Title XIX Eligibility Yes Title XIX CMSN Eligible Losing Title XIX Eligibility & Transferring to Title XXI CMSN Yes Current Title XXI Enrollee who Misses a Premium Payment Yes (after 30 days) Previous Title XXI Enrollee with a break in Coverage Due to Reason Other than Non-Payment of premium Yes

Families who do not pay their monthly premium on time will be disenrolled from coverage and will not be eligible for reinstatement for a minimum of 60 days, in accordance with state law. Effective July 1, 2009, children disenrolled due to voluntary non-payment of premium will be eligible for reinstatement after 30 days. The following chart shows the minimum waiting period for cancellation due to non- payment of premium since the inception of the Florida KidCare program.

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 55 Effective Date of Policy Waiting Period Before Reinstatement – For Cancellations Due to Non-Payment of Premium July 1998 – December 2003 Minimum 60 day waiting period before reinstatement December 2003 – October 2004 Minimum 6 month waiting period before reinstatement October 2004 – June 2009 Minimum 60 day waiting period before reinstatement July 2009 - Present Minimum 30 day waiting period before reinstatement

At the end of any disenrollment period for non-payment of premium, the children will be reinstated, provided the premium has been paid prior to the end of the disenrollment period. Reinstated children receive coverage without being required to re-apply for the program; however, a reinstatement date may not be assigned until the family has complied with any new eligibility requirements. In such instances when enrollment caps are reached or Title XXI enrollment is closed, applications will continue to be accepted and will be screened for potential Medicaid eligibility. All applicants that appear to be Medicaid eligible will be referred to DCF in the same manner as is done when enrollment is open. If not eligible for Medicaid, the family will be notified that they must re-apply or call to re-activate their application during the next open enrollment period. Once new enrollment can be processed, applications will be approved for coverage based on a first completed, first served basis, and based on available funding.

The number of children able to receive PIC services will be limited based on funding available at each of the pilot sites. It is estimated that approximately 15 children will be able to receive services at each site for an expected target enrollment of 150 Title XXI children. The goal of enrollment is to have 50 newly diagnosed children, 50 in the mid-stage of their life-threatening illness, and 50 at the end-of-their life. The total target enrollment in the pilot is 150 Title XXI children and an additional 150 Title XIX children.  Check here if this section does not apply to your state.

4.4. Describe the procedures that assure that:

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 56 4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A)) (42CFR 457.350(a)(1) and 457.80(c)(3))

The Florida Healthy Kids Corporation or its third party administrator will perform Title XXI eligibility determinations for the Florida KidCare program except for Medicaid eligibility determinations. Applications for all children who apply for one of the Florida KidCare components will be screened for potential Medicaid eligibility based on age, family size and income indicators (after applying income disregards), according to the most recent Federal Poverty Guidelines. Applications for children who appear to be eligible for Medicaid will be referred to the Department of Children and Families for a full Medicaid eligibility determination. During an open enrollment period, applications that indicate that a child has a special health care need are flagged for referral to the CMSN. In addition to being screened for possible Medicaid eligibility, CMSN staff will also screen the applications of children with special health care needs for participation in the CMSN. If a child has a special behavioral health care need, the CMSN review team will include representatives from the behavioral health network and/or the Department of Children and Families. In the event the enrollment ceiling is reached and enrollment in the Title XXI programs ceases, children found ineligible for Title XIX will be returned to the FHKC and the family will receive a letter indicating that they are not eligible for Medicaid, that enrollment is currently closed for Title XXI coverage, and that they should re-apply or call KidCare Customer Service toll free (800) 821- 5437, to re-activate their application during the next open enrollment period. 4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2)) All children who apply to the Florida KidCare program and who appear to be Title XIX eligible based on the Medicaid screening, will be referred to the Department of Children and Families for a full Medicaid eligibility determination. Those who are determined to be Medicaid-eligible will be

