Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth St., Suite 4T20 Atlanta, Georgia 30303-8909

January 4, 2010

Mr. Phil E. Williams Interim Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Attn: Robin Ingram

RE: Florida Title XIX State Plan Amendment, Transmittal #09-023

Dear Mr. Williams:

We have reviewed the proposed amendment to the Florida State Plan, submitted under transmittal number FL-09-023 received on December 9, 2009. This amendment requests approval to extend the initial Transitional Medical Assistance period from 6 to 12 months, in accordance with Section 5004 of the American Recovery and Reinvestment Act.

Based on the information provided, we are pleased to inform you that this amendment was approved on December 22, 2009. The effective date is December 1, 2009. We are enclosing the approved form HCFA-179 and plan page. If you have any questions or need any assistance, please contact Elaine Elmore at 404-562-7408.

Sincerely,

/s/

Mary Kaye Justis, RN, MBA Acting Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

October 2009 OMB No.: 0938-1070

CMS-10283

SUPPLEMENT 12 TRANSITIONAL MEDICAL ASSISTANCE ELIGIBILITY UNDER SECTION 1925 OF THE ACT State: Florida ATTACHMENT 2.6-A Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

The State covers low-income families and children for Transitional Medical Assistance (TMA) under section 1925 of the Social Security Act (the Act). This coverage is provided for families who no longer qualify under section 1931 of the Act due to increased earned income, or working hours, from the caretaker relative’s employment, or due to the loss of a time-limited earned income disregard. (42 CFR 435.112, 1902(a)(52), 1902(e)(1), and 1925 of the Act) The amount, duration, and scope of services for this coverage are specified in Section 3.5 of this State plan. For Medicaid eligibility to be extended through TMA, families must have been Medicaid eligible under section 1931 (months of retroactive eligibility may be used to meet this requirement): ____ During at least 3 of the 6 months immediately preceding the month in which the family became ineligible under section 1931.

____ For fewer than 3 of the 6 previous months immediately preceding the month in which the family became ineligible under section 1931. Specify: The State extends Medicaid eligibility under TMA for an initial period of:

____ 6 months. For TMA eligibility to continue into a second 6-month extension period, the family must meet the reporting, technical, and income eligibility requirements specified at section 1925(b) of the Act.

X 12 months. Section 1925(b) does not apply for a second 6-month extension period. The State collects and reports participation information to the Department of Health and Human Services as required by section 1925(g) of the Act, in accordance with the format, timing, and frequency specified by the Secretary and makes such information publicly available. TN No.: 2009-023 Supersedes TN No.: New Approval Date: 12/22/09 Effective Date: 12/1/09

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

| TRANSMITTAL AND NOTICE OF APPROVAL OF

| STATE PLAN MATERIAL

1. TRANSMITTAL NUMBER: 2009-023

2. STATE Florida

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4. PROPOSED EFFECTIVE DATE December 1, 2009

5. TYPE OF PLAN MATERIAL (Check One):

|_ [J NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

[J] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 435.112, 1902(a)(52), 1902(e)(1), and 1925 of the Act

7. FEDERAL BUDGET IMPACT: (in thousands) a. FFY 2009-10: $2.73 b. FFY 2010-11: $3.31

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Supplement 12 to Attachment 2.6-A Page 4

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

10. SUBJECT OF AMENDMENT: Transitional Medical Assistance

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

{XJ OTHER, AS SPECIFIED: Reviewed by the Deputy Secretary for Medicaid who is the Governor's designee.

12. SIGNATURE OF STATE AGENCY OFFICIAL: Laue, ' 13. TYPED NAME: Mr. Phil E. Wilhams 14. TITLE: Interim Deputy Secretary for Medicaid | 15. DATE sat

t

16. RETURN TO: Mr. Phil E. Williams Interim Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Attention: Robin Ingram

1774 MRA

FOR REGIONAL OFFICE USE ONLY

17, DATE RECEIVED: 12/09/09

18. DATE APPROVED: 12/22/09

PLAN APPROVED — ONE COPY ATTACHRD

19. EFFECTIVE DATE OF APPROVED MATERIAL: 12/01/09

20. SIG ly i OFFI :

21. TYPED NAME:

23, REMARKS:

22. TITLE:

Acyng Associate Regional Administrator

FORM HCFA-179 (07-99)

Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth St., Suite 4T20 Atlanta, Georgia 30303-8909

January 26, 2010

Ms. Roberta Bradford Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Attn: Robin Ingram

RE: Florida Title XIX State Plan Amendment, Transmittal #09-024

Dear Ms. Bradford:

We have reviewed the proposed amendment to the Florida State Plan, submitted under transmittal number FL-09-024 received on December 9, 2009. The State requests approval of this amendment to implement a prior authorization for health services visits, based on medical necessity.

Based on the information provided, we are pleased to inform you that this amendment was approved on January 22, 2010. The effective date is November 1, 2009. We are enclosing the approved form HCFA-179 and plan pages. If you have any questions or need any assistance, please contact Elaine Elmore at 404-562-7408.

Sincerely,

/s/

Mary Kaye Justis, RN, MBA Acting Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Attachment 3.1-A

HOME HEALTH SERVICES

5/1/02 Home health service visits are limited to no more than four visits per day (7a) per recipient. The four visits may be any combination of licensed nurse and home health aide visits.

Home health services are authorized by a physician’s orders and must be part of a written plan of care that the physician reviews every 60 days except for medical supplies, equipment, and appliances suitable for use in the home.

3/14/95 Home health aide services are provided under the direction and (7b) supervision of a registered nurse.

1/1/93 Diabetic supplies, that is, disposable needle/syringe combinations and (7c) blood glucose test strips are available without limitation. For non-EPSDT recipients 21 years of age or older, medical supplies, appliances, and durable medical equipment (DME) furnished through a home health agency and/or medical supply/appliance/DME supplier are limited to those items listed in the agency’s provider handbook. Refer to EPSDT section for EPSDT limitations.

1/1/2003 Therapy services are not provided for non-EPSDT recipients 21 years of (7d) age and older except with the following exception: physical therapist and occupational therapist initial evaluation for the need for a wheelchair, one follow-up evaluation when the wheelchair is delivered to make adjustments and to fit the wheelchair to the recipient, one follow-up evaluation six (6) months after the wheelchair is delivered to recommend any additional adjustments, and additional re-evaluations that are deemed medically necessary by the primary care provider. Service limitations for EPSDT recipients are listed in the EPSDT section.

11/1/09 All home health service visits require pre-authorization by the state agency or agency designee, based on medical necessity.

Amendment TN: 2009-024

Effective: 11/1/09

Supersedes: 2003-03

Approved: 01-22-10

28

Attachment 3.1-B

HOME HEALTH SERVICES

5/1/02 Home health service visits are limited to no more than four visits per day (7a) per recipient. The four visits may be any combination of licensed nurse and home health aide visits.

Home health services are authorized by a physician’s orders and must be part of a written plan of care that the physician reviews every 60 days except for medical supplies, equipment, and appliances suitable for use in the home.

3/14/95 Home health aide services are provided under the direction and (7b) supervision of a registered nurse.

1/1/93 Diabetic supplies, that is, disposable needle/syringe combinations and (7c) blood glucose test strips are available without limitation. For non-EPSDT recipients 21 years of age or older, medical supplies, appliances, and durable medical equipment (DME) furnished through a home health agency and/or medical supply/appliance/DME supplier are limited to those items listed in the agency’s provider handbook. Refer to EPSDT section for EPSDT limitations.

1/1/2003 Therapy services are not provided for non-EPSDT recipients 21 years of (7d) age and older except with the following exception: physical therapist and occupational therapist initial evaluation for the need for a wheelchair, one follow-up evaluation when the wheelchair is delivered to make adjustments and to fit the wheelchair to the recipient, one follow-up evaluation six (6) months after the wheelchair is delivered to recommend any additional adjustments, and additional re-evaluations that are deemed medically necessary by the primary care provider. Service limitations for EPSDT recipients are listed in the EPSDT section.

11/1/09 All home health service visits require pre-authorization by the state agency or agency designee, based on medical necessity.

Amendment: 2009-024

Effective: 11/1/09

Supersedes: 2003-003

Approved: 01/22/10

29

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: 2009-024

2. STATE Florida

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

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

4. PROPOSED EFFECTIVE DATE November 1, 2009

5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN

LL] AMENDMENT TO BE CONSIDERED AS NEW PLAN

{) AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 440.70

7. FEDERAL BUDGET IMPACT: (in thousands) a. FFY 2009-10: $(215) b. FFY 2010-11: $(214)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.1-A Page 28 and Attachment 3.1-B Page 29

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-A Page 28 and Attachment 3.1-B Page 29

10. SUBJECT OF AMENDMENT: Prior Authorization for Home Health Services

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

{] OTHER, AS SPECIFIED: Reviewed by the Deputy Secretary for Medicaid who is the Governor’s designee.

12. Se OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Mr, Phil E, Williams

14. TITLE: > Interim Deputy Secretary for Medicaid

15. DATE SUBMI Dpto

16. RETURN TO: Mr. Phil E. Williams Interim Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Attention: Robin Ingram

‘FOR REGIONAL OFFICE USE ONLY

‘17. DATE RECEIVED:1229109

11/01/09

18. DATE AEPROV ED 01/22/10 "PLAN APPROVED — ONE COPY ATTACHED 19. pei DATE OF APPROVED MATERIAL: 20. SIGNATU E. OF REGIONAL OFFICIAL:

al. SSERO again Maty Kaye Justis, RN, MBA

ae ctide’Associate Regional Administrator ision Sf Medicaid & CI hidren’ ‘Ss Health Opns

75 REMARKS

FORM HGFA-179 (07-92)

Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth St., Suite 4T20 Atlanta, Georgia 30303-8909

January 25, 2011

Mrs. Roberta K. Bradford Deputy Secretary for Medicaid 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Re: Florida Title XIX State Plan Amendment, Transmittal #10-014

Dear Mrs. Bradford:

We have reviewed the proposed amendment to the Florida Medicaid State Plan that was submitted under transmittal number 10-014. This State Plan Amendment addresses the new requirements regarding Estate Recovery under section 1917(b)(1) of the Social Security Act by encouraging dual eligible beneficiaries to fully utilize Medicare cost-sharing benefits available through the Medicare Savings Program. Based on the information provided, the Medicaid State Plan Amendment FL 10-014 was approved on January 25, 2011. The effective date of this SPA is October 1, 2010. The signed HCFA-179 and the approved plan page are enclosed.

If you have any questions or need any further assistance, please contact Rita Nimmons at (404) 562-7415.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Révision: HCPASPM.95-3 (MB). May 1995

Page 53a-1

STATE PLAN UNDER TITLE XIX-OF THE SOCIAL SECURITY ACT

State/Territory:

Florida

4.17 (b). Adjustments or Recoveries

(3) (Continmed)

Limitations on Estate Recovery - Medicare Cost Sharing:

(i) Medical-assistance for Medicare cost sharing is protected from estate recovery for the following categories of dual eligibles: QMB, SLMB, QI, QDWI, OMB+, SLMB+. This protection extends to medical assistance for four Medicare cost. sharing benefits: (Part A and B premiums, deductibles, coinsurance, co-payments) with dates of service on or after January 1,2010, The date of

"service for deductibles; coinsurance, and.co-” payments is the date the request for payment is

-_ received by the State Medicaid Agency. The date

of service for premiums is the date the State

_’ Medicaid Agency paid the premium:

(ii In addition to being a. qualified dual eligible the ‘individual must also-be age 55 or over. The above protection from estate recovery for Medicare cost sharing benefits (premiums, deductibles, . coinsurance, co-payments) applies to approved mandatory (ie), nursing facility, home and community-based services, and related prescription drugs and hospital services) as well as optional Medicaid services identified iti the State plan, which are applicable to the categories of duals referenced above.

TN No.: 2010-014 Supersedes TN No.: NEW

Approval Date: SAN)

2a] Effective Date: 10/1/10

DEPARTMENT OF HEALTH AND HUMAN SERVICES. HEALTH CARE FINANCING ADMINISTRATION 2

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL ;

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

FOR: HEALTH CARE FINANCING. ROMINETE NES

TO: REGIONAL ADMINISTRATOR ia) ’ HEALTH CARE FINANCING ADMINISTRAT [0] DEPARTMENT OF HEALTH AND: HUMAN | s

5. TYPE OF PLAN MATERIAL (Check One);

() NEW STATE PLAN () AMENDMER

‘COMPLETE BLOCKS 6 THRU 10 IF THIS IS,

6. FEDERAL STATUTE/REGULATION CITATION: j 1917(b)(1) of the Act.

8: PAGE NUMBER OF TH PLAN ance OR ATTACHMENT: 9. 7 FRGE NONE OF THE SUPERSEDED PLAN SECTION Page Sam) : :

al for each apaden IMPACT: Gn thousands)

10, SUBJECT OF AMENDMENT: Limitations on Estate Recovery = Medicare Cost Sharing

1. GOVERNOR’S REVIEW (Check One): 2 : Pe -CGOVERNOR’S OFFICE REPORTED NO COMMENT f 4 righ as SPECIFIED: [] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED - Es rn Reviewed by the: Deputy Secretary for Medicaid Oo NO. REPLY RECEIVED WITHIN 45 DAYS OF alc : who i is the Governor's ‘ecingiah pees

12. SIGNATURE OF ye ce OFFICI

13: TYPED NAME:

Ms. Roberta K. Bradford 14. TITLE: -

Deputy Secretary for Medicaid _ 15. DATE SUBMITTED: 2 /

FORM BCR A170 197.07)

Table of Contents

State/Territory Name: Florida State Plan Amendment (SPA) #: 13-007 This file contains the following documents in the order listed: 1) Regional Office Follow-up Approval Letter 2) Pharmacy Approval Letter 3) CMS 179 Form 4) Approved SPA Pages 5) Drug Rebate

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

September 12, 2013

Mr. Justin Senior Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mailstop #20 Tallahassee, Florida 32308

Attention: April Cook

RE: Title XIX State Plan Amendment, FL 13-007

Dear Mr. Senior:

This is to affirm approval of the above referenced State Plan Amendment which was submitted to the Regional Office on June 17, 2013. The State’s requested effective date of August 1, 2013 has been accepted.

Enclosed for your records are:

1. a copy of the approval letter dated September 10, 2013 that was submitted to the State by Larry Reed, Director, Division of Pharmacy;

2. the original signed 179; and

3. the approved plan pages.

If you have any additional questions regarding this amendment, please contact Etta Hawkins, State Coordinator for Florida, at 404-562-7429.

Sincerely,

//s//

Charna R. Pettaway

Acting Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosure(s)

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

Disabled & Elderly Health Programs Group

September 10, 2013

Justin M. Senior Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308 Attention: April Cook

Dear Mr. Senior:

We have reviewed Florida State Plan Amendment (SPA) 13-007, Supplemental Rebate Agreement, received in the Regional Office on June 17, 2013. This amendment proposed to update the Supplemental Rebate Agreement to include rebate payments generated by Managed Care Organization (MCO) generated prescriptions.

We are pleased to inform you that the amendment is approved, effective August 1, 2013. A copy of the CMS-179 form, as well as the pages approved for incorporation into the Florida state plan, will be forwarded by the Atlanta Regional Office. If you have any questions regarding this amendment, please contact Terry Simananda at (410) 786-8144.

Sincerely,

/s/

Larry Reed

Director

Division of Pharmacy

cc: Jackie Glaze, ARA, Atlanta Regional Office Etta Hawkins, Atlanta Regional Office

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: 2013-007

2. STATE Florida

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

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

4. PROPOSED EFFECTIVE DATE August 1, 2013

5. TYPE OF PLAN MATERIAL (Check One):

| CJ NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

&) AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 U.S.C. 1395 as described in 42 U.S.C. 1396b{m)

7. FEDERAL BUDGET IMPACT: (in thousands) FFY 2013-2014 no fiscal impact FFY 2014-2015 no fiscal impact

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.1-A pages 46-46.a16 and 3.1-B pages 45-45.a16 (includes Rebate Agreement, which is new)

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-A pages 46-46.al and 3.1-B pages 45-45.al

| 10. SUBJECT OF AMENDMENT: Supplemental Rebate Agreement

| 11. GOVERNOR'S REVIEW (Check One):

| (JGOVERNOR’S OFFICE REPORTED NO COMMENT

(] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

(] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

{J OTHER, AS SPECIFIED: Reviewed by the Deputy Secretary for Medicaid who is the Governor's designee.

12. SIGNATURE OF STATE AGENCY OFFICIAL: Isil

16. RETURN TO: Mr. Justin M. Senior

13. TYPED NAME: Mr. Justin M. Senior

Deputy Secretary for Medicaid Agency for Health Care Administration

14. TITLE: Deputy Secretary for Medicaid

15. DATE SUBMITTED: 06-13-13

2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Attention: April Cook

PRESCRIBED DRUGS: Attachment 3. LA Covered Legend Drugs:

Covered outpatient drugs are those produced by any manufacturer that has entered into and complies with an agreement under Section 1927(a) of the Act, and which are prescribed for a medically accepted indication. Drugs must be prescribed and dispensed’in accordance with medically accepted indications for uses and dosages.

Coverage for immunizations is limited to the following recipients who are not covered by Medicare Part D: e Influenza and pneumococcal vaccine for institutionalized recipients age 21-64 ; and e Herpes Zoster (Shingles) vaccine for institutionalized recipients age 60-64

Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B as provided by Section 1935(d)(1) of the Act.

The Medicaid agency provides coverage for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses to all Medicaid recipients, including full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit —Part D.

As provided by Section 1927(d)(2) of the Act, certain outpatient drugs may be excluded from coverage. Those excluded are DESI drugs; experimental drugs; anorectics (unless prescribed for an indication other than obesity); non-legend drugs (except as specified below), insulin, aspirin, aluminum and calcium products used as phosphate binders, sodium chloride for specific medical indications; and any drugs for which the manufacturer has not entered into rebate agreements with the Department of Health and Human Services, the Veteran’s Administration and the Public Health Service.

As provided by Section 1935(d)(2) of the ACT: M The following excluded drugs are covered:

(a) agents when used for anorexia, weight loss, weight gain None of the drugs under this drug class are covered

(b) agents when used to promote fertility None of the drugs under this drug class are covered

HO &o

(c) agents when used for cosmetic purposes or hair growth None of the drugs under this drug class are covered

oO

(d) agents when used for the symptomatic relief cough and colds Some drugs categories covered under the drug class e Legend cough and cold preparations, including antitussives, decongestants, and expectorants are covered for recipients under the age of 21 years. ¢ Legend or OTC single entity guaifenesin products are covered for all recipients. M (e) prescription vitamins and mineral products, except prenatal vitamins and fluoride

8a

Amendment 2013-007

Effective 08/01/2013

Supersedes 2013-001

Approved %-/0-/5 46

Attachment 3.1-A

Some drug categories covered under the drug class e Legend vitamin and mineral products are covered for dialysis patients. MI (f) nonprescription drugs M Some drug categories covered under the drug class e Insulin; aspirin; 650mg acetaminophen tablets; aluminum and calcium products used as phosphate binders; sodium chloride for specific medical indications for all recipients When prescribed the following OTC medications that have previously been legend drugs are covered: Urinary analgesic Proton pump inhibitor Smoking cessation and nicotine replacement products (for non-Part D eligible recipients) Topical antiparasitics Vaginal antifungals OTC single-entity antihistamines (Loratidine and Cetirizine with age restrictions on liquids) and

antihistamine-decongestant combinations (Loratidine D and Cetirizine D with age restrictions on liquids).

O (g) covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee None of the drugs under this drug class are covered

© (h) barbiturates

M (Except for dual eligible individuals effective January 1, 2013 when used in the treatment of epilepsy, cancer or a chronic mental health disorder as Part D will cover those indications.)

© (i) benzodiazepines M (Except for dual eligible individuals effective January 1, 2013 as Part D will cover all indications.)

M (j) smoking cessation for non-dual eligibles as Part D will cover Some drugs categories covered under the drug class

e Approved smoking cessation and nicotine replacement products are covered services (for non-Part D eligibles)

e Approved smoking cessation and nicotine replacement products are covered services (for non-Part D eligibles) The Medicaid agency will provide coverage of prescription and over-the-counter (OTC) smoking/tobacco cessation covered outpatient drugs for pregnant women as recommended in “Treating Tobacco Use and Dependence - 2008 Update: A Clinical Practice Guideline” published by the Public Health Service in May 2008 or any subsequent modification of such guideline

Drug Rebate Agreement: The state is in compliance with Section 1927 of the Act. Based on the requirements for Section 1927 of the Act, the state has the following policies for drug rebate agreements:

e The drug file permits coverage of participating manufacturers’ drugs.

e Compliance with the reporting requirements for state utilization information and restrictions to coverage. Amendment 2013-007 Effective 08/01/2013 Supersedes 2013-001 Approved 7- (0-13

46a

Attachment 3.1-A

A supplemental rebate agreement, Version 05/20/2013, between the state and a drug manufacturer that is separate from the drug rebate agreements of Section 1927 is authorized by the Centers for Medicare and Medicaid Services. The agreement to be used between the State of Florida and drug manufacturers for supplemental rebates for drugs provided to the Medicaid population has been reviewed and authorized by the Centers for Medicare and Medicaid Services. The state reports rebates from separate agreements to the Secretary for Health and Human Services. The state will remit the federal portion of any cash state supplemental rebates collected.

Manufacturers are allowed to audit utilization data.

The unit rebate amount is confidential and cannot be disclosed for purposes other than rebate invoicing and verification.

Prior authorization programs provide for a 24-hour turn-around on prior authorization from receipt of a completed request, and at least a 72-hour supply in emergency situations.

Amendment 2013-007 Effective 08/01/2013 Supersedes 2013-001 Approved 9-10-13 46a.1

PRESCRIBED DRUGS: Attachment 3.1-B Covered Legend Drugs:

Covered outpatient drugs are those produced by any manufacturer that has entered into and complies with an agreement under Section 1927(a) of the Act, and which are prescribed for a medically accepted indication. Drugs must be prescribed and dispensed in accordance with medically accepted indications for uses and dosages.

Coverage for immunizations is limited to the following recipients who are not covered by Medicare Part D: e Influenza and pneumococcal vaccine for institutionalized recipients age 21-64 ; and e Herpes Zoster (Shingles) vaccine for institutionalized recipients age 60-64

Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B as provided by Section 1935(d)(1) of the Act.

The Medicaid agency provides coverage for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses to all Medicaid recipients, including full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit —Part D.

As provided by Section 1927(d)(2) of the Act, certain outpatient drugs may be excluded from coverage. Those excluded are DESI drugs; experimental drugs; anorectics (unless prescribed for an indication other than obesity); non-legend drugs (except as specified below), insulin, aspirin, aluminum and calcium products used as phosphate binders, sodium chloride for specific medical indications; and any drugs for which the manufacturer has not entered into rebate agreements with the Department of Health and Human Services, the Veteran’ s Administration and the Public Health Service.

As provided by Section 1935(d)(2) of the ACT: M The following excluded drugs are covered:

(a) agents when used for anorexia, weight loss, weight gain None of the drugs under this drug class are covered

oO

(b) agents when used to promote fertility None of the drugs under this drug class are covered

8oO

(c) agents when used for cosmetic purposes or hair growth None of the drugs under this drug class are covered

(d) agents when used for the symptomatic relief cough and colds Some drugs categories covered under the drug class e Legend cough and cold preparations, including antitussives, decongestants, and expectorants are covered for recipients under the age of 21 years. e Legend or OTC single entity guaifenesin products are covered for all recipients. MM () prescription vitamins and mineral products, except prenatal vitamins and fluoride

RA AO

Amendment 2013-007

Effective 08/01/2013

Supersedes 2013-001

Approved 4-013. 45

Attachment 3.1-B

Some drug categories covered under the drug class

e Legend vitamin and mineral products are covered for dialysis patients. M (f) nonprescription drugs M1 Some drug categories covered under the drug class

e Insulin; aspirin; 650mg acetaminophen tablets; aluminum and calcium products used as phosphate binders; sodium chloride for specific medical indications for all recipients When prescribed the following OTC medications that have previously been legend drugs are covered:

Urinary analgesic

Proton pump inhibitor

Smoking cessation and nicotine replacement products (for non-Part D eligible recipients) Topical antiparasitics

Vaginal antifungals

OTC single-entity antihistamines (Loratidine and Cetirizine with age restrictions on liquids) and

antihistamine-decongestant combinations (Loratidine D and Cetirizine D with age restrictions on liquids). .

C1 (g) covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee M1 None of the drugs under this drug class are covered

(b) barbiturates

M (Except for dual eligible individuals effective January 1, 2013 when used in the treatment of epilepsy, cancer or a chronic mental health disorder as Part D will cover those indications.)

© (i) benzodiazepines M (Except for dual eligible individuals effective January 1, 2013 as Part D will cover all indications.)

Gj) smoking cessation for non-dual eligibles as Part D will cover M Some drugs categories covered under the drug class

e Approved smoking cessation and nicotine replacement products are covered services (for

non-Part D eligibles)

e Approved smoking cessation and nicotine replacement products are covered services (for

non-Part D eligibles) The Medicaid agency will provide coverage of prescription and over-the-counter (OTC) smoking/tobacco cessation covered outpatient drugs for pregnant women as recommended in “Treating Tobacco Use and Dependence - 2008 Update: A Clinical Practice Guideline” published by the Public Health Service in May 2008 or any subsequent modification of such guideline

Drug Rebate Agreement: The state is in compliance with Section 1927 of the Act. Based on the requirements for Section 1927 of the Act, the state has the following policies for drug rebate agreements:

e The drug file permits coverage of participating manufacturers’ drugs.

e Compliance with the reporting requirements for state utilization information and restrictions to coverage.

Amendment 2013-007 Effective 08/01/2013 Supersedes 2013-001

Approved 9-s0-43 45a

Attachment 3.1-B

A supplemental rebate agreement, Version 05/20/2013, between the state and a drug manufacturer that is separate from the drug rebate agreements of Section 1927 is authorized by the Centers for Medicare and Medicaid Services. The agreement to be used between the State of Florida and drug manufacturers for supplemental rebates for drugs provided to the Medicaid population has been reviewed and authorized by the Centers for Medicare and Medicaid Services. The state reports rebates from separate agreements to the Secretary for Health and Human Services. The state will remit the federal portion of any cash state supplemental rebates collected.

Manufacturers are allowed to audit utilization data.

The unit rebate amount is confidential and cannot be disclosed for purposes other than rebate invoicing and verification.

Prior authorization programs provide for a 24-hour turn-around on prior authorization from receipt of a completed request, and at least a 72-hour supply in emergency situations.

Amendment 2013-007

Effective 08/01/2013

Supersedes 2013-001

Approved 9-/-/3_ 45a.1

Table of Contents State/Territory Name: Florida State Plan Amendment (SPA) #: 13-0015-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

November 18, 2013

Mr. Justin Senior Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mailstop #20 Tallahassee, Florida 32308

Attention: April Cook

RE: Title XIX State Plan Amendment, FL 13-0015-MM1

Dear Mr. Senior:

Enclosed is an approved copy of Florida’s state plan amendment (SPA) 13-0015-MM1, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 12, 2013. SPA 13- 0015-MM1 incorporates the MAGI-based eligibility groups into Florida’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of the SPA is January 1, 2014.

Based on the information provided, Medicaid State Plan Amendment FL-13-0015-MM1 was approved on November 18, 2013. The effective date of this amendment is January 1, 2014. We are enclosing the approved HCFA-179 and the plan pages, S14, S25, S28, S30, S32, S33, S50, S51, S52, S53, S54, S55, S57, and S59. Please incorporate the approved plan pages within a separate section at the back of Florida’s approved state plan.

In addition, enclosed is a summary of state plan pages which are superseded by FL SPA 13-0015- MM1, which should also be incorporated into a separate section in front of the approved state plan.

If you have any questions, please contact Etta Hawkins, R.Ph. at (404) 562-7429 or Etta. Hawkins@cms.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosure

Medicaid State Plan Eligibility: Summary Page (CMS 179) • State/Territory name: Florida • 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-13-0015 • Proposed Effective Date 01/01/2014(mm/dd/yyyy) • Federal Statute/Regulation Citation S25:42 CFR • Federal Budget Impact Federal Fiscal Year Amount First Year 2014

$ 1325000.00 Second Year 2015

$ 1769000.00 • Subject of Amendment Character Count: out of 2000

MAGI-Based Eligibility Groups: S14, Approved Conversion Plan

• Governor's Office Review o Governor's office reported no comment o Comments of Governor's office received Describe:

o No reply received within 45 days of submittal o Other, as specified Describe: Character Count: out of 2000 Review ed by the Deputy Secre

• Signature of State Agency Official o Submitted By: April Cook o Last Revision Date: Nov 6, 2013 o Submit Date:

Sep 12, 2013 o

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0015

STATE:

Florida

Pages or sections of pages being superseded by S25,

S28,

S30, S51,

S52, S53, S55, S57,

and S14 and related pages or sections of pages being deleted as obsolete

State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A.2.b Page 3 Page 2, A.2.c Page 3a Page 2a, A.3 Page 4 Page 5, A.10 Page 4a Page 9c, B.1 remove Attachment 2.2-A Page 12 “Caretaker relatives” Page 13 and “Pregnant women” Page 13a Page 20, B.14 Page 14 Page 23c, B.21 Page 14a Page 25, C.4 Page 23 Supplement 1 to Attachment 2.2-A Page 1 Page 3b, #8 and 9 Page 1, A.2.a(i) and Page lla (iii) Page 19 Page 6 related to AFDC Page 19a recipients, pregnant Attachment 2.6-A Page 19b women, infants, and Page 21 children Page 7, 1.a(1) and (2) Page 12, 5.e(2) Page 18, 5.e Page 25, 11.a(3) Supplement 1 to Attachment 2.6-A Pages 1-4 Supplement 2 to Attachment 2.6-A Pages 1-5

Page 1, census disregard for AFDC- related

Supplement 8a to Attachment categorically needy

2.6-A family & children’s groups Addendum page la for children’s groups

Supplement 8b to Attachment Page 2 for children’s groups

2.6-A

Supplement 12 to Attachment Pages 1-3

2.6-A

supp tement 14 to Attachment Page 1

AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

The standard is as follows:

@ Statewide standard C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

Enter the AFDC Standards below. All states must enter:

Household size | Standard ($)

el 174 Hy} 2 235 13 305

E 360

| s 417

pa a 16 471

7 521

ky : ty

seis 569 19 608

666

MAGIl-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and

@ Yes CNo

Increment amount $

Medicaid Eligibility

Additional incremental amount

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

48

C Yes @No

The dollar amounts increase automatically each year

TN No: 13-0015-MM1 Approval Date: 11/18/13

Florida

$14-1

Effective Date: 01/01/14

ccmMs Medicaid Eligibility

The standard is as follows:

@ Statewide standard

C Standard varies by region

© Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount @ Yes (No

Household size | Standard ($)

180

Increment amount $ |62

241

303

364

426

487

549

610

671

733

The dollar amounts increase automatically each year

C Yes @No

The standard is as follows:

@ Statewide standard © Standard varies by region

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $14-2

CcCmMs Medicaid Eligibility

CORED FOR MeDCAde a MOKA EVE

© Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount @ Yes (No

Household size | Standard ($)

Increment amount $ |100

The dollar amounts increase automatically each year C Yes @No

The standard is as follows:

© Statewide standard © Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes CNo

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $14-3

CCMs Medicaid Eligibility

The dollar amounts increase automatically each year

C Yes (No

The standard is as follows:

C Statewide standard

© Standard varies by region © Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes (No

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida S$14-5

Medicaid Eligibility

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

42 CFR 435.110 . 1902(a)(10)(A)()) 1931(b) and (d)

w Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state.

The state attests that it operates this eligibility group in accordance with the following provisions: [M] Individuals qualifying under this eligibility group must meet the following criteria:

wl Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included.

The state elects the following options:

This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old,

CO provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

(2) Options relating to the definition of caretaker relative (select any that apply):

KI Options relating to the definition of dependent child (select the one that applies):

The state elects to eliminate the requirement that a dependent child must be deprived of parental support or

@ care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent.

The child must be deprived of parental support or care, but a less restrictive standard is used to measure “ unemployment of the parent (select the one that applies):

[M] Have household income at or below the standard established by the state.

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

[@] Income standard used for this group

[@] Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards.

The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

[Maximum income standard

™N No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida 695-1

s Medicaid Eligibility

NER OM AMEONCARE & MONA SEINE

The state certifies that it has submitted and received approval for its converted income standard(s) for parents and

other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to

be used for parents and other caretaker relatives under this eligibility group.

The state's maximum income standard for this eligibility group is:

@

Cc

The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

C

@

Cc

A percentage of the federal poverty level: %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in $14 AFDC Income Standards.

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI-

equivalent standard. The standard is described in $14 AFDC Income Standards.

The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards.

Other dollar amount

[i] Income standard chosen:

Indicate the state's income standard used for this eligibility group:

Cc @

a)

The minimum income standard

The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage

increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards.

Another income standard in-between the minimum and maximum standards allowed

[@] There is no resource test for this eligibility group.

[H) Presumptive Eligibility

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14

Florida

S25-2

Medicaid Eligibility

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

C Yes @No

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $25-3

NI FOR MCA NARRICAID HON

cms Medicaid Eligibility

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

42 CFR 435.116 . 1902(a)(10)(A)(i\(II) and (IV)

1902(a)(10)(A)(ii)(1), (IV) and (IX)

1931(b) and (d)

1920

[a] Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: [W) Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4.

Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110.

@ Yes C No

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

[Ml Income standard used for this group [] Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so.

@ Yes (No

Enter the amount of the minimum income standard (no higher than 185% FPL):|150 % FPL

[®] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

The state's maximum income standard for this eligibility group is:

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-

@ related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)() (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(TV)

(institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $28-1

Medicaid Eligibility

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II) (qualified pregnant women), 1902(a)(10)(A)(i)(I1V) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(D (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. ~

C The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as ~ of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as ~ of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 185% FPL

The amount of the maximum income standard is:}191 % FPL

[lM Income standard chosen Indicate the state's income standard used for this eligibility group: © The minimum income standard @ The maximum income standard C Another income standard in-between the minimum and maximum standards allowed. [Wf] There is no resource test for this eligibility group. [Ml Benefits for individuals in this eligibility group consist of the following: @ All pregnant women eligible under this group receive full Medicaid coverage under this state plan.

. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive ~ only pregnancy-related services.

[] Presumptive Eligibility

The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity.

@ Yes (No

[ The presumptive period begins on the date the determination is made. [Hl The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[WH There may be no more than one period of presumptive eligibility per pregnancy.

A written application must be signed by the applicant or representative.

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida c72e.9

Ms Medicaid Eligibility

ml

aw

Yes @ No The presumptive eligibility determination is based on the following factors: [Hf] The woman must be pregnant [lM] Household income must not exceed the applicable income standard at 42 CFR 435.116. [X] State residency (1 Citizenship, status as a national, or satisfactory immigration status

The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

A qualified entity is an entity that is determined by the agency to be capable of making presumptive | | eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities | used to determine presumptive eligibility for this eligibility group:

XI Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental (J Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

Oo

oO Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(J Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs

(7 Isa state or Tribal child support enforcement agency under title [V-D of the Act

oO Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program

R of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

oO Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

([] Other entity the agency determines is capable of making presumptive eligibility determinations:

TN No: 13-0015-MM1 : Approval Date: 11/18/13 Effective Date: 01/01/14

Florida

$28-3

CCMS Medicaid Eligibility

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

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

TN No: 13-0015-MM1 Approval Date: 11/18/13

Effective Date: 01 Florida $28-4 @: 01/01/14

Medicaid Eligibility

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

42 CFR 435.118 ~

1902(a)(10)(A)(i)(ID), (IV), (VI) and (VII) 1902(a)(10)(A)(ii\(IV) and (IX) 1931(b) and (d)

rl Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group.

The state attests that it operates this eligibility group in accordance with the following provisions: fm] Children qualifying under this eligibility group must meet the following criteria: [BM] Are under age 19 [M]_ Have household income at or below the standard established by the state.

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

[MH] Income standard used for infants under age one [] Minimum income standard

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so.

@ Yes (©No

Enter the amount of the minimum income standard (no higher than 185% FPL):|150 % FPL

{Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one.

The state's maximum income standard for this age group is:

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

@ infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $30-1

cms Medicaid Eligibility

. CITERE FOR MEORCARE OHNO CD

°C

CO

@

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II]) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(LX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. ~

The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

185% FPL

Enter the amount of the maximum income standard: |206 % FPL

[M] Income standard chosen

The state's income standard used for infants under age one is:

The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(TV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IL) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL,

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

[®] Income standard for children age one through age five, inclusive

[8] Minimum income standard

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14

Florida

620.9

Medicaid Eligibility

The minimum income standard used for this age group is 133% FPL. (@] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five.

The state's maximum income standard for children age one through five is:

The state's highest effective income level for coverage of children age one through five under sections 1931 (low- e income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- ” related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age one through five under sections 1931 (low-

Cc income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age one through five under a Medicaid 1115 * demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Enter the amount of the maximum income standard: |140 % FPL

[mB] Income standard chosen The state's income standard used for children age one through five is: @ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified children),

C. 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A )(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGIT-equivalent percent of FPL.

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $30-3

Medicaid Eligibility

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

(@)

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than ~” the effective income standard for this age group in the state plan as of March 23, 2010.

{m) Income standard for children age six through age eighteen, inclusive

®

Cy

Minimum income standard The minimum income standard used for this age group is 133% FPL. Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen.

The state's maximum income standard for children age six through eighteen is:

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II]) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 “ demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 “ demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

@ 133% FPL

Income standard chosen

The state's income standard used for children age six through eighteen is:

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14

Florida

$30-4

ccmMs Medicaid Eligibility

@ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IID) (qualified children),

© 1902(a)(10)(A)(i)(VID) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and

if not chosen as the maximum income standard, the state's effective income level for any population of children

~ age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

[M] There is no resource test for this eligibility group. [M] Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity.

© Yes @No

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14

Florida $30-5

ee CCMsS Medicaid Eligibility

TNS TOR MAAC 8 ECARD SHUI

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

1902(a)(10)(A)(i)( VIEL) 42 CFR 435.119

The state covers the Adult Group as described at 42 CFR 435.119. © Yes @No

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $32-1

Medicaid Eligibility

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

42 CFR 435.150 ; 1902(a)(10)(A)(i)(LX)

wl Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care.

The state attests that it operates this eligibility group under the following provisions:

[M] Individuals qualifying under this eligibility group must meet the following criteria: [By Are under age 26. im Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group.

Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state

[@ plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program.

The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system.

CYes @No

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

CYes @No

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

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $33-1

Medicaid Eligibility

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

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

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

C Yes @No

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $50-1

ccmMs Medicaid Eligibility

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

42 CFR 435.220 1902(a)(10)(A)(i)(1)

Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220.

C Yes (@No

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $51-1

CCMS Medicaid Eligibility

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

42 CFR 435.222 1902(a)(10)(A)(ii)(1) 1902(a)(10)(A)(ii)(IV)

Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222.

@ Yes (No

The state attests that it operates this eligibility group in accordance with the following provisions:

im Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria:

[Ml] Be under age 21, or a lower age, as defined within the reasonable classification.

iw Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification. .

[B) Not be eligible and enrolled for mandatory coverage under the state plan.

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

The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@® Yes C No

The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@ Yes CNo

Reasonable Classificati vered in the Medicaid State PI 2. i

The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group.

Current Coverage of All Children under a Specified Age

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $52-1

CCMS Medicaid Eligibility

The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid

1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. ~

@ Yes (No

Indicate below the age under which all children are covered under this eligibility group, based on a specific age group used previously in the Medicaid state plan or under a Demonstration, which is equal to or higher than the age group for coverage of all children in the Medicaid state plan as of March 23, 2010.

@ Under age 21 C Under age 20 (Underage 19 = Under age 18

Enter the income standard used for this age group. The standard must be higher than the mandatory income standard for the individual's age, not more restrictive than that used in the Medicaid state plan as of March 23, 2010 and not less restrictive than that used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

[] Income standard used

[] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in $14 AFDC Income Standards.

[@] Maximum income standard

No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

© Yes @No

The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the iq maximum income standard to be used for this classification of children under this eligibility

group.

The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

The state's effective income level for this classification of children under the Medicaid state plan @ as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for this classification of children under the Medicaid state plan C as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Elarida S52-2

CCMSsS Medicaid Eligibility

The state's effective income level for this classification of children under a Medicaid 1115 © Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for this classification of children under a Medicaid 1115 © Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

© A percentage of the federal poverty level: %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-

equivalent standard. This standard is described in $14 AFDC Income Standards. This option

should only be selected for children 19 and older, and only if the state has not elected to cover the

Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is

© described in $14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

C Other dollar amount [iM] Income standard chosen Individuals qualify under this classification under the following income standard: C The minimum standard. @ The maximum income standard.

If not chosen as the maximum income standard, the state's effective income level for this C. classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used

Cc under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

Another income standard in-between the minimum and maximum standards allowed, provided it is C._ higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $52-3

Medicaid Eligibility

Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010

The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income.

C@ Yes @ No Other Reasonable Classifications Previously Covered

The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group.

C Yes @No

Additional new age groups or reasonable classifications covered

If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage.

The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard.

C Yes @No

{@ There is no resource test for this eligibility group.

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $52-4

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XTV) 42 CFR 435.229 and 435.4 ° 1905(u)(2)(B)

Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229.

C Yes @No

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Llorida S$54-1

ccmMs Medicaid Eligibility

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

42 CFR 435.226 ~ 1902(a)(10)(A)(ii)(XVI)

Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their | 8th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226.

@ Yes CNo The state attests that it operates this eligibility group in accordance with the following provisions: {@] Individuals qualifying under this eligibility group must meet the following criteria:

[i] Are under the following age @ Under age 21 C Under age 20 © Under age 19

[M) Were in foster care under the responsibility of a state on their 18th birthday.

{@) Are not eligible and enrolled for mandatory coverage under the Medicaid state plan.

[lM Have household income at or below a standard established by the state.

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

The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. @ Yes (No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes (No

The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most

a liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013):

@ All children under the age selected © A reasonable classification of children under the age selected: [Mf] Income standard used for this eligibility group

[M] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in $14 AFDC Income Standards.

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14 Florida $57-1

cms Medicaid Eligibility

[=] Maximum income standard

No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. .

@ Yes ©No

aw No income test was used (all income was disregarded) for this eligibility group under (check all that apply):

{] The Medicaid state plan as of March 23, 2010.

{X] The Medicaid state plan as of December 31, 2013.

(J A Medicaid 1115 demonstration as of March 23, 2010. CD A Medicaid 1115 demonstration as of December 31, 2013.

The state's maximum standard for this eligibility group is no income test (all income is disregarded).

[®] Income standard chosen

Individuals qualify under this eligibility group under the following income standard:

This eligibility group does not use an income test (all income is disregarded).

[mM] There is no resource test for this eligibility group.

PRA Disclosure Statement

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

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14

Florida

S57-2

"CMS Medicaid Eligibility

NTI OR RICKI 8 MONARO MON

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

1902(a)(10)(A)(ii)XXT) ~ 42 CFR 435.214

Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214.

© Yes @No

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

TN No: 13-0015-MM1 Approval Date: 11/18/13 Effective Date: 01/01/14

ccra.1

CMCS/OSG: 12/2/13

_____________________________________________________________________________

Table of Contents State/Territory Name: Florida State Plan Amendment (SPA) #:13-0016-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) Summary Form (with 179) 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan (delete if not applicable)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, GA 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 9, 2013

Mr. Justin Senior Deputy Secretary for Medicaid Florida Agency for Health Care Administration 2727 Mahan Drive Mail Stop 8 Tallahassee, Florida 32308

Dear Mr. Senior:

Enclosed is an approved copy of Florida’s state plan amendment (SPA) 13-0016-MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 10, 2013. SPA 13- 0016-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Florida’s state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of 13-0016-MM2 includes full approval of your state’s alternative single streamlined paper application. Beginning December 1, 2013 and through October 31, 2014, the state will use an interim online alternative application used to apply for multiple human service programs. By October 31, 2014, the state will implement a revised online alternative application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Florida’s approved state plan:

• S94, pages S94-1, S94-2 • Attachment 1 – State of Florida’s alternative single streamlined paper application • Attachment 2 – Statement of use with respect to the alternative single streamlined online application • Attachment 3 – Statement related to the coordination of eligibility and enrollment

In addition, enclosed is a summary of state plan pages which are superseded by SPA 13-0016-MM2, which should also be incorporated into a separate section in the front of the state plan.

• Superseding Pages of State Plan Material, 13-0016-MM2

Mr. Justin Senior Page 2

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan amendment. If you have any questions concerning this SPA, please contact Etta Hawkins at 404-562- 7429 or by email at Etta.Hawkins@cms.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 9, 2013

Mr. Justin Senior Deputy Secretary for Medicaid Florida Agency for Health Care Administration 2727 Mahan Drive Mail Stop 8 Tallahassee, Florida 32308

Dear Mr. Senior:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) 13-0016-MM2, which was submitted to CMS on September 10, 2013. Our review of this submission included a review of the state’s alternative single streamlined paper application and online alternative application used to apply for multiple human service programs.

Beginning December 1, 2013 and through October 30, 2014, the state will use an interim online alternative application used to apply for multiple human service programs. This interim online application needs to be revised to reflect the following changes.

Necessary changes: Date by which changes will be completed:

1. The following questions will not appear on applicants for health coverage only: • What is this person’s country of birth? • Has this person been out of the US in the last 30 days? (and follow-up details) • Does [name] buy food and eat meals with [name]? • Questions requesting details about school enrollment status, other than whether age-appropriate household members are attending school full-time • Questions regarding absent parent details • Questions regarding non-taxable income such as child support, veterans’ payments, workers’ compensation

October 31, 2014

Mr. Justin Senior Page 2

2. The following questions will not appear for household members not seeking any benefits: • Is this person a resident of Florida? • Is this person disabled or blind? • Is this person a US Citizen? • All questions on non-citizenship details

October 31, 2014

3. Applicants who do not appear eligible for Medicaid and CHIP based on income attestation will be asked whether they are offered health insurance from a job, and if so, will be asked additional details about that insurance offer.

October 31, 2014

Please submit the revised online alternative application used to apply for multiple human service programs to CMS for review no later than October 1, 2014 to ensure approval by October 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 786-8684. If you have any questions about this letter or need any additional information, please contact Etta Hawkins at (404) 562-7429 or Etta.Hawkins@cms.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

MacPro Reporting System: Summary Page (CMS 179) Page 1 of 2

FL.0297.R00.00 - Oct 01, 2013

Control Panel General Information File Management Tribal Input

Summary (CMS179)

| Medicaid State Plan Eligibility

Home Logout Finder Save Validate Print Help

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Florida

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-13-0016

Proposed Effective Date

10/01/2013

Federal Statute/Regulation Citation

42 CFR 435, Subpart J and Subpart M

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00

Subject of Amendment

Transmittal of $94 Eligibility Proc for ACA Implementation.

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified Describe:

http://157.199.113.99/MMDL/faces/protected/mac/c01/pages/mac_00.jsp 11/07/2013

MacPro Reporting System: Summary Page (CMS 179) Page 2 of 2

Reviewed by the Deputy Secretary for Medicaid, who is the Governor's designee.

Signature of State Agency Official

Submitted By: April Cook Last Revision Date: Nov 7, 2013 Submit Date: Sep 10, 2013

CONTINDE ,

FAQs | Form Support | Contact | Medica

http://157.199.113.99/MMDL/faces/protected/mac/c01/pages/mac_00.jsp 11/07/2013

Medicaid Eligibility

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

General Eligibility Requirements Eligibility Process S94

42 CFR 435, Subpart J and Subpart M

Eligibility Process

The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid.

Application Processing

Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard.

Oo The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act

An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary.

An attachment is submitted.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the {&] agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

An attachment is submitted.

l

Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard:

The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and ) approved by the Secretary, and supplemental forms to collect additional information needed to determine cligibility on such other basis, submitted to the Secretary.

An attachment is submitted.

ir An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary.

An attachment is submitted.

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f). by telephone, via mail, and in person.

The agency also accepts applications by other electronic means:

@ Yes © No

TN No: 13-0016-MM2 Approval Date: 12/06/13 Effective Date: 01/01/14 Florida $94-1

Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description

[ | — es

+ Facsimile Customers may also fax applications to the agency.

xX

The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title 1V-A program, including Federally-qualified health centers and disproportionate share hospitals.

Parents and Other Caretaker Relatives | Pregnant Women

Infants and Children under Age 19 ‘Redetermination Processing

iz Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916:

{@] Once every 12 months

iw Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional {il information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

} i Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply):

[IX] Once every 12 months [] Once every 6 months () Other, more often than once every 12 months

Coordination of Eligibility and Enrollment

The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between [7] Medicaid. CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complet this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy 0 the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearane Officer, Mail Stop (4-26-05, Baltimore. Maryland 21244-1850.

TN No: 13-0016-MM2

Approval Date: 12/06/13 Florida

Effective Date: 01/01/14 con_.>

COORDINATION OF ELIGIBILITY AND ENROLLMENT

TRANSMITTAL NUMBER:

FL 13-0016-MM

STATE:

Florida

Notwithstanding the final checked statement on page 2, the single state agency has not entered into an agreement with the Federally-facilitated Marketplace to date. The single state agency will make a good faith effort to enter into a memorandum of agreement with the Federally-facilitated Marketplace before December 1, 2013. At such time the agreement is signed, it will be incorporated by reference

into this attachment

TN No: 13-0016-MM2 Florida

Approval Date: 12/06/13

Effective Date: 01/01/14

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

FL 13-0016-MM Florida

Through October 31, 2014, the state is using an interim online alternative single streamlined application. After October 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

TN No: 13-0016-MM2

Approval Date: 12/06, Florida 106/13

Effective Date: 01/01/14

Family-Related ="=s Medical Assistance

Application

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Form Approved OCF Na. XXXX-XXXX

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THINGS TO KNOW

Use this application te a what coverage

choices you quality for

+ Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP)

+ Affordable private health insurance plans that offer comprehensive coverage to help you stay well

. A new tax credit that can immediately help pay your premiums for health coverage

Whe . Use this application to ; apply for anyone in your family. + Apply even if you or your child already has health coverage. You could be eligible Hl for lower-cost or free coverage. | . \f you're single, you may be able to use a short form ° Visit HealthCare.gov. . Families that include immigrants can apply. You can apply for your child even if you aren't eligible for coverage. Applying won't affect your immigration status or chances of becoming a permanent resident or citizen. . \f someone is helping you fill out this application, you may need to complete Appendix C

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Way de we this inrorination’

We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We'll keep all the information you provide private and secure, as required by law.

ask

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“OUR APPLICATION? Visit

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Apply faster online

Apply faster online at www. ‘lovidakidcare.org.

What } you may i Social Security Numbers (or document numbers for any legal immigrants who need insurance)

. Employer and income information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements)

+ Policy numbers for any current health insurance

. Information about any job-related health insurance available to your family

. If more documents are needed, please send copies. Do not send originals

TO aooly

What hanoen: Send your complete, signed application

to the address on page 7.

If you don’t have all the information

we ask for, sign and submit

your application anyway. You'll get instructions on the next steps to complete your health coverage. If you Gon't hear from us, visit

wer iloria » Or Call 1-888-540- 5437. Filling out this application doesn't

mean you have to buy health coverage.

YOXE

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with

. Online: vw Florida ki + Phone: Call our Call Center at + 888-540-5437. «+ In person: There may be Community

Partners in your area who can help. . Visit our website or call

1-888-540-5437 for more information

ren (londakide ace.arg or Call us at 1-888-540-5437. Para obtener una copia de este formulario on

Espanol, llame 1-888-540-5437. If you need help in a language other than English, call 1-888-540-5437 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-877-427-9825

TN No: 13-0016-MM2 Florida

Approval Date: 12/06/13

Effective Date: 01/01/14

Yell us about yourself.

(We need one adult in the family to be the contact person for your application.)

1. First name, Middle name, Last name & Suffix

2. Date of birth (mm/dd/yyyy) 7 3. Sex Male Female

4. Social Security number (SSN) - - If none, date SSN applied for

We need this if you want health coverage and have a SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who's eligible for help with health coverage costs. if someone wants| help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should cai! 1-800- 7325" 0778.

5.4 Home address (Leave blank if you don't have one.) 6. Apartment or suite number

7.City — 7 a |e State P zIPcode ——_|10, County OO

N. Malling address (if different from home address) n2. Apartment or suite number L_

13. City ~ oo 14.State «15. ZIP code. ——SCS=«*dST. Courrnty _

8. Cell phone. number

CD) =

17, Home Phone number

C ) -

19. Email address:

Do ydu want to get information about this application by email? [] Yes [_]No

nat 1s your preferred spo

or written language (if not English)? .

20.

21. Da you plan to file a federal income tax ‘return NEXT YEAR? (You can still apply for health ‘insurance even if you don't file a federal income tax return.)

a wo — - So

ves. If yes, please answer questions a-c, LJ no. tf frno, skip to question < Cc a. will y you file jointly with a spouse? OlYes [JNo

If yes, name of spouse:

b. Will you claim any dependents on your tax return? [_] Yes [_JNo If yes, list name(s) of dependents:

c. wi you be claimed as a dependent on someone's tax return? UJ yYes oO No If yes, please list the name of the tax filer:

How are you related to the tax filer?

22. Are you pregnant? oO Yes oO No. a. If yes, how many babies are expected during this pregnancy?

23. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.)

(_] VES. If yes, answer all the questions below. (] “6. If no, SKIP to the income questions on page 3. Leave the rest of this page blank.

24 Do you have a a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? {lyes CINo

25. Are you a U.S. citizen or U.S. national? ( Yes oO No

26. tf you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status? (J) Yes. Fill in your document type and ID number below.

a. Immigration document type b. Document ID number

c. Have you lived in the U.S. since 1996? Oo Yes Oo No d. Are you, or your spouse or parent a veteran or an active-duty __member of the U.S. military? OU yYes Oo No

" 2 CUS Ca lOs? Visit: sewilondakideces.ore or catl us at 1-888-540-5437, Para obtener una copia de este formulario en Espanol, tame 1-888-540-5437. If you need help in a language other than English, cal! 1-888-540-5437 and teil the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-877-427-9825

TN No: 13-0016-MM2 Approval Date: 12/06/13 Effective Date: 01/01/14 Florida

(Continue with yourself}

27. Do you want help paying for medical bills from the last 3 months? [_] Yes oO No

28. Do you live with at least one child under the age of 18, and are you the main person taking care of this child? [] Yes [] No

29.:Are you a full-time student? [] Yes []No 30. Did you age out or were you adopted out of foster care in Florida? i] Yes [JNo

31. if Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) (J mexican [Mexican American []Chicano/a [Puerto Rican [JCuban [Other 32 ‘Race (OPTIONAL—check all that apply.)

LJ white ( American Indian or | LJ Filipino J vietnamese (1) Guamanian or Chamorro OU Black or African Alaska Native J Japanese (J Other Asian (J Samoan ‘American UJ Asian Indian (J Korean CJ Native Hawaiian (] Other Pacific Islander j oO Chinese o Other Current sob & income information LJ Employed LJ Not employed L) Self-employed If you're currently employed, tell Skip to question 44. Skip to question 43. us about your income. Start with question 33. CURREN® JOB 33. Employer name and address 34. Employer phone number

35. Wages/tips (before taxes) [Hourly (_]Weekly [_]Every 2 weeks [_] Twice amonth []Monthly [] Yearly

$

36. Average hours worked each WEEK

© (lf you have more jobs amd need more space, attach another sheet of paper.)

37. Employer name and address 38. Employer phone number 39. Wages/tips (before taxes) []Hourly [_] Weekly [_] Every 2 weeks []Twiceamonth []Monthly (J Yearly

$

40. Average hours worked each WEEK

Al. If your normal monthly income is different from the income you listed above, use this space to tell us why.

42. in the past year, did you: Oo Change jobs Oo Stop working [(_] Start working fewer hours CJ None of these

43. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? $

44.0% INCOME TH MS Check all that apply, and give the amount and how often you get it.

NOTE: You do not need to tell us about child support, Veteran's Administration (VA) payment, workers’ compensation, or Supplemental Security Income (SSI)

LJ None (J Unemployment $ How often? Cnet farming/fishing = $ How often? C1 Pensions $ How often? (] Net rental/royalty $ How often? (_} Social Security $ How often? CJ other income $ How often? {Retirement accounts $ How often? Type {_] Alimony received $ How often? SEED & SLO ETS YOUR APR OY OM® Visit ovedocdakideare.ora or call us at 1-888-540-5437. Para obtener una copia de este formulario en

Espanol. lame 1-888-540-5437. If you need heip in a language other than English, call 1-888-540-5437 and tell the customer service representative the language you need. We'll get you help at no cost to vou. TTY users should call 1-R77-427-ARI5

TN No: 13-0016-MM2 Approval Date: 12/06/13 Effective Date: 01/01/14 Florida

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Sorntinue with yourself>

45. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Note: Refer to the Adjusted Gross Income Section from IRS.gov for items that can be included in this section. You shouldn't include a cost that you already considered in your answer to net self-employment (question 44b).

{J Alimony paid $ How often? {J Other deductions $ How often?

LU Student loan interest $ How often? Type:

46. 7EAR 1A "=: Complete only if your income changes from month to month.

If you don't expect changes to your monthly income, skip to the next person.

Your total income this year Your total income next year (if you think it will be different) $ | $

TR ANI

WE Meg TO KNOW abou

52

us about your family

Who do you need to include on this application?

Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax returh. (You don’t need to file taxes to get health coverage).

x

DO Include: You DON’T have to include:

. Your spouse . + Your unmarried partner who doesn't need health

* Your children under 21 who live with you coverage

+ Your unmarried partner who needs health coverage * Your unmarried partner's children

+ Anyone you include on your tax return, even if they + Your parents who live with you, but file their own tax don't live with you return (if you're over 21)

* Atyone else under 21 who you take care of and lives * Other adult relatives who file their own tax return

with you

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with other adults and children. If you have more than 2 people in your family, you'll need to make a copy of the pages and attach them. You don't need to provide immigration status or a Social Security Number (SSN) for family members who don't need health coverage. We'll keep all the information you provide private and secure as required by law. We'll use personal information only to check if you're eligible for health coverage.

PSOne? Visit savy. tocidakiscare ore or Call us at 1-888-540-5437. Para obtener una copia de este formulario en Espanol, lame 1-888-540-5437. If you need help in a language other than English, call 1-888-540-5437 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-877-427-9825.

Power

TN No: 13-0016-MM2 Approval Date: 12/06/13 Effective Date: 01/01/14 Florida

Complete Step 2 for your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. !f you don't file a tax return, remember to still add family members who live with you. NOTE: If you have more than two people to include, make a copy of Step 2: Next Person and complete.

1. First name, Middle name, Last name, & Suffix 2. Relationship to you?

3. Date of birth (mm/dd/yyyy) 4. Sex O Male (Female

5. Social Security number (SSN) - - If none, date SSN applied for We need this if you want health coverage and have an SSN.

6. Daes the NEXT PERSON live at the same address as you? [_] Yes CINo If no, | list address: ee 7. Does the NEXT PERSON plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.) Cl YES. If yes, please answer questions a-c (LI NO. If no, skip to question c. a. Will the NEXT PERSON file jointly with a spouse? OlYes CINo If yes, name of spouse: b: Will the NEXT PERSON claim any dependents on his or her tax return? oO Yes oO No If yes, list name(s) of dependents: c. Will the NEXT PERSON be claimed as a dependent on someone's tax return? [] Yes []No If yes, please list the name of the tax filer: asad is the NEXT PERSON related to the tax filer?

8 Is) ‘the NEXT PERSON pregnant? O Yes oO No a.lf yes, how many babies are expected during this pregnancy?

9. Daes the NEXT PERSON need health coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.)

a YES. If yes, answer_all the questions below. & 0 so 1 no, SKIP to the income questions on page 5. &

i Leave the rest of this page blank.

10. Does the NEXT PERSON have a physical, mental, or emotional health condition that causes limitations in ‘activities dike bathing, dtessing, daily chores, etc) or live in a medical facility or nursing home? oO Yes oO No

ll. Is the NEXT PERSON a USS. citizen or U.S national? 0 Yes

12. If the NEXT PERSON isn't a U.S. citizen or U.S. national, do they have eligible immigration status? Cl yes. Fill in their document type and ID number below

a. Document type b. Document ID number

c. Has the NEXT PERSON lived in the U.S. since 1996? oO Yes oO) No d. Is the NEXT PERSON or their spouse or parent a veteran or an active-duty member in the U.S. military? oO Yes C) No

13. Does the NEXT PERSON want help 14. Does the NEXT PERSON live with at least one |15. Was the NEXT PERSON aged out paying for medical bills from the last 3 child under the age of 18, and are they the of or adopted out of foster care in months? main person taking care of this child? Florida?

ClYes LINo ClYes LINo Uves CINo |

To help you get access to specialized care, if this NEXT PERSON i: is vage 20 or 7 younger “and has a chronic and serious “medical, behavioral, or other health condition that has lasted or is expected to last at least 12 months, please answer the > following three @ questions.

16. Is this NEXT PERSON limited or prevented in any way in his or her ability to do the same things most children of ‘the same age do?

17. Does the NEXT PERSON need to get special therapy, such ¢ as ; physical, occupational o or ‘speech ‘therapy, ¢ or ‘treatment or counseling for an emotional, developmental, or behavioral problem? oO Yes oO No

18. ‘Does the NEXT PERSON need or use more medical care, mental health, or ; educaitonal services than is usual for most children of the same ge? Ov Yes = No

19. Is the NEXT ‘PERSON a full time > student? a Yes On No

20. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) oO Mexican [_] Mexican American { ‘] Chicano/a OJ Puerto Rican oO Cuban Oo Other

© Visit yoowalGuctakidcarc.ara or call us at 1-888-540-5437, Para obtener u una copia de ¢ este formulario ¢ en Espanol, lame 1-888-540-! 5437 If you need help in a language other than English, call 1-888-540-5437 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-877-427-9825.

TN No: 13-0016-MM2 Approval Date: 12/06/13 Effective Date: 01/01/14 Florida

| STEP 2: NEXT PERSON | NEXT PERSON

21. Race (OPTIONAL—check all that apply.) (J white (J American Indian or (J Filipino 0 vietnamese () Guamanian or Chamorro OO Black or African Alaska Native (J Japanese (J Other Asian 0) Samoan American 0 Asian Indian 0 Korean ( Native Hawaiian C) Other Pacific islander ( Chinese ( Other

: NEXT PERSON =

Noe APE

(J Employed C] Not employed C) Self-employed IF you're currently employed, tell us about i Skip to question 33 Skip to question 32. your income. Start with question 22.

CURRENT JOB 7:

22. Employer name and address 23. Employer phone number

24. Wages/tips (before taxes) []Hourly [] Weekly []€very 2 weeks [JTwiceamonth []Monthly [] Yearly $

25. “Average hours worked each WEEK

CURRENT 208 2) (if you have more jobs and need more space, attach another sheet of paper.) -

26. Employer name and address ‘27. Employer phone number

_ ee ee ee

28. Wages/tips (before | taxes) | Hourly. o Weekly 0 Every 2weeks [] Twice a month oO Monthly [J Yearly $

29 ‘Average hours worked each WEEK

30. f your normal monthly income is different from the income you listed above, use this space to tell us ; why, —_

(pounce snnetereenecntaemnimnth rane ot

31. In the past year, did the NEXT PERSON: Ol Change jobs oO Stop working O: Start working fewer hours o None of these

32. If self-employed, answer the following questions: |

a. Type of work b. How much net income (profits once business expenses are

paid) will you get from this self-employment this month?

$

33.07

ac

wCOMe TiS MONT? Check all that apply, and give the amount and how often you get it.

NOTE: You do not need to tell us about child support, veteran's payment, workers’ compensation or Supplemental Security Income (SSI).

(J None

(J Unemployment $ How often? (J Net farming/fishing $ How often? CO Pensions $ How often? (J Net rental/royalty $ How often? (1) Social Security $ How often? (J Other income $ How often? (JRetirement accounts $ How often? Type:

O Alimony received $ How often?

34.025 ren iOS. Check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Note: Refer to the Adjusted Gross Income Section from IRS.gov for items that can be included in this section You shouldn't include a cost that you already considered in your answer to net self-employment (question 32b).

(J Alimony paid $ How often? (J Other deductions $ How often?

(] Student loan interest $ How often? Type:

tow * Visit «viw. itor cidcare.org Or Call us at 1-888-540-5437. Para obtener una copia de este formulario en spanol, llame 1-888-540-5437. If you need help in a language other than English, call 1-888-540-5437 and tel! the customer service representative the language you need. We'll get you hep at no cost to you. TTY users should call 1-877-427-9825.

Naf oe

TN No: 13-0016-MM2 Approval Date: 12/06/13 Effective Date: 01/01/14 Florida

STEP 2: NEXT PERSON

35. VEARLY [NC OME: Complete only if the NEXT PERSON’s income changes from month to month. If you don't expect changes to the NEXT PERSON’ 's monthly income, add another person or skip to the next section

The NEXT PERSON's total income this year The NEXT PERSON’s total income next year (if you think it will be $ different) $

ANKE:

> we need to know about ihe NEXT PERSON

JAN f famiby rv

anandian or Alaska Native

1. Are you or is anyone in your family American indian or Alaska Native?

O If No, skip to Step 4. O Yes. If yes, go to Appendix B.

Answer these questions for anyone who needs health coverage.

1. ts anyone enrolled in health coverage now from the following? (1 YES. If yes, check the type of coverage and write their name(s) next to the coverage they have. wo

QO Medicaid (1 Employer insurance Florida KidCare Name of health insurance: Medicare Name of person insured: Policy number: Is this COBRA coverage? [_] Yes [| No . ts this a retiree health plan? i) Yes Ol No VA health care programs CI Other

a

O

Oo TRICARE (Don't check if you have direct care or Line of Duty) Name of health insurance:

O

Peace Corps | Name of person insured:

Policy number:

Is this a limited-benefit plan (like a school accident policy)?

Uyes [JNo

21s. anyone > listed on this application offered health coverage ° from a job? Check yes even if the coverage is from someone else" S job, such as a parent or spouse.

im YES. If yes, you'll need to complete and include Appendix A. Is this a state employee benefit plan? Lives LINo q NO. If no, continue to Step 5.

3 Has anyone voluntarily canceled health i insurance for children i in n the last two months for any of these reasons?

(7]). The cost of an applicant child's health insurance is more than 5% (6. the employer providing the applicant child's coverage canceled of your family’s income. the coverage. (12. pomestic violence led to the loss of coverage for an applicant child. |] 7. the applicant child's coverage ended because the child reached the

(1 3. Parent lost a job that provided employer-sponsored coverage for an maximum lifetime coverage limit or an annual benefit limit

applicant child (18. An appticant child has a medical condition that, without medical

| 4. The coverage does not cover the applicant child's health care needs care, would cause serious disability, loss of function, or death

(11s. Parent who had the health insurance coverage for an applicant child (9. The applicant child's parent canceled COBRA coverage or the is deceased COBRA coverage reached its legal limit

Cio. A non-custodial parent dropped the applicant child's coverage

(1 YES. If yes, month/year canceled __ LJ NO. If no, continue to Step 5.

PRA Disclosure Statement Accofding 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 0938-1191. The time required to complete this information collection is estimated to average {insert Time (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 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 os, Baltimore, Maryland 21244-185 50.

tO? Visit . ridlakidicare: ora or call us at 1-888- 540- 5437 ‘Para obtener Espaol, tl llame 1-888-540-5437. If you need help in a language other than English, call 1-888-540-5437 and tell the customer service representative the anguage you need. We'll get you help at no cost to you. TTY users should call 1-877-427-9825.

copia de este formulario en

TN No: 13-0016-MM2 Approval Date: 12/06/13 Effective Date: 01/01/14 Florida

Read & siqn this application,

+ I'm signing this application under penalty of perjury which means I've provided true answers to all the questions on this form to the best of my knowledge. ! know that | may be subject to penalties under federal and state law if | provide false and or untrue information.

+ | know that | must report if anything changes (and is different than) what | wrote on this application. | understand that a change in my information could affect the eligibility for member(s) of my household.

+ | know that under federal law, discrimination isn't permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. | can file a complaint of discrimination by visiting www.hhs.gov/oci/oftice/tile

* | confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not,

is incarcerated. (name of person)

| know this information will be used to check my eligibility for help paying for health coverage if | choose to apply. We'll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. We will not tell the United States Citizenship and Immigration Services (USCIS) about the immigration status of those living in your household who are not applying. If the information doesn’t match, we may ask you to send us proof.

| understand that the information will be kept confidential in accordance with Florida and federal law.

| authorize the release of personal, financial, and medical information for determining eligibility, conducting research, or providing health care treatment, payment and administration.

| attest that the information provided on this application establishes the identity of children under age 16. | have read and understood my rights and responsibilites as they apply to the Medicaid program.

If anyone on this application is eligible for Medicaid

+ | dm giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. | am also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

* Does any child on this application have a parent living outside of the home? O Yes O No

+ If yes, | know I will be asked to cooperate with the agency that collects medical support from an absent parent. If | think that cooperating to collectmedical support will harm me or my children, | can tell Medicaid and | may not have to cooperate.

.

My right to appeal

If | think Florida KidCare has made a mistake, | can appeal its decision. To appeal means to tell someone at Florida KidCare that | think the action is wrong, and ask for a fair review of the action. | know that | can find out how to appeal by contacting Florida KidCare at 1-888-540-5437. | know that | can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Sign this application. The person who filled out Step 1 should sign this application. If you're an authorized representative you may sign here, as long as you have provided the information required in Appendix C.

Signature

Date (mm/dd/yyyy)

Signature

'|Date (mm/dd/yyyy)

|

_. i

Mail your signed application to:

Florida KidCare P.O. Box 980 Tallahassee, FL 32302

if you want to register to vote, you can complete a voter registration form at 2:

YOUR KP AL CT tOM? Visit wevetloridakicteare.ore or call us at 1-888-540-5437. Para obtener una copia de este formulario en Espanal, lame 1-888-540-5437 |f you need help in a language other than English, call 1-888-540-5437 and tell the customer service representative the language you need. We'll get you help at na cost ta you. TTY users should call 1-877-427-9825,

tn No: 13-0016-MM2 Approval Date: 12/06/13 Effective Date: 01/01/14 Florida

Table of Contents State/Territory Name: Florida State Plan Amendment (SPA) #: 13-0017-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

October 28, 2013

Mr. Justin Senior Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mailstop #20 Tallahassee, Florida 32308

Attention: April Cook

RE: Title XIX State Plan Amendment, FL 13-0017-MM3

Dear Mr. Senior:

We have reviewed the proposed State Plan Amendment, FL-13-0017-MM3, which was submitted to CMS on September 12, 2013. This amendment incorporates the MAGI-Based Income Methodologies into Florida’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of the SPA is January 1, 2014.

Notwithstanding any other provisions of the Florida Medicaid State Plan, the financial eligibility methodologies described in SPA FL-13-0017-MM3 will apply to all MAGI-based eligibility groups covered under Florida’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603 (j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Based on the information provided, Medicaid State Plan Amendment FL-13-0017-MM3 was approved on October 25, 2013. The effective date of this amendment is January 1, 2014. We are enclosing the approved HCFA-179 and the plan pages, S10-1 and S10-2. Please incorporate the approved plan pages within a separate section at the back of Florida’s approved state plan.

In addition, enclosed is a summary of state plan pages which are superseded by FL SPA 13-0017- MM3, which should also be incorporated into a separate section in front of the approved state plan.

Mr. Justin Senior Page 2

If you have any questions, please contact Etta Hawkins, R.Ph. at (404) 562-7429 or etta.hawkins@cms.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosure

State/Territory name: Florida Submitted By: April Cook Last Revision Date: Oct 1, 2013 Submit Date: Sep 12, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. FL-13-0017 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment MAGI-Based Income Methodologies Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Reviewed by the Deputy Secretary for Medicaid, who is the Governor's designee. Signature of State Agency Official Page 1 of 2

DATE RECEIVED: ; DATE APPROVED:

09/12/13 10/25/13

- PLAN APPROVED — ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: TYPED NAME: 7 TITLE: Associate Regional Administrator

Division of Medicaid & Children Health Opns Jackie Glaze

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: FL-13-0017-MM3 Florida

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

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

Notwithstanding any other provisions of the Florida Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment FL-13-0017-MM3 will apply to all MAGI- based eligibility groups covered under Florida’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

ccms. Medicaid Eligibility

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

S10

1902(e)(14) 42 CFR 435.603

im The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603.

In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date.

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman:

C The pregnant woman is counted just as herself.

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

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

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

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

@ Current monthly household income and family size

C Projected annual household income and family size for the remaining months of the current calendar year

In determining current monthly or projected annual household income, the state will use reasonable methods to: ([] Include a prorated portion of a reasonably predictable increase in future income and/or family size. {"] Account for a reasonably predictable decrease in future income and/or family size.

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

In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d).

Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

C Yes @No

Page | of 2

Medicaid Eligibility

{Ml] The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is:

C Age 19

@ Age 19, or in the case of full-time students, age 21

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

Page 2 of 2

Table of Contents

State/Territory Name: Florida State Plan Amendment (SPA) #:13-0020-MM6

This file contains the following documents in the order listed:

1) Approval Letter

2) Summary Form (with 179-like data) 3) Superseding Pages Notice

4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

Atlanta Regional Office < M S 61 Forsyth Street, Suite 4T20

Atlanta, GA 30303 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 24, 2014

Mr. Justin Senior

Deputy Secretary for Medicaid

Florida Agency for Health Care Administration 2727 Mahan Drive

Mail Stop 8

Tallahassee, Florida 32308

Dear Mr. Senior:

Enclosed is an approved copy of Florida’s state plan amendment (SPA) 13-0020-MM6, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 27, 2013. SPA 13-0020-MM6 incorporates the citizenship regulations, specifies reasonable opportunity period options, and specifies policy options related to eligible non-citizens into Florida’s state plan in accordance with the Social Security Act and regulations at 42 CFR Part 435. This SPA was approved on February 24, 2014. The effective date of this SPA is January 1, 2014.

We are enclosing the approved HCFA-179 and the plan pages. Please incorporate the approved plan pages within a separate section at the end of Florida’s approved state plan.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Etta Hawkins, at either 404-562-7429 or by email at Etta. Hawkins@cms.hhs.gov.

Sincerely,

/Is//

Jackie Glaze

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

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Florida

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-13-002(

Proposed Effective Date

01/01/2014

! (mm/dd/yyyy)

Federal Statute/ Regulation Citation

1902(a)(4€

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $ 0.00

it

Second Year 2015 g| 20°

Subject of Amendment

Character Count: out of 2000

Initial submission of S89 Non-Fit Citizenship and Non-Citizen Blig

| oe |

Governor's Office Review

c Governor's office reported no comment

Cc Comments of Governor's office received

4

| ae aa

Describe:

co No reply received within 45 days of submittal

cE Other, as specified

Describe:

Character Count: out of 2000

Review ed by the Deputy see

a Lt J

Signature of State Agency Official

Submitted By: April Cook

Last Revision Date: Nov 26, 2013

Submit Date: Nov 26, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: FL-13-0020-MM6 Florida PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable):

S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility Attachment 2.6-A: Page 2, item (3), paragraphs (a) , (b), and (c), TN 91-39

Attachment 2.6-A: Page 3, item (3), paragraphs (d) and (e), TN 91-39

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

1902(a)(46)(B)

8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4)

42 CFR 435.4

42 CFR 435.406

42 CFR 435.956

Citizenship and Non-Citizen Eligibility

The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status.

The state provides Medicaid eligibility to otherwise eligible individuals: igtbility [®) Who are citizens or nationals of the United States; and

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

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or

Ly satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

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

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process.

@Yes (No

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual.

@ Yes (No The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status.

© The date the reasonable opportunity notice is sent.

C Other date, as described:

TN No: 13-0020-MM6 Approval Date: 02/24/14 Effective Date: 01/01/14 Florida $89-1

Medicaid Eligibility

The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613).

@ Yes CNo

The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act.

C Yes @No

wl An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan.

{™) An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than I year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. Is a non-citizen who belongs to one of the following classes: {@] Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively;

im Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

{§) Granted employment authorization under 8 CFR 274a.12(c);

[@) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

[@) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; [@) Granted Deferred Action status;

@ Granted an administrative stay of removal under 8 CFR 241;

{@) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who -

[®) Has been granted employment authorization; or [M) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J);

8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b));

TN No: 13-0020-MM6 Approval Date: 02/24/14 Effective Date: 01/01/14 Florida $89-2

Medicaid Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

(D Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following

individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN:

[M) Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613;

nl Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b).

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

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

TN No: 13-0020-MM6 Approval Date: 02/24/14

Florida 589.3 Effective Date: 01/01/14

Table of Contents

State/Territory Name: Florida State Plan Amendment (SPA) #: 14-0005-MM4

This file contains the following documents in the order listed:

1) Approval Letter

2) Summary Form (with 179-like data) 3) Superseding Pages Notice

4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

Atlanta Regional Office < Mi

61 Forsyth Street, Suite 4T20

Atlanta, GA 30303 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

May 23, 2014

Mr. Justin Senior

Deputy Secretary for Medicaid 2727 Mahan Drive, MS#8 Tallahassee, Florida 32308

Re: Title XIX State Plan Amendment, FL 14-0005 MM4 Dear Mr. Senior:

Enclosed is an approved copy of Florida’s state plan amendment (SPA) 14-0005 MM4, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on February 28, 2014. SPA 14-0005-MM4 establishes the single state agency and entities responsible for determinations of eligibility and appeals/fair hearings in accordance with the Affordable Care Act. This SPA was approved on May 23, 2014. The effective date of this SPA is

January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of Florida’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 14-0005-MM4, which should be incorporated into a separate section in the front of the state plan.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions, please contact Etta Hawkins at 404-562-7432 Etta. Hawkins@cms.hhs.gov.

Sincerely,

/Is//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Florida

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- 14-000!

Proposed Effective Date

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

Federal Statute/Regulation Citation

| 42 CFR 43

Federal Budget Impact

Federal Fiscal Year Amount

First Year [204 gl 290 Second Year 2015 gl 20°

Subject of Amendment

Character Count: out of 2000

oo0o°00

State Plan Administration, Desig -

AL a

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

Describe:

Ls ma

No reply received within 45 days of submittal

° Other, as specified

Describe:

Character Count: out of 2000

Review ed by the Deputy ee

=

Signature of State Agency Official

Submitted By: April Cook Last Revision Date: May 22, 2014

Submit Date: Feb 28, 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE:

Fl 2014-0005 Florida

PAGE NUMBER OF THE PLAN SECTION OR COMPLETE PAGES PARTIAL PAGES

ATTACHMENT: SUPERSEDED: SUPERSEDED:

Al - A3 Pages 1-9 Section 1.4 (page 9)(State

Medical Care Advisory

Attachment 1.1-A (Attorney Committee only. Tribal General certification) consultation will remain in the

state plan.) Attachment 1.2-A (Organizational chart)

Attachment 1.2-B (Description of the functions of the single State agency)

Attachment 1.2-C (Description of professional medical and

supporting staff)

Attachment 1.2-D

Al-A2 Notwithstanding any other provisions of the Medicaid State Plan, the agencies designated in Al and A2 will determine eligibility for coverage to the extent specified in Al and A2.

Medicaid Administration

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

42 CFR 431.10

Designation and Authority

State Name: Florida

As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of]

this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department.

Name of single state agency: Agency for Health Care Administration

Type of Agency: C Title 1V-A Agency C Health C Human Resources

@ Other

Type of Agency |State Medicaid Agency

The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.)

The state statutory citation for the legal authority under which the single state agency administers the state plan is:

Section 409.902(1), Florida Statutes

The single state agency supervises the administration of the state plan by local political subdivisions.

C Yes @No

The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided.

The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies.

The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it).

C Yes @No

TN N.: FL-14-0005-MM4 Approval Date: 05/23/14 Effective date: 01/01/14 A1-1

= Medicaid Administration

OC TOE EOC OA ION

RI Waivers of the single state agency requirement have been granted under authority of the Intergovernmental Cooperation Act of

D

1968.

The waivers are still in effect.

@ Yes (No

| Date waiver granted (MM/DD/YY): |05/21/14

The type of responsibility delegated is (check all that apply):

(J Determining eligibility

| {X] Conducting fair hearings

| (J Other

Name of state agency to which responsibility is delegated:

Department of Children and Families (IV-A Agency) !

Describe the organizational arrangement authorized, the nature and extent of responsibility for program administration delegated to the above named agency, and the resources and/or services of such agency to be utilized! j in administration of the plan: '

The Agency for Health Care Administration (AHCA) delegates its authority to conduct fair hearings to the Department of Children and Families (DCF), the state's Title |V-A agency. The Office of Appeals Hearings, part of DCF's Office of Inspector General, is responsible for conducting fair hearings pursuant to 42 CFR Part 431,

| Subpart E, for Medicaid applicants and recipients pertaining to eligibility and service-related appeals. This agreement is defined in the “State of Florida Cooperative Agreement for Medicaid between the Agency for Health |’ Care Administration and the Department of Children and Families." | DCF's Office of Appeal Hearings employs full time hearing officers to conduct hearings. ' AHCA retains oversight over the State Plan and the development and issuance of policies, rules and regulations | on program matters. |

The methods for coordinating responsibilities among the agencies involved in administration of the plan under the alternate organizational arrangement are as follows:

The Agency for Health Care Administration retains oversight of the State Plan and will establish a process to monitor the appeals process, including the quality and accuracy of the final decisions made by the Department of i Children and Families.

| The Agency for Health Care Administration will ensure that every applicant and beneficiary is informed, in | i writing, of the fair hearing process and how to contact the Department of Children and Families and how to obtain

i information about fair hearings from that agency.

i The Agency for Health Care Administration will ensure that the Department of Children and Families complies with all federal and state laws, regulations and policies.

The agency that administers or supervises the administration of the plan under Title X of the Act as of January I, 1965, has been separately designated to administer or supervise the administration of that portion of this plan related to blind individuals.

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Medicaid Administration

The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are:

(1 The Medicaid agency

< Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

(J An Exchange that is a government agency established under sections 131 1(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are:

(1) The Medicaid agency

Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title | or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

{_] An Exchange that is a government agency established under sections 131 1(b)(1) or 1321(c)(1) of the Affordable Care Act [X] The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: (] Medicaid agency Title IV-A agency

(_] An Exchange

The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are:

Medicaid agency ([] An Exchange that is a government agency established under sections 131 1(b)(1) or 1321(c)(1) of the Affordable Care Act {[] An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies.

C Yes @No

42 CFR 431.10 42 CFR 431.11

Organization and Administration

Provide a description of the organization and functions of the Medicaid agency.

AGENCY FOR HEALTH CARE ADMINISTRATION STATEMENT OF AGENCY ORGANIZATION AND OPERATION

GENERAL DESCRIPTION

The Agency for Health Care Administration (the Agency) is the chief health policy and planning entity for the state. The Agency is responsible for health facilities licensure. inspection. and regulatorv enforcement; investigation of consumer complaints related +~

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Ss Medicaid Administration

COEF ORME ATH A MMAR BEATE

health care facilities and managed care plans; the implementation of the Certificate of Need program; the operation of the Florida Center for Health Information and Policy Analysis; the administration of the Medicaid program; the administration of the Title XX1 program; the certification of health maintenance organizations and prepaid health clinics; and other duties prescribed by statute or agreement.

The head of the Agency is the Secretary, who is appointed by the Governor, subject to confirmation by the Senate.

ORGANIZATIONAL STRUCTURE The Agency is divided into various units and subunits as follows:

Chief of Staff

The Chief of Staff's office coordinates Medicaid and health care regulation policy with other state agencies, the Florida Legislature and the federal government. This office oversees Communications, Legislative Affairs, and the Division of Information Technology, and serves as the liaison to the Florida Washington Office.

Division of Operations

The Division of Operations is the Agency’s business support unit. It assists the Agency with financial, personnel and support related functions. This division is also responsible for Third Party Liability activities which include; casualty recovery, estate recovery, and Medicare and other third party payer recoveries.

Division of Health Quality Assurance

The Division of Health Quality Assurance is responsible for:

* state licensure, federal certification, and criminal background checks for owners, operators and certain health care provider staff; * routine and complaint inspections and plans and construction reviews for certain facilities;

* providing consumer and public information regarding health care facilities including licensure and inspection information to the public and public record requests;

* performing financial reviews and analysis for licensure and regulatory assessments; and

* commercial managed care regulation, including network verification licensure, complaint investigations, and subscriber grievance review.

Division of Medicaid

The Division of Medicaid directs all Medicaid program planning and development activities. It plans, develops, organizes and monitors program planning, reimbursement policies and oversees provider and consumer relations. The Division prepares the Medicaid annual budget, administers the Medicaid fiscal agent contract and formulates long-term plans for service delivery. It contains the following subunits:

Assistant Deputy Secretary for Medicaid Finance

The Assistant Deputy Secretary for Medicaid Finance is responsible for:

+ data analysis, forecasting of Medicaid caseloads and expenditures, setting rates for health plans reimbursed on a capitated basis, managing risk adjustment payments and processes, calculating cost effectiveness and budget neutrality for all 1915(b) and 1115 waivers, and performing audits on nursing home cost reports.

+ developing and monitoring the Medicaid budget, coordinating the preparation of legislative budget requests, developing Medicaid cost reimbursement plans for nursing homes and hospitals, forecasting future program costs and calculating the impact of federal program changes on the Florida Medicaid program.

* monitoring all activities of the Medicaid fiscal agent for compliance with the contract agreement and all federal mandates, state rules and regulations; coordinating eligibility information transfer between the Department of Children and Families’ FLORIDA eligibility system and Florida Medicaid Management Information System; assisting Medicaid providers in claims resolution; managing and coordinating Florida Medicaid HIPAA activities in conjunction with the HIPAA Privacy and Security Compliance Office; assisting providers with enrollment and re-enrollment into the Medicaid program; and all systems hardware and software processes, changes and additions.

Assistant Deputy Secretary of Medicaid Operations

The Assistant Deputy Secretary for Medicaid Operations is responsible for:

+ developing, coordinating and implementing Medicaid program coverage policies and procedures; administering the program’s medical authorization functions; developing and maintaining the Medicaid State Plan, administrative rules and manuals;

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AIA

Medicaid Administration

CONTI TOE SAT A A TCAD ICT

coordinating policy development with other departmental entities and health care organizations; preparing and maintaining federal Medicaid waivers; and analyzing the impact of new and amended state and federal laws and rules; developing and maintaining managed care contracts and managed care policy;

* managing contracts for research and evaluations of Medicaid programs; establishing and enforcing quality standards for Medicaid

health care programs; overseeing federally mandated evaluations of waiver programs; and sponsoring research in areas that impact Medicaid.

Assistant Deputy Secretary for Medicaid Health Systems

The Assistant Deputy Secretary for Medicaid Health Systems is responsible for:

* managing Medicaid managed care contracts;.

+ managing Field Offices that are responsible for monitoring the implementation of Medicaid policies and procedures; providing technical assistance, consultation and training to providers, governmental agencies and community organizations; assisting in the recruitment and retention of Medicaid providers; and assisting Medicaid enrollees and providers with issues related to Medicaid services.

* overseeing the comprehensive beneficiary managed care Choice Counseling program, including special services for the disabled and recipients with special health care needs; and overseeing the Medicaid enrollment broker contract that enrolls Medicaid recipients in health plans.

Inspector General

The Inspector General works to ensure that the Agency’s programs and services comply with all applicable laws, policies and procedures. This unit includes the Bureau of Medicaid Program Integrity, which is responsible for overseeing the activities of Medicaid recipients and Medicaid providers and their representatives to ensure that fraudulent and abusive behavior and neglect of recipients is mitigated, and for recovering overpayments and imposing sanctions. The Inspector General’s office is also responsible for investigations or inquiries designed to detect and prevent fraud, waste, misconduct, mismanagement and other abuses within the Agency; conducting reviews, audits, management consulting engagements and control self- assessments; and advising and assisting the Agency in its compliance efforts and to assist Medicaid beneficiaries in exercising their rights under HIPAA.

General Counsel

The General Counsel functions as the chief legal advisor to the Secretary in his/her official capacity. The duties of the Office of the General Counsel include: providing counsel to Agency staff regarding legal issues that arise in the day-to-day operation of the Agency; representing the Agency in lawsuits in which the Agency or its employees are named in their official capacity; functioning as the Chief Ethics Officer for the Agency; and serving as the Agency’s liaison to the general counsels of other state agencies and the Governor’s Office of General Counsel.

Upload an organizational chart of the Medicaid agency.

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Ss Medicaid Administration

CEE TOR MOC ANN 4 aarTCID NIE

| | | | | |

Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies.

The Agency for Health Care Administration (Agency) is the state Medicaid agency. All health, human service and public assistance agencies, including the Agency, are under the purview of the Governor. The Governor appoints, and the Senate confirms, the head of each agency.

The following outlines the Agency’s involvement with the state’s health, human service and public assistance agencies, as well as other state organizational entities:

Agency for Persons with Disabilities: implements the Medicaid home and community based services waiver program for individuals with intellectual disabilities; operates intermediate care facilities for individuals with intellectual disabilities.

Department of Children and Families: is the state's Title 1V-A agency; implements policy and determines Medicaid eligibility for all MAGI and non-MAGI eligibility categories other than those determined by the Social Security Administration; is the single state authority on substance abuse and mental health with the Substance Abuse and Mental Health (SAMH) Program and is responsible for the oversight of a statewide system of care for the prevention, treatment, and recovery of children and adults with serious mental illnesses or substance abuse disorders; is the state’s child welfare agency.

Department of Elder Affairs: conducts level of care assessments for the Institutional Care Program and home and community based services waivers; is the operating agency overseeing the Program of All-inclusive Care for the Elderly; conducts monitoring functions for the Statewide Medicaid Managed Care Long-term Care program.

Department of Health: provides medical care to children with chronic disabling conditions or potentially disabling conditions through Children’s Medical Services; assists with planning and implementing preventive health care programs and primary care programs; provides child health checkup, family planning and primary care services; operates Medicaid home and community based services waiver programs; licenses healthcare practitioners.

Department of Transportation: coordinates planning for the transportation of disadvantaged individuals.

Office of the Attorney General: investigates and prosecutes Medicaid provider and recipient fraud.

‘Type of entity that determines eligibility:

> Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title | or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

C An Exchange that is a government agency established under sections 131 1(b)(1) or 1321(c)(1) of the Affordable Care Act

C The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

The Department of Children and Families (DCF) is the state's Title IV-A agency. The Economic Self-Sufficiency Program/ ACCESS Florida Program is a division within DCF responsible for determining eligibility for all Medicaid populations (MAGI and non-MAGI groups) other than those determined by the Social Security Administration.

Economic Self-Sufficiency Specialist: Processes applications and redeterminations for the purpose of determining eligibility for the Medicaid Program. This process includes collecting and updating required eligibility information on applicants, recipients and their households members while

interacting with the Florida Online Recipient Integrated Data Access (FLORIDA) computer system, for the purpose of establishing

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ms Medicaid Administration

CONEY TORE SAE NCARE A ARICA REET

eligibility for the Economic Self-Sufficiency Public Assistance Programs.

Interview Clerk:

Primary responsibility to review applications for the basic demographic information on applications; performs statewide clearance/ prior contact, check/collateral contacts; and reconciles any discrepancies on all household members through the Florida Online Recipient Integrated Data Access (FLORIDA) computer system. This may require assisting the applicant in the completion of the application for assistance.

Type of entity that determines eligibility:

Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title | or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act @ The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Security

Income recipients.

Type of entity that conducts fair hearings:

C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act C An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

Add

Supervision of state plan administration by local political subdivisions (if described under Designation and Authority)

Is the supervision of the administration done through a state-wide agency which uses local political subdivisions?

C Yes C No

42 CFR 431.10 42 CFR 431.12 42 CFR 431.50

Assurances

The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50.

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Medicaid Administration

All requirements of 42 CFR 431.10 are met.

There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12.

The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters.

Assurance for states that have delegated authority to determine eligibility:

There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d).

Assurances for states that have delegated authority to conduct fair hearings:

oO There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d).

oO When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency.

Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings:

The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis.

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

V 20130917

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a Effective date: 01/01/14

Table of Contents

State/Territory Name: Florida State Plan Amendment (SPA) #:14-006

This file contains the following documents in the order listed:

1) Approval Letter

2) Additional Companion letter 3) CMS 179 Form

4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office

61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

September 26, 2014

Mr. Justin Senior

Deputy Secretary for Medicaid 2727 Mahan Drive, MS#8 Tallahassee, Florida 32308

Re: Florida State Plan Amendment, Transmittal #14-006 Dear Mr. Senior:

Florida submitted state plan amendment 14-006 that was received by the Centers for Medicare & Medicaid Services (CMS) on June 30, 2014. The proposed effective date of this amendment is April 1, 2014. The purpose of this amendment is to amend the Consumer Directed Care Option (CDC+) for individuals enrolled in the Traumatic Brain and Spinal Cord Injury (TBI/SCI) and the Aging and Disabled Adult (ADA) waivers. Participants from the ADA waiver were transitioned to the Managed Care-Long Term Care (MC-LTC) waiver program, and individuals enrolled in the TBI/SCI wavier will be offered the option to enroll in the MC-LTC program.

Based on the information provided, we are now ready to approve Florida SPA 14-006 as of September 26, 2014. The signed CMS-179 and the approved plan pages are enclosed.

A companion letter is also being issued with this approval to address concerns related to the waiver components of the SPA.

If you have any questions or need any further assistance, please contact Etta Hawkins at (404) 562- 7429.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, GA 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

September 26, 2014

Mr. Justin Senior Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mailstop #20 Tallahassee, Florida 32308

RE: Florida State Plan Amendment 14-006

Dear Mr. Senior:

This letter is being sent as a companion to our approval of Florida state plan amendment 14-006 which amends the Consumer Directed Care Option for individuals enrolled in the Traumatic Brain and Spinal Cord Injury (TBI/SCI) and the Aging and Disabled Adult (ADA) waivers. Participants from the ADA waiver were transitioned to the Managed Care Long-Term Care (MC-LTC) waiver program, and individuals enrolled in the TBI/SCI wavier will be offered the option to enroll in the MC-LTC program.

However, the CMS has the following concerns related to the waiver components of the SPA. They are as follows:

1. The state provided a copy of a notice sent to participants in the TBI/SCI waiver who were self-directing services through the CDC+ program, notifying them that they can choose a managed care plan and that CDC+ will not be offered by that plan or by the TBI/SCI waiver, effective March 1, 2014. If March 1 was the effective date of the change, the state is out of compliance with the current approved waiver, which still contains the option to self-direct services through the state’s 1915(j). Please confirm the date this letter was sent to participants, and confirm that March 1, 2014 was the effective date of the change. 2. An amendment removing the 1915(j) concurrent authority from the TBI/SCI waiver is required in addition to a 1915(j) SPA removing the population and the services. Such a change to the 1915(c) waiver is considered a substantive change, and requires that the state provide public notice as outlined in 42 CFR §441.304. In addition, the date for waiver amendments including substantive changes cannot be retroactive, and must have a prospective effective date. The 1915(j) and (c) will need to have the same effective date. 3. The state provided a crosswalk of services available for participant direction in the CDC+ program as compared to the services in the MC-LTC waiver. Only five services are

Mr. Justin Senior Page 2

available for participant direction in the MC-LTC waiver, which is considerably fewer than those available through CDC+. Please provide us with a list and description of the five services that are available for participant direction in MC-LTC. This represents a significant change to the scope and delivery of services available to these individuals. What form of notice was provided to consumers to indicate which services they would be able to continue to self-direct, and which they would not? Within 90 days of the date of this letter, the state is required to submit a waiver amendment that resolved the issues, or a corrective action plan to resolve the issues, whichever is appropriate. During the 90-day period, we are happy to provide any technical assistance that the state requires. State plans that are not in compliance with requirements referenced above are grounds for initiating a formal compliance process. If you have any questions or need any further assistance, please contact Etta Hawkins, R.Ph. at (404) 562-7429.

Sincerely,

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH CARE FINANCING ADMINISTRATION ‘OMB NO.0938.0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | !. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 2014-006 Florida

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4. PROPOSED EFFECTIVE DATE April 1, 2014

5. TYPE OF PLAN MATERIAL (Check One):

L] NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

[] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Section 1915(j) of the Social Security Act

7. FEDERAL BUDGET IMPACT: (in thousands) FFY 2013-2014 $ (1,860) FFY 2014-2015 _ $ (1,890)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Supplement 4 to Attachment 3.1-A, pages: 1-19 Attachment 4.19-B page 47

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

Supplement 4 to Attachment 3.1-A, pages: 1-21

Attachment 4.19-B page 47

10. SUBJECT OF AMENDMENT:

Self-Directed Care

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

&] OTHER, AS SPECIFIED: Reviewed by the Deputy Secretary for Medicaid who is the Governor’s designee.

12. SIGNATURE OF STATE AGENCY OFFICIAL: Isi/

13. TYPED NAME: Mr. Justin M. Senior

14. TITLE: Deputy Secretary for Medicaid

15. DATE SUBMITTED: 06-30-14

16. RETURN TO: Mr. Justin M. Senior Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Attention: April Cook

FORM HCFA-179 (07-92)

Supplement 4 to Attachment 3.1 -A Page | 1

Notwithstanding anything else in this State Plan provision, the coverage will be subject to such other requirements that are promulgated by CMS through interpretive issuance or final regulation.

State of _ Florida 1915(j) Self-Directed Personal Assistance Services State Plan Amendment Pre-Print

i. Eligibility The State determines eligibility for Self-Directed Personal Assistance Services:

A. __X_In the same manner as eligibility is determined for traditional State Plan personal care services, described in Item 24 of the Medicaid State Plan.

B. __X_In the same manner as eligibility is determined for services provided through a 1915(c) Home and Community-Based Services Waiver.

ii. Service Package

The State elects to have the following included as Self-Directed Personal Assistance Services:

A. __X__State Plan Personal Care and Related Services, to be self-directed by individuals eligible under the State Plan.

Only children under 21 years of age, enrolled in the Developmental Disabilities waiver(s) will be self-directing their State Plan personal care services.

B. __X___ Services included in the following section 1915(c) Home and Community- Based Services waiver(s) to be self-directed by individuals eligible under the waiver(s). The State assures that all services in the impacted waiver(s) will continue to be provided regardless of service delivery model. Please list waiver names and services to be included.

Service providers will be enrolled with the authorized state agency Fiscal Employer Agent (FEA) designated on behalf of the Consumer Directed Care Plus (CDC+). Providers must attest to the provision of services in order to receive payment for services. All providers must be at least 16 years of age and must satisfy the qualifications, requirements and applicable licensure for the service that is provided. Providers must also comply with the background screening requirements and provisions of the applicable Florida Statutes.

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Supplement 4 to Attachment 3.1 -A Page | 2

Individual Budgeting (iBudget) Waiver: Life Skills Development, Adult Dental Services, Behavior Analysis Services, Behavior Assistant Services, Personal Supports, Specialized Medical Equipment and Supplies, Dietitian Services, Environmental Accessibility Adaptations, Private Duty Nursing, Occupational Therapy, Personal Emergency Response System, Physical Therapy, Residential Habilitation, Respiratory Therapy, Respite, Skilled Nursing, Special Medical Home Care, Specialized Mental Health Counseling, Speech Therapy, Supported Living Coaching, Transportation, Family and Guardian Training, and Person-Centered Planning.

iii. Payment Methodology

A. __X__ The State will use the same payment methodology for individuals self-directing their PAS under section 1915(j) than that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services. The State uses the same payment methodology for individuals self-directing their State plan personal care services.

B. __X__ The State will use a different payment methodology for individuals self- directing their PAS under section 1915(j) than that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services. Amended Attachment 4.19-B page(s) are attached. The State uses a different payment methodology for individuals self-directing their section 1915(c) Home and Community- Based waiver services.

iv. Use of Cash

A. The State elects to disburse cash prospectively to participants self-directing personal assistance services. The State assures that all Internal Revenue Service (IRS) requirements regarding payroll/tax filing functions will be followed, including when participants perform the payroll/tax filing functions themselves.

B. _X___ The State elects not to disburse cash prospectively to participants self-

directing personal assistance services. v. Voluntary Disenrollment The State will provide the following safeguards in place to ensure continuity of services and assure participant health and welfare during the period of transition between self-

directed and traditional service delivery models.

A program consumer may elect to discontinue participation in the Consumer-Directed Care Plus (CDC+) program at any time.

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Supplement 4 to Attachment 3.1 —A Page |3 In the event disenrollment is requested, the consumer’s consultant completes a CDC+ Change Form to disenroll the consumer and forwards the form to program staff. All

disenrollments are effective the first day of the month following receipt of the disenrollment form.

Program staff notifies the Agency for Health Care Administration about all disenrollments. Upon disenrollment from CDC+ the consumer may access waiver services through traditional means.

The consumer’s consultant is responsible for ensuring the consumer has traditional waiver services in place to begin the first day of the month. Therefore, there will be no lapse in services.

vi. Involuntary Disenrollment

A. The circumstances under which a participant may be involuntarily disenrolled from self-directing personal assistance services, and returned to the traditional service delivery model are noted below. Consumers may be disenrolled by consultants and CDC+ program directors.

Reasons for involuntary disenrollment include:

Consumer moved out of state;

Temporary or permanent long-term care facility admission; Hospitalization for more than 30 consecutive days;

Loss of Medicaid eligibility;

Loss of waiver eligibility;

Representative not available if necessary for participation; Death of consumer;

Mismanagement of budget;

Consumer health or safety at risk;

Consumer can no longer be served safely in the community. Admission to a licensed facility (group home, ALF, etc.)

B. The State will provide the following safeguards in place to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional service delivery models.

In the event disenrollment is required, the consumer’s consultant completes a Consumer- Directed Care Plus (CDC+) Change Form to disenroll the consumer and forwards the form to program staff. All disenrollments are effective the first day of the month following receipt of the disenrollment form.

Program staff notifies the Agency for Health Care Administration about all disenrollment. Upon disenrollment from CDC+ the consumer may access waiver services through traditional means.

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Supplement 4 to Attachment 3.1 -A Page | 4

The consultant is responsible for ensuring the consumer has traditional waiver services in place to begin effective the first day of the month. Therefore, there will be no lapse in services.

vii. Participant Living Arrangement

Any additional restrictions on participant living arrangements, other than homes or property owned, operated, or controlled by a provider of services, not related by blood or marriage to the participant are noted below.

The 1915(c) iBudget waiver allows individuals to live in licensed facilities. Those individuals will not be allowed to participate in the CDC+ program based on this requirement.

viii.

A.

Geographic Limitations and Comparability

X___ The State elects to provide self-directed personal assistance services on a statewide basis.

The State elects to provide self-directed personal assistance services on a targeted geographic basis. Please describe:

The State elects to provide self-directed personal assistance services to all eligible populations.

X____ The State elects to provide self-directed personal assistance services to targeted populations. Please describe: Eligibility for the program is limited to individuals under 21 years of age enrolled in the iBudget Waiver.

__X___ The State elects to provide self-directed personal assistance services to an unlimited number of participants.

The State elects to provide self-directed personal assistance services to (insert number of) participants, at any given time.

ix. Assurances

A.

The State assures that there are traditional services, comparable in amount, duration, and scope, to self-directed personal assistance services.

The State assures that there are necessary safeguards in place to protect the health and welfare of individuals provided services under this State Plan Option, and to assure financial accountability for funds expended for self-directed personal assistance services.

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Supplement 4 to Attachment 3.1 —A

Page |5

C. The State assures that an evaluation will be performed of participants’ need for personal assistance services for individuals who meet the following requirements:

i. Are entitled to medical assistance for personal care services under the Medicaid State Plan; or

ii. Are entitled to and are receiving home and community-based services under a section 1915(c) waiver; or

iii. May require self-directed personal assistance services; or

iv. May be eligible for self-directed personal assistance services

TN No: 2014-006

Supersedes Approval Date: 09-26-14 Effective Date: 4/1/14 TN No: 2011-016

Supplement 4 to Attachment 3.1 -A Page | 6

D. The State assures that individuals are informed of all options for receiving self- Directed and/or traditional State Plan personal care services or personal assistance services provided under a section 1915(c) waiver, including information about self- direction opportunities that is sufficient to inform decision-making about the election of self-direction and provided on a timely basis to individuals or their representatives.

E. The State assures that individuals will be provided with a support system meeting the following criteria: i, Appropriately assesses and counsels individuals prior to enrollment: ii. Provides appropriate counseling, information, training, or assistance to ensure that participants are able to manage their services and budgets: iii. Offers additional counseling, information, training, or assistance, including financial management services: 1. At the request of the participant for any reason; or 2. When the State has determined the participant is not Effectively managing their services identified in their service plans or budgets.

F. The State assures that an annual report will be provided to CMS on the number of individuals served through this State Plan option and total expenditures on their behalf, in the aggregate.

G. The State assures that an evaluation will be provided to CMS every 3 years, describing the overall impact of this State Plan option on the health and welfare of participating individuals, compared to individuals not self-directing their personal assistance services.

H. The State assures that the provisions of section 1902(a)(27) of the Social Security Act, and Federal Regulations 42 CFR 431.107, governing provider agreements, are met.

I. The State assures that a service plan and service budget will be developed for each individual receiving self-directed PAS. These are developed based on the assessment of needs.

J. The State assures that the methodology used to establish service budgets will meet the following criteria: i. Objective and evidence based, utilizing valid, reliable cost data ii. Applied consistently to participants iii. | Open for public inspection

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iv.

vi.

Vii.

Viii.

ix.

xi.

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Includes a calculation of the expected cost of the self-directed PAS and supports if those services and supports were not self-directed.

Includes a process for any limits placed on self-directed services and supports and the basis/bases for the limits.

Includes any adjustments that will be allowed and the basis/bases for the adjustments.

Includes procedures to safeguard participants when the amount of the limit on services is insufficient to meet a participant’s needs.

Includes a method of notifying participants of the amount of any limit that applies to a participant’s self-directed PAS and supports.

Does not restrict access to other medically necessary care and services furnished under the plan and approved by the State but not included in the budget.

Service Plan

The State has the following safeguards in place, to permit entities providing other Medicaid State Plan services to be responsible for developing the self-directed personal assistance services service plan, to assure that the service provider’s influence on the planning process is fully disclosed to the participant and that procedures are in place to mitigate that influence.

Not applicable. Quality Assurance and Improvement Plan

The State’s quality assurance and improvement plan is described below, including

How it will conduct activities of discovery, remediation, and quality improvement in order to ascertain whether the program meets assurances, corrects shortcomings, and pursues opportunities for improvement; and

The State will conduct activities of discovery, remediation and quality improvement by using tools to collect data, take action and continuously improve the program. The tools developed for CDC+ fit into a complete quality management plan. These tools include: consumer satisfaction surveys, toll-free helpline, Person Centered Planning process (PCP) and the same follow-up instrument for each group, data reports, a Quality Advisory Committee, and monitoring of consultants and consumers.

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The Consumer Satisfaction Surveys will be distributed on a yearly basis. The surveys will be accompanied by a letter from the program director explaining its importance and that feedback is necessary for continuous program improvement. Confidentiality will be kept on the surveys, however there is an option to include the responders name and appropriate information if the responder feels necessary or would like to be contacted.

Discovery: The survey requests basic information regarding the consumer and respondent such as: the person filling out the survey (consumer or representative) and the city where the consumer resides. Location allows the program office to see how each area rates.

Remediation: Areas with low survey ratings or low submission to program offices will alert the program office to do necessary outreach or training in those particular areas. The performance indicators are listed in the survey. Performance indicators are goals that each program office found important for their particular consumer population. Performance Indicators are questions such as: 1) The training provided by my consultant included a complete user-friendly consumer notebook. 2) I am able to find qualified employees and/or vendors to provide my services. Consideration will be given to those answers in which the majority or a large portion of the consumer population is unhappy with a particular item. For example, if one consumer indicated that he/she is unhappy with the consumer notebook. However, the rest of the consumers were very happy with their notebooks. The program office might decide that changing the notebook in that situation would be unnecessary. The survey asks whether or not each performance indicator is important to the respondent as well as the respondent to rate how they feel about the answer to each question. The rating is a 5-point Likert scale ranging from 1-(Strongly Disagree) to 5-(Strongly Agree). There is also a box labeled “Not applicable” for those respondents who feel that question does not apply to them. Every performance indicator includes a comments/suggestion section. Respondents are asked to explain a rating of 3- (Neither Agree or Disagree) or less.

Quality Improvement: The surveys are compiled into a data system (such as excel) for reporting. The surveys are evolving documents, meaning if a significant percentage of the responders indicate a performance indicator is not appropriate or relevant, then the performance indicator may be removed or changed in the survey document. Also the program office will review performance indicators with a 3 or less that are not being met by 80% or more of the respondents for relevance and appropriateness. The State assures all CMS’ assurances listed in this application regarding consumer services, options and support system will be addressed in the survey.

The toll-free helpline is provided at the main program office for the Agency for Persons with Disabilities (APD). In addition, APD provides their consumers an e-mail address for questions; the e-mail is answered daily during normal business hours Monday through Friday from 8:00 A.M. until 5:00 P.M. Eastern Standard Time (EST) excluding holidays.

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Supplement 4 to Attachment 3.1 -A Page | 9

Discovery: The helpline enables consumers, representatives, consultants, members of the general public, etc. to call about anything from requesting general information, payment problem trouble-shooting, or making complaints. The e-mail addresses assists consumers with budget plan issues as well as timesheet and vendor invoice questions.

Remediation: Calls and emails into the helpline and e-mail addresses will be logged, researched and responded to within 48 business hours (Monday through Friday from 8:00 A.M. until 5:00 P.M. Eastern Standard Time [EST] excluding holidays). Resolution does not guarantee that the caller is satisfied with the response of the call but was given an answer to their question or issue.

Quality Improvement: Helpline and e-mail logs will be reviewed on a quarterly basis as part of ongoing quality assurance. The logs will describe the type of caller (consumers or consultants) and how quickly the call was answered or resolved. The logs will aid the program office in quality assurance enabling them to see what issues are facing the callers. For example, prospective consumers may call with reports of false information being distributed concerning the program. This type of information will allow the program office to provide outreach to the public, identify and refute misinformation as well as distribute correct information about the program. Consumers use the helpline and the consumer e- mail addresses to resolve payment issues, questions about budget/purchasing plans, and general program questions. The operating agency also has a current web-site with current information and forms for consumers. The operating agency tracks consumer issues by a “Notes” section on its database and records any issue regarding the consumer. That way any staff member can access a consumer file for current consumer information.

The Person Centered Planning (PCP) process will provide waiver support coordinators/consultants with information gathering tools and techniques that are critical to identifying the strengths, abilities, interests and personal goals of individuals with developmental disabilities on the iBudget waiver.

Discovery: The PCP process for the iBudget waiver allows consumers to list their needs and goals and define what services and supports will help them to satisfy their needs and reach their goals. For example a personal goal might be to spend more time with family and friends. The service they can use to reach that goal may include a certain frequency of homemaker hours once a week so the consumer can feel comfortable having visitors.

Remediation: These tools help the consumer decide what services and supports should be listed on their purchasing plan. The PCP process for the iBudget waiver is implemented when the consumer begins the program and at their yearly assessment. A follow-up instrument is completed at the semi-annual visit.

Quality Improvement: The follow-up instrument asks the consumers if their goals have been reached. Questions include: 1) Have you met Goal #1 listed on the PCP Tool? 2) Do you want to change any of your current goals? From this point, the consumer might decide their goals have changed. The follow-up instrument will be conducted no less than once a

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Supplement 4 to Attachment 3.1 -A Page | 10

year at the consumer’s annual reassessment. The follow-up instrument also incorporates a “mini-survey” from consumers concerning health, safety, and welfare, their service needs, and their feelings regarding the program. From the follow-up instrument, the program office can glean pertinent consumer issues for the annual consumer survey.

Consultant services for individuals with developmental disabilities will be provided by certified support coordinators trained to assume the consultant’s role and responsibilities. These certification and training requirements will help assure effective and competent consultants and preserve waiver consumers’ choice of consultant. Consultants are trained by Consumer-Directed Care Plus (CDC+) program staff in the overall philosophy of self- direction and specifically in the operations of the CDC+ program. To provide services to CDC+ consumers, consultants are required to be Medicaid waiver service providers for consultant services only. Consultants cannot serve as the consumer’s representative. Consultants who are not certified case managers/support coordinators will be considered for enroliment on a case-by-case basis and the Agency for Health Care Administration (AHCA) has the final approval authority. Approval will be granted to those individuals who have a valid provider agreement with the Medicaid agency and who must meet the same training and certification provider requirements as those on the iBudget 1915(c) Home and Community-Based Services (HCBS) waiver.

Discovery: Consultant monitoring will include desk reviews and individual participant interviews. Desk reviews will be conducted on a quarterly basis to a random sampling of no less than 10% of all consultants. For consultants serving five or more CDC+ consumers, the desk reviews will include monitoring the consultant file for at least five randomly selected consumers. For consultants serving less than five CDC+ consumers, two files shall be reviewed. The file must include all necessary documentation for that consumer.

Documentation includes items such as: annual Medicaid eligibility determination and a completed and signed Person Centered Planning (PCP) process for the iBudget waiver. The consultant must have monthly contact with the consumer and visit the consumer in their home or community activity no less than once per six-month period. Monthly contact may be in the form of phone calls or in person, whichever is the preferred method of the consumer. Documentation of home visits and monthly contact must be in the consultant files for each consumer.

There is a Monthly Contact Review Form that must be completed by the consultant and includes topics such as: 1) Reviewed Monthly Budget Statement with the consumer and services are purchased along with purchasing plan. 2) Change in service needs due to change in circumstances.

Remediation: The consultant receives a copy of the consumer’s Monthly Budget Net Worth Statement from APD for the iBudget consumers. If the consumer is not making purchases in accordance with his/her approved budget/purchasing plan, the consultant must complete a Corrective Action Plan (CAP) with the consumer. Consumers must sign that they

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Supplement 4 to Attachment 3.1 -A Page | 11

understand the implications of the CAP as well following the required action. The CAP must be implemented immediately and all purchases should reflect the CAP by the next monthly consultant review. If the consumer’s purchases are still outside the guidelines of CDC-+ and/or the budget/ purchasing plan after 60 days, then the consumer will be disenrolled from the program and returned to the traditional 1915(c) HCBS waiver.

Quality Improvement: At the semi-annual home visit, the consultant must look for indicators of fraud, abuse, neglect or exploitation and must report any findings to the proper authorities within 24 hours of the visit. Failure of the consultant to perform the monitoring duties will terminate the consultant from providing services on the CDC+ program. The program office will immediately assist the consumer in locating a new, local consultant. The operating program office (APD) has a contingency plan for consultant deficiencies. The State assures that all of Centers for Medicare and Medicaid Services (CMS) assurances listed in this application regarding participant safeguards, participant eligibility and budget development will be addressed in the monitoring of consultants.

The Quality Advisory Committee (QAC) is comprised of key program stakeholders. . The QAC will serve in an advisory capacity on behalf of APD.

Discovery: All reporting data is shared with the QAC. Along with reviewing data, the QAC will also look at other ways to improve the program and make suggestions to the program offices. The QAC meets on a quarterly basis. The QAC may include consumers, program staff, consultants, consumer-representatives, care-givers, Area Office staff, (AHCA) external reviewers (if applicable), and community advocates. APD will recommend members to the QAC as appropriate, and AHCA will serve as the approval authority.

Remediation: The QAC will consist of a maximum of six members. All members are trained in expectations, roles and responsibilities, federal and state laws and program policies and procedures.

Quality Improvement: The QAC also reviews the Program Self-Assessment (PSA). The QAC will identify and advise the program office of the areas in which the program should improve itself and will aid in setting the priorities for improvement. The QAC reviews all program policies, consultant and consumer brochures and training materials.

The program office is also charged in completing a PSA that assesses the program structure and policies to see if the program is meeting the performance indicators. The PSA is developed using the guidelines created by SCRIPPS' in the Guide to Quality in Consumer Directed Services.

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Discovery: The PSA is developed by the program office in assistance with the QAC. The final document must be approved by AHCA. The PSA asks the program office to evaluate itself with statements such as:

1) Consumers, family members and advocates help design, develop, operate and evaluate the program.

2) Can consumers determine which services to use and can they select, hire and dismiss their workers? The main purpose of the PSA is to assist the program office in identifying program goals, having a plan to meet the goals, ensuring the goals are met and aiding the program office in re-assessing itself in an ongoing capacity. The PSA also alerts the program office of unmet goals or issues that the program office might need to address so the program office continues to excel in its efforts.

Remediation: The APD Program Office will work with the QAC on identifying performance indicators to list in the PSA. Performance Indicators will be identified from areas that are listed by the consumer in the satisfaction surveys and areas to be improved upon in consultant training gathered from the monitoring reports, etc.

Quality Improvement: The QAC reviews the PSA and helps the program office to determine what areas the program office is lacking and the priorities for correcting any deficiencies. The QAC also aids the program office in identifying program improvements needed by the program offices. During the QAC meeting, the program office is responsible for updating the QAC on steps taken to meet requirements of the PSA and any future activities related to program improvement.

VII. APD requires monthly bank reconciliation reports from its subagent to balance consumer accounts. The requirement for the monthly bank reconciliation is listed in the contract between APD and its subagent.

Discovery: APD submits Monthly Budget Reports to the consumer, consultant, and program office and keeps a helpline log for calls to their helpline. APD will review Monthly Budget Statements before they are sent out.

Remediation: APD requires copies of all state and federal filing completed by the subagent.

Quality Improvement: The State assures that all of Centers for Medicare and Medicaid Services (CMS) assurances listed in this application regarding provider agreements will be met by the subagent for APD.

i. The system performance measures, outcome measures, and satisfaction measures that the State will monitor and evaluate.

Below is a list of the system performance measures, outcome measures and satisfaction measures of all aspects of the Consumer-Directed Care Plus (CDC+) program. Please note that the measures are evolving as they are based on performance indicators for the program.

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System Performance Measures: All of the following reports/measures will be compiled from the program office database.

e The program office will submit an annual report to Agency for Health Care Administration (AHCA), which will demonstrate: client demographic data and a statement of future goals and activities. It will include detailed financial data, reports on performance measures and relevant facts about program operations. Among the data reporting is enrollment and disenrollment information and per member cost expenditures.

— This report will help the program office to establish a baseline for performance indicators and to enhance or modify those indicators as necessary.

e The program office will submit a quarterly evidence report to AHCA with monitoring efforts and results. Also included will be actions taken/proposed to address deficiencies. All monitoring must address CMS assurances.

— This report will allow AHCA to monitor program office performance and activities and to provide feedback to the program office.

e The yearly Program Self-Assessment (PSA) will be delivered to the Quality Advisory Committee (QAC) and the program office must be in compliance with the performance indicators for the program. If the program office is not in compliance, they must work on program improvement activities with the QAC.

— This will allow the program office with the assistance of the QAC to monitor program progress as well as modify performance indicators as necessary.

e All consultants must use an incident reporting system as specified in the traditional 1915(c) Home and Community-Based Services (HCBS) waiver and all incident information must be reported to the program office. The incident information will be compiled and included with the annual report to Agency for Health Care Administration (AHCA). The incidents will be logged by type of incident and must include appropriate action taken to remedy the situation. — This will aid in monitoring of incident reporting and follow-up as well as possible

discovery of abuse or neglect.

e The subagent for APD will maintain a current Medicaid Provider Agreement.

— This is required in the assurances.

e APD maintains a Government Policies and Procedures Manual which reflects all requirements described in the subagent's Medicaid Provider Agreement and contract. The manual includes policies, procedures and internal controls for all operations tasks. The manual also includes a policy and procedure for staying up-to-date with all federal and state requirements and for updating the manual at least annually and as needed. ~— The manual acts as the "blueprint" for government FEA operations, is a training tool for

new government FEA staff and is a key component of a quality management system.

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Supplement 4 to Attachment 3.1 —A Page | 14

e APD will implement a helpline call log.

— This aids in monitoring so the program office is made aware of what types of complaints or questions are called in to the APD.

The Outcome Measures listed below are taken from the PCP process for the iBudget waiver and follow-up instrument; there are also quarterly monitoring items:

e The PCP process for the iBudget waiver must be completed before a consumer completes their first budget/purchasing plan.

— This aids the consumer in identifying their goals and needs in order to input the services and supplies which will help them to complete their goals.

e Each consumer will need to list their personal goals and identify which services or supports will help them to reach those goals.

— This will help the consumer to identify and achieve their goals. For example: Goal #1 might be to live in their own home and remain as independent as possible. In order to reach that goal, the consumer might need to hire someone during the week days to provide personal assistance.

e The follow-up instrument will be conducted at least every six months.

— This will aid the consumer in determining if their goals are being met.

e The consumer will also be able to identify if they need to modify their goals at their bi- annual follow-up. All consumers must be able to request a change to their service plan based on a change in needs or health status. Service plans must be reviewed annually, or whenever necessary due to a change in a consumer's needs or health status.

— This will allow the consumer to identify new goals or change current goals and identify the services and supports that will meet the new goals and include them on their purchasing plan, removing any services or supports that are no longer necessary.

e The consultant file must include the annual Medicaid eligibility document for each consumer. This helps to assure the State that there are not ongoing issues with consumers being ineligible for Medicaid because of a missed meeting or other situation that could have been taken care of by completing a document or attending a meeting.

— This will aid the program office in ensuring all consumers retain their Medicaid eligibility and all consultants are tracking annual Medicaid meetings for their consumers.

e Every consultant must maintain a signed consent form. The form must be either signed by the consumer or representative, if applicable. The consent form will serve as verification that the consumer is responsible for directing their own care and fully understands the program.

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~ This will aid the State to ensure all consumers understand and consent to participate in this program.

The following Satisfaction Measures are taken from the Consumer Satisfaction Survey:

e The Budget/Purchasing Plan had clear instructions on how to complete.

— The program office will verify information and instructions distributed to consumers are user-friendly. At least 80% of the consumers must agree that program materials are user- friendly. All results from the Satisfaction Survey will be given to the Quality Advisory Committee (QAC). The QAC will help determine the priorities for the performance indicators in which the State will need to meet. If the State is falling behind expectations on the performance indicators, the QAC will help determine how to correct or improve the processes.

e Payments for consumers’ invoices and timesheets must be made in a timely manner. — This will inform the program office if the subagent is performing its duties and in a timely manner. If not, the program office will need to discuss a corrective action plan with the subagent.

e Payment issues were responded to within 48 business hours. — While a response is expected within 48 business hours (a response could include situations in which the issue is still being researched), 90% of issues should be resolved within 72 business hours.

e The consumer’s net worth/monthly statement must be received every month.

— This will aid the program office in determining if consumers are indeed receiving their statements. Statements must be received in order for the consumers to reconcile their balances monthly. Also consumers use their statements to ensure their purchases are accurately reflected.

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Supplement 4 to Attachment 3.1 -A Page | 16 Risk Management

A. The risk assessment methods used to identify potential risks to participants are described below.

Potential risks to the consumer are assessed during the service development process. Strategies to mitigate risk are incorporated into the budget/purchasing plan, subject to consumer needs and preferences. The budget/purchasing plan development process addresses emergency backup plans. Each consumer is screened for capacity to direct their own care and required to identify a representative if indicated.

B. The tools or instruments used to mitigate identified risks are described below.

I. Criminal Background Checks are mandatory for all employees, even family members. Criminal Background Checks are mandated by state law. The Criminal Background Checks are performed at no cost to the consumer but are to be paid by the employee. All individuals who will be rendering care to a consumer enrolled in this program must either:

e Bea Medicaid enrolled provider who received background screening at the time of their enrollment into the Medicaid program ( and who remains in good standing with the Medicaid program); or

e Pass a background screening; or

e Provide proof of a State of Florida and/or a Federal background screening completed within six-months prior to employment, the outcome of which was a finding of no disqualifying offenses.

II. | Each Consumer-Directed Care Plus (CDC+) consumer is required to develop an emergency back-up plan before starting to manage a budget on CDC+. The emergency backup plan should describe the alternative services delivery methods that will be used under any of the following circumstances: 1) if the primary employees fail to report to work or otherwise cannot perform the job at the time and place required, 2)if the consumer experiences a personal emergency, or 3) if there is a community-wide emergency(e.g., requiring evacuation). The personal emergency portion of the emergency back-up plan will allow the participant to identify circumstances that would cause an emergency for him/her based upon his/her unique needs. The emergency back-up plan must also address ways to assure that the needs of the individual are met should an unexpected shortage of funds occur.

Ill. The Consumer/Representative Agreement is a written agreement between a consumer and the consumer’s representative that sets forth the CDC+ responsibilities of the representative. All consumers have the option of choosing one individual to act as a representative (friend, caregiver, family member or other person, etc.) to assume budget and care management responsibilities. Representatives may not work for the consumer

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Supplement 4 to Attachment 3.1 —A Page | 17

or be paid by the consumer. Consumers may also receive assistance with their CDC+ responsibilities without appointing a representative; however these individuals cannot sign documents, speak for or otherwise act on behalf of the consumer.

IV. The monthly monitoring of consumers by consultants will be used to assess for risks to the consumer. The consultant will monitor both the consumer's monthly budget to assess the consumer's spending and service utilization in comparison with the purchasing plan and the consultant will also assess the consumer's risk for abuse, neglect or exploitation at the semi-annual home visits.

C. The State's process for ensuring that each service plan reflects the risks that an individual is willing and able to assume, and the plan for how identified risks will be mitigated, is described below.

Prior to enrollment in the CDC+ program, each consumer will receive a Home and Community- Based Waiver care/support plan based on an assessment of need that includes an identification of risks and potential mitigation strategies. All consumers in CDC+ must take part in an initial training prior to the development of the budget/purchasing plan. In this training, the consumer is given lists of roles and responsibilities, which provides a detailed description of the roles and responsibilities of the consumer in the program including a detailed description of the roles, responsibilities and support functions of the consultant, and APD staff. This document will be thoroughly reviewed with the consumer and/or the representative to ensure that there is a clear understanding of the responsibilities related to the health and safety and mitigation risks to be assumed by the consumer. The consumer will list all identified risks in the emergency back-up plan including the plan that each individual consumer will use in the case of an emergency. The consumer/representative will develop a purchasing plan to specify how the monthly budget will be used to meet the consumer's care needs, and how other identified needs might be met through generic, community supports, and Medicaid State plan services. Risks will be documented and updated at the consumer's semi-annual home visit or more frequently if needed.

D. The State's process for ensuring that the risk management plan is the result of discussion and negotiation among the persons designated by the State to develop the service plan, the participant, the participant's representative, if any, and others from whom the participant may seek guidance, is described below.

The consumer/representative is responsible for developing their own budget/purchasing plan to show how their budget will be spent each month. In that plan, the consumer will identify the risks that were discussed with the consultant during their initial and semi-annual monitoring assessment.

The consumer must identify and manage their personal emergency back-up plan/risk mitigation strategy in their PGS tool. Consultants will provide support and technical assistance in order to facilitate the development of the budget/purchasing plan by the consumer/representative.

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Consultants will not assume responsibility for developing the budget/purchasing plan, but will review and approve the plan to ensure that proposed services are adequate, purchases are cost- effective and related to the consumer's needs, and that an emergency back-up plan is in place. The consultant reviews the proposed budget/purchasing plan with the consumer/representative and others identified by the consumer as a method to assess the consumer/representative's ability to assume service management responsibilities and to further generate discussion around risk management.

ii. Qualifications of Providers of Personal Assistance

E.__X__The State elects to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget.

F. The State elects not to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget.

ili, | Use of a Representative

G.__X_ The State elects to permit participants to appoint a representative to direct the provision of self-directed personal assistance services on their behalf.

i. The State elects to include, as a type of representative, a State mandated representative. Please indicate the criteria to be applied.

H. The State elects not to permit participants to appoint a representative to direct the provision of self-directed personal assistance services on their behalf.

iv. Permissible Purchases

I.__X__The State elects to permit participants to use their service budgets to pay for items that increase a participant's independence or substitute for a participant's dependence on human assistance.

J. The State elects not to permit participants to use their service budgets to pay for items that increase a participant's independence or substitute for a participant's dependence on human assistance.

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xvi. Financial Management Services

A. The State elects to employ a Financial Management Entity to provide financial management services to participants self-directing personal assistance services, with the

exception of those participants utilizing the cash option and performing those functions themselves.

i. __ X_ The State elects to provide financial management services through a reporting or subagent through its fiscal intermediary in accordance with section 3504 of the IRS Code and Revenue Procedure 80-4 and Notice 2003-70; or

ii. _____ The State elects to provide financial management services through vendor organizations that have the capabilities to perform the required tasks in accordance with section 3504 of the IRS Code and Revenue Procedure 70-6. (When private entities furnish financial management services, the procurement method must meet the requirements set forth Federal regulations in 45 CFR section 74.40 — section 74.48.)

iii. The State elects to provide financial management services using “agency with choice” organizations that have the capabilities to perform the required tasks

in accordance with the principles of self-direction and with Federal and State Medicaid rules.

B. __X__ The State elects to directly perform financial management services on behalf of participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves.

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Supersedes Approval Date: 09-26-14 Effective Date: 4/1/14 TN No: 2011-019

Attachment 4.19-B Page 47

19154) SELF-DIRECTION METHODOLOGY

DEVELOPMENTAL DISABLED WHO HAVE THE OPTION TO REMAIN IN THE STATE PLAN SELF-DIRECTION METHODOLOGY

Florida’s methodology for determining the consumer’s budget is based on the assessment of needs and the development of the service plan. The cost of providing the services included in the service plan is calculated based on the expected reimbursement for services listed on page 2 of Supplement 4 to Attachment 3.1-A under the 1915(c) waiver and the expected reimbursement for the cost of State Plan personal care services. It is adjusted to account for the self-directed service delivery model. Based on historical utilization patterns and differences in set-up and oversight, the State will use an adjustment factor of 87.25% of the expected waiver/State Plan service reimbursement to calculate the consumer’s service budget for self-directed personal assistance services.

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Table of Contents

State/Territory Name: Florida State Plan Amendment (SPA) #:15-0002 This file contains the following documents in the order listed:

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF M EDICAID & CHILDREN’S HEALTH OPERATIONS

May 11, 2015

Mr. Justin Senior Deputy Secretary for Medicaid 2727 Mahan Drive, MS#8 Tallahassee, Florida 32308

Attention: April Cook

RE: Title XIX State Plan Amendment (SPA) 15-0002

Dear Mr. Senior:

Enclosed is an approved copy of Florida’s state plan amendment (SPA) 15-0002, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 23, 2015. SPA 15-0002 approves the state recognition of same-sex couples as spouses if they are legally married under the laws of the state, territory or foreign jurisdiction in which the marriage was performed. The state will only make a determination regarding marital status when completing a determination of income in order to determine Medicaid eligibility. This amendment also indicates that the recognition of same-sex marriages apply when determining post-eligibility income, spousal impoverishment, asset transfers and estate recovery, as permitted by law. This SPA was approved on May 7, 2015. The effective date of the SPA is January 6, 2015.

We are enclosing the HCFA-179 and the approved plan pages. Please incorporate the approved plan pages within a separate section at the end of Florida’s approved state plan.

If you have any questions, please contact Etta Hawkins at (404) 562-7429 or Etta.Hawkins@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

FL.1658.R00.00 - Jan 06, 2015 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Florida Transmittal Number:

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

FL-15-0002

Proposed Effective Date 01/06/2015 (mm/dd/yyyy)

Federal Statute/Regulation Citation 1902(e)(14)(G) and 1902(a)(17)

Federal Budget Impact

Federal Fiscal Year Amount First Year 2015 $0.00 Second Year 2016 $0.00

Subject of Amendment

Medicaid Eligibility Marriage Policy recognizing same sex couples in the State of Florida if they are legally married under the laws of the state or territory in which they were married.

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

> Other, as specified Describe: Reviewed by the Deputy Secretary for Medicaid, who is the Governor's designee.

Signature of State Agency Official

Submitted By: April Cook Last Revision Date: Apr 16, 2015 Submit Date: Mar 23, 2015

https://wms-mmdl.cdsvde.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 05/08/2015

ccms Medicaid Eligibility

State Name:|Florida | FL - 15-0002 OMB Control Number: 0938-1148

Transmittal Numb

1902(e)(14)(G) 1902(a)(17)

i With respect to individuals for whom the state must complete a determination of income either based on MAGI or for MAGI- excepted groups utilizing AFDC-related or SSI-related methodologies, the state:

@ Recognizes same-sex couples as spouses, if they are legally married under the laws of the state, territory, or foreign jurisdiction in which the marriage was celebrated.

C Does not recognize same-sex couples as spouses, even if they were legally married in a state, territory, or foreign jurisdiction that recognizes same-sex marriages.

With respect to individuals whose eligibility for Medicaid is based on eligibility for another benefit program, and for whom the [mi] state does not complete a determination of income for Medicaid eligibility, the state will not make any determination concerning marital status. Medicaid eligibility will continue to be based on the determination of eligibility for the applicable benefits.

The option elected above, with respect to income determinations, also governs the state’s definition for post-eligibility issues, including spousal impoverishment, asset transfers and estate recovery rules, to the degree permitted by state law.

Ly]

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 | hour 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.20141021

TN No.: 15-0002 Approval Date: 05/07/15 Effective date: 01/06/15 Florida $12

Table of Contents State/Territory Name: Florida State Plan Amendment (SPA) #: 19-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures Financial Management Group April 20, 2021 Beth Kidder Deputy Secretary for Medicaid Agency for health Care Administration 2727 Mahan Drive MS #8 Tallahassee, FL 32308 RE: Florida State Plan Amendment 19-0003 Dear Ms. Kidder: We have reviewed the proposed amendment to your state plan submitted on November 13, 2019. The amendment includes the Practitioner Reimbursement Methodology for services outlined within the State Plan. Based upon the information provided by the State, we have approved the amendment with an effective date of December 1, 2019. We are enclosing the approved CMS-179 (HCFA-179) and a copy of the new table of contents and exhibit pages. If you have any additional questions or need further assistance, please contact Moe Wolf at 410-786-9291 or Moshe.Wolf@CMS.HHS.gov.

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 2019-003 Florida 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: HEALTH CARE FINANCING ADMINISTRATION rep eee aay ay | TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION December 1, 2019

| DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One):

(NEW STATE PLAN ______ [AMENDMENT TO BE CONSIDERED AS NEW PLAN __ [RX] AMENDMENT ___________— COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: | 7. FEDERAL BUDGET IMPACT: (in thousands)

42 CFR 447.201 FFY 2020 $0

a _ | FFY 2021 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 4.19-B Exhibit II OR ATTACHMENT (ff Applicable): New

Table of contents pages for Attachment 4. 19-B pages 1 and la. }) Atiacl 4. 19-B pages 12, 13, 24, 26, 27, 28, 30, and 45

10. SUBJECT OF AMENDMENT: Practitioner Reimbursement Methodology

11. GOVERNOR’S REVIEW (Check One):

(] GOVERNOR’S OFFICE REPORTED NO COMMENT {] OTHER, AS SPECIFIED: [_] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Reviewed by the Deputy Secretary for Medicaid | (J NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL who is the Governor’s designee. Y OFFICIAL: 16. RETURN TO: 7 Ms. Beth Kidder Deputy Secretary for Medicaid Agency for Health Care Administration : 2727 Mahan Drive, Mail Stop #8 . " nan Tallahassee, FL 32308 |____ Deputy Secretary for Medicaid 2... 15. DATE SUBMITTED: oe sat November 13, 2019 pe ed | FOR REGIONAL OFFICE USE ONLY | 17. DATE RECEIVED: 18, DATE APPROVED: November 13, 2019 April 20, 2021 | PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE December 1, 2019 21. TYPED NAME: Todd McMillion 22. TITLE: Direct vice 23. REMARKS:

Pen & ink changes authorized by state via email: Box 8: added "Table of contents pages for Attachment 4. 19-B pages 1 and la. "

Box 9: added "Attachment 4. 19-B pages 12, 13, 24, 26, 27, 28, 30, and 45 " via technical correction, and "New"

FORM HCFA-179 (07-92)

Attachment 4.19-B STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF FLORIDA 1 Amendment: 2019-0003 Effective: 12/1/2019 Supersedes: 2017-013 Approval:

PAYMENT FOR SERVICES Table of Contents Pages 1. Contents 1a. Contents (Continued) 2. Emergency Service 3. Rehabilitative Services 3a. Personal Care/Assistive Care Services 3b. Community-Based-Substance Abuse Services 3c. Personal Care Services: Prescribed Pediatric Extended Care (PPEC) 3.1 Early Intervention Services 3.2 School Based Therapy Services 3.3 School Based Psychological Services 3.4 School Based Social Work Services 3.5 School Based Nursing Services 3.6 School Based Nursing Services by County Health Departments 3.7 School based Behavioral Services by County Health Departments 4. Prescribed Drugs 4a. Prescribed Drugs (Continued) 4b. Preventive Services 4c. Preventive Services for Pregnant Women 5. Rural Health Clinic Services 6. Outpatient Hospital Services 7. Hospice Care Services 7a. Obstetrics/Pediatrics 8. Payment of Pediatric Services 8a. Immunization Injection 8b. Immunization Injection (Continued) 9. Immunization Injection (Continued) 10. Established Patient 11. Adequacy of Access (Pediatrics) 14. Abortion/Diagnostic Ultrasound 15. Adequacy of Access (Obstetrics) 16. HMO Obstetrical and Pediatric Coverage and Capitation Rates 17. HMO Obstetrical and Pediatric Coverage and Capitation Rates (Continued) 17a. HMO Obstetrical and Pediatric Coverage and Capitation Rates (Continued) 17b. HMO Obstetrical and Pediatric Coverage and Capitation Rates (Continued) 18. Florida’s Medicaid Areas/Counties 19. Maximum Payment Rates for Listed Obstetrical Services for Physicians 20. Maximum Payment Rates for Listed Obstetrical Services for Physicians (Continued) 20a. Maximum Payment Rates for Listed ARNP Obstetrical Services 21. (Reserved) 22. (Reserved) 23. (Reserved) 25. EPSDT Services 28. Individual Practitioners Services (Physicians, Chiropractors, Dentists, Osteopathy, Optometry) 28a. Medical School Faculty Reimbursement Methodology 31. Christian Science Sanatoria Services 4/20/21

Attachment 4.19-B STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF FLORIDA PAYMENT OF SERVICES Table of Contents Pages (Continued) 1a Amendment: 2019-003 Effective: 12/1/19 Supersedes: 2017-013 Approval:

32. Home Health Services 32a. Home Health Aides 33. Clinic Services: Birthing Centers 33a. Clinic Services: Ambulatory Surgical Centers 33c. Clinic Services: Freestanding Dialysis Center Services 34. Transportation 34a-f Certified Public Expenditure Program for Emergency Transportation 35. Emergency Services to Aliens 36. Federally Qualified Health Center Services 37. Case Management Services 38. (Blank) 39. Respiratory Services 40. Personal Care Services 41. Private Duty Nursing 42. Therapies 43. Durable Medical Equipment including Prosthetic Devices and Orthotics 44. Inpatient Psychiatric Services for Individuals under 21 46. Dental Services 47. 1915(j) Self Directions Methodology 48. Cancer Hospitals Reimbursement Methodology Supplement I: Payment of Medicare Parts A, B and C Deductibles and Coinsurance Supplement II: FQHC Reimbursement Plan Supplement III: County Health Department Reimbursement Plan Exhibit I: Outpatient Hospital Reimbursement Plan Exhibit II: Practitioner Reimbursement Methodology 4/20/21

Page 1 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ FLORIDA TITLE XIX PRACTIOTIONER REIMBURSEMENT METHODOLOGY VERSION I EFFECTIVE DATE: December 1, 2019 I. Practitioner Reimbursement Methodology This section defines the Agency for Health Care Administration’s (Agency’s) practitioner reimbursement methodology utilizing a Resource-Based Relative Value Scale (RBRVS). The methodology applies to all practitioners rendering the below services to eligible Florida Medicaid recipients in the fee-for-service delivery system: A. Allergy services as listed in Attachment 3.1-A coverage pages. B. Anesthesia services as listed in Attachment 3.1-A coverage pages. C. Cardiovascular services as listed in Attachment 3.1-A coverage pages. D. Chiropractic services as listed in Attachment 3.1-A coverage pages. E. Evaluation and Management services as listed in Attachment 3.1-A coverage pages. F. Gastrointestinal services as listed in Attachment 3.1-A coverage pages. G. Genitourinary services as listed in Attachment 3.1-A coverage pages. H. Hearing services as listed in Attachment 3.1-A coverage pages. I. Integumentary services as listed in Attachment 3.1-A coverage pages. J. Laboratory services as listed in Attachment 3.1-A coverage pages. K. Neurology services as listed in Attachment 3.1-A coverage pages. L. Oral and Maxillofacial services as listed on Attachment 3.1-A coverage pages. M. Orthopedic services as listed in Attachment 3.1-A coverage pages. N. Pain Management services as listed in Attachment 3.1-A coverage pages. O. Podiatry services as listed on Attachment 3.1-A coverage pages. P. Radiology and Nuclear Medicine services as listed on Attachment 3.1-A coverage pages. 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 2 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ Q. Reproductive services as listed on Attachment 3.1-A coverage pages. R. Transplant services as listed in Attachment 3.1-A coverage pages. S. Visual Aid services as listed on Attachment 3.1-A coverage pages. T. Visual Care services as listed on Attachment 3.1-A coverage pages. Except as otherwise noted in the plan, State-developed fee schedule rates are the same for both governmental and private providers for Practitioners. The Agency’s fee schedule rate was set as of December 1, 2019 and is effective for services provided on or after that date. All rates are published on the Agency’s website under “Rule 59G-4.002, Provider Reimbursement Schedules and Billing Codes”. II. Calculations This section defines the methods used by the Florida Medicaid Program for the calculations used in the practitioner reimbursement methodology. A. A physician shall be reimbursed the lesser of the amount billed by the provider or the Medicaid maximum allowable fee established by the Agency. B. Relative Value Units (RVUs) - The Agency adopts Medicare’s Relative Value Units (RVUs). There are three components of the RVU, which include (1) Work RVU, (2) Facility Practice Expense (FAC PE RVU) or Non-Facility Practice Expense (NON FAC PE RVU), and (3) Malpractice RVU. Standard calculations include: 𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑅𝑅𝑅𝑅𝑅𝑅= 𝑊𝑊𝑊𝑊𝑊𝑊𝑊𝑊 𝑅𝑅𝑅𝑅𝑅𝑅+ 𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝑙𝑙𝑖𝑖𝑖𝑖𝑖𝑖 𝑃𝑃𝑃𝑃 𝑅𝑅𝑅𝑅𝑅𝑅+ 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝑅𝑅𝑅𝑅𝑅𝑅 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑅𝑅𝑅𝑅𝑅𝑅= 𝑊𝑊𝑊𝑊𝑊𝑊𝑊𝑊 𝑅𝑅𝑅𝑅𝑅𝑅+ 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃 𝑅𝑅𝑅𝑅𝑅𝑅+ 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝑅𝑅𝑅𝑅𝑅𝑅 𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑇𝑇𝑇𝑇 𝑅𝑅𝑅𝑅𝑅𝑅= 𝑊𝑊𝑊𝑊𝑊𝑊𝑊𝑊 𝑇𝑇𝑇𝑇 𝑅𝑅𝑅𝑅𝑅𝑅+ 𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃 𝑇𝑇𝑇𝑇 𝑅𝑅𝑅𝑅𝑅𝑅+ 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑟𝑟𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎 𝑇𝑇𝑇𝑇 𝑅𝑅𝑅𝑅𝑅𝑅 𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃 𝑅𝑅𝑅𝑅𝑅𝑅= 𝑊𝑊𝑊𝑊𝑊𝑊𝑊𝑊 𝑃𝑃𝑃𝑃 𝑅𝑅𝑅𝑅𝑅𝑅+ 𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃 𝑅𝑅𝑅𝑅𝑅𝑅+ 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝑃𝑃𝑃𝑃 𝑅𝑅𝑅𝑅𝑅𝑅 C. Rates for services that have Medicare defined RVUs, rates are set utilizing the below calculations. Non-Facility Rate: 𝐹𝐹𝐹𝐹𝐹𝐹= 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺ℎ𝑖𝑖𝑖𝑖 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼 𝑜𝑜𝑜𝑜 1 ∙ 𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑅𝑅𝑅𝑅𝑅𝑅 ∙𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝐹𝐹𝐹𝐹𝐹𝐹 𝑆𝑆𝑆𝑆ℎ𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼= 𝐹𝐹𝐹𝐹𝐹𝐹 ∙1.04 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 3 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ When service is defined by Medicare to include a Technical Component (TC) and Professional Component (PC): 𝑇𝑇𝑇𝑇= 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺 𝑜𝑜𝑜𝑜 1 ∙𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑇𝑇𝑇𝑇 𝑅𝑅𝑅𝑅𝑅𝑅 ∙𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑇𝑇𝑇𝑇𝑇𝑇ℎ𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑛𝑛𝑡𝑡 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼= 𝑇𝑇𝑇𝑇 ∙1.04 𝑃𝑃𝑃𝑃= 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺 𝑜𝑜𝑜𝑜 1 ∙𝑁𝑁𝑁𝑁𝑁𝑁 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃 𝑅𝑅𝑅𝑅𝑅𝑅 ∙𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼= 𝑃𝑃𝑃𝑃 ∙1.04 Facility Rate: 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝐹𝐹𝑒𝑒𝑒𝑒= 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐺𝐺𝐺𝐺𝐺𝐺𝐺𝐺 𝑜𝑜𝑜𝑜 1 ∙𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝑅𝑅𝑅𝑅𝑅𝑅 ∙𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹𝐹 𝐹𝐹𝐹𝐹𝐹𝐹 𝑆𝑆𝑆𝑆ℎ𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼= 𝐹𝐹𝐹𝐹𝐹𝐹 ∙1.04 D. Rates for services that do not have Medicare defined RVUs rates are set utilizing the below calculations. (a) Medicare First Coast Services Options (FCSO), Inc. Local Rate Calculations FCSO rates are reviewed among the three Florida locales: 03, 04 and 99. When applicable, an available rate may correspond to an FS, TC, PC and/or Facility rate determined based on the corresponding modifier. Each available local rate is then calculated based on a weighted average basis. The weighted averages are calculated based on the population of each Florida locale: 𝐴𝐴= 𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿 03 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐵𝐵= 𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿 04 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐶𝐶= 𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿 99 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐹𝐹𝐹𝐹 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 Local Rate Weight 03 Rate = R03 A 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 4 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ The weighted average rate, when all three locales are available: 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹𝐹𝐹 𝑆𝑆𝑆𝑆ℎ𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅= (𝑅𝑅03 𝐹𝐹𝐹𝐹 ∙𝐴𝐴) + (𝑅𝑅04 𝐹𝐹𝐹𝐹 ∙𝐵𝐵) + (𝑅𝑅99 𝐹𝐹𝐹𝐹∙𝐶𝐶) The Medicaid Fee schedule (Medicaid FS) rate calculation: 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹= 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹𝐹𝐹 𝑆𝑆𝑆𝑆ℎ𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅 ∙0.60 The weighted average rate, when two locales are available (i.e. only A and B): 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑊𝑊𝑊𝑊𝑊𝑊𝑊𝑊ℎ𝑡𝑡 (𝑓𝑓𝑓𝑓𝑓𝑓 2 𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿𝐿) = 𝐴𝐴+ 𝐵𝐵 𝐴𝐴1 = 𝐴𝐴 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑊𝑊𝑊𝑊𝑊𝑊𝑊𝑊ℎ𝑡𝑡 𝐵𝐵1 = 𝐵𝐵 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑊𝑊𝑊𝑊𝑊𝑊𝑊𝑊ℎ𝑡𝑡 𝐴𝐴2 = 𝐴𝐴1 ∙𝐶𝐶 𝐵𝐵2 = 𝐵𝐵1 ∙𝐶𝐶 𝐴𝐴𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓= 𝐴𝐴+ 𝐴𝐴2 𝐵𝐵𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓= 𝐵𝐵+ 𝐵𝐵2 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹𝐹𝐹 𝑆𝑆𝑆𝑆ℎ𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅= ൫𝑅𝑅04 𝐹𝐹𝐹𝐹 ∙𝐴𝐴𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓൯+ (𝑅𝑅04 𝐹𝐹𝐹𝐹∙𝐵𝐵𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓) The Medicaid fee schedule calculation: 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹= 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹𝐹𝐹 𝑆𝑆𝑆𝑆ℎ𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅 ∙0.60 The rate, when only one rate is available (i.e., only A): 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹 𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅= 𝑅𝑅03 The Medicaid fee schedule calculation: 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹= 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝐹𝐹𝐹𝐹 𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅 ∙0.60 04 Rate = R04 B 99 Rate = R99 C 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 5 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ (b) Anesthesia Calculation Formula: 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶= 𝐹𝐹𝐹𝐹𝐹𝐹+ (𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑖𝑖𝑖𝑖 15 min 𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖 𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢 ∙14.50 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴ℎ𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅) Increments of time not totaling 15 minutes are automatically rounded down to the nearest 15- minute increment. The pediatric rate increase of 4% applies to anesthesia services for children under the age of 21. (c) Practitioner laboratory services FCSO is reviewed for laboratory services. If the service is not found on the locales from FCSO, the FCSO clinical lab fee schedule is used on a per test basis. The value included in the FCSO clinical lab fee schedule is the TC component. The Agency cannot