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 57 enrolled in the Medicaid program. The Medicaid screening tool: • Counts only the natural parent's income. • Counts Social Security benefits. • Disregards child support paid by parents as child support for children living outside of the home. • Does not count stepparents in the filing unit. • Does not count children's earned income, if in school. • Deducts $90 for each member with earned income. • Deducts a maximum of $200 childcare expense for children under 2, a maximum of $175 for children over 2. • Deducts $50 if child support is received. (see Appendix A for a more detailed description of the Medicaid screening criteria). 4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4)) Children found ineligible for Title XIX will be processed for coverage in the appropriate Florida KidCare program component (MediKids, Healthy Kids, or the CMSN). If the application was received after the enrollment ceiling has been reached and applications for the Title XXI programs are not accepted, the family will be so advised and informed that they should re-apply or call to re- activate their application during the next open enrollment period. Effective July1, 2004, Title XIX children who are determined no longer eligible for Medicaid due to being over income or aging out will be given an opportunity to transfer to a Title XXI program regardless of whether or not the enrollment ceiling is reached. Effective September 14, 2004, this policy was made retroactive for children who were determined no longer eligible for Medicaid on or after March 12, 2004. Effective September 2002, as soon as DCF determines that an applicant is ineligible for Medicaid, they submit that information electronically to Florida Healthy Kids’ third-party administrator so that the application can continue to process, as quickly as possible, for Title XXI enrollment.

Effective July, 1, 2009, the Department of Children and Families will transfer to FHKC, a nightly file of children who were denied or are no longer eligible for Medicaid due to being over income or aging out, to facilitate the transfer of

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 58 children from Medicaid to Title XXI. The nightly file includes all of the data elements used by the Department of Children and Families to determine eligibility. A Title XXI eligibility determination will be made using the Medicaid data elements and other documentation as needed.

4.4.4. The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c)) 4.4.4.1.  Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. All Title XXI Components All applicants to the Florida KidCare program must be uninsured at the time of application and may not have voluntarily cancelled employer sponsored health insurance within the sixty days preceding their application for KidCare coverage, unless the cancellation reason meets one of the exemptions to the 60 day policy included in section 4.1.7. An annual evaluation of the Florida KidCare program is also conducted which questions new enrollees about their health insurance status prior to enrollment in Florida KidCare. Florida KidCare Program The University of Florida, Institute for Child Health Policy, under contract with the Agency for Health Care Administration, conducts annual evaluations of the Florida KidCare program. This evaluation also queries the parents of new enrollees as to their child’s insurance status prior to enrollment in the Florida KidCare program.

Healthy Kids The Florida Healthy Kids Corporation, as with all other KidCare program components other than Medicaid, requires children to be uninsured at the time of application to the program. This, coupled with open enrollment periods, contributes to FHKC’s findings about crowd out. Recent studies of the insurance status of children prior to enrolling in Healthy Kids show that over 90% of participants were uninsured in excess of 12 months before seeking coverage through the Healthy Kids program. Of the 10% who had insurance at one point within the year prior to enrolling in Healthy Kids, only 13% had

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 59 employer-based private health insurance. Of the parents whose children are enrolled in Healthy Kids, 86% are employed, 38% of whom are employed part-time. Most of these parents work in blue collar and service industry positions. For example, 9% of the reported jobs are in construction, 6% are cleaning and janitorial, and 6% are food service. Another 9% of the total reported jobs are in the category of self- employed. Healthy Kids serves as a bridge between public sector and private health insurance coverage. Of the children who disenrolled from Healthy Kids, 48% obtained other insurance coverage. Of those that obtained other coverage, the majority moved to employer-based coverage with the next largest group reporting that they enrolled in the Medicaid program. All of these findings support the continuation of the requirement that children be uninsured at the time of application. In addition, the State of Florida conducted a study assessing crowd out in the Florida Healthy Kids program utilizing the same methodologies used in the study dated January 15, 1998, and reported the findings to the Centers for Medicare and Medicaid Services within 6 months of implementation. Florida will also fully study and re-evaluate this policy at the end of 36 months. Children’s Medical Services Network A child must be uninsured at the time of application for enrollment in the CMSN and the child must meet the clinical and financial Title XXI eligibility criteria for the CMSN. In addition to meeting other Title XXI eligibility requirements, a child must also meet clinical eligibility requirements to qualify for the CMSN.

4.4.4.2.  Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. 4.4.4.3.  Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. 4.4.4.4.  If the state provides coverage under a premium assistance program, describe:

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10 60

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

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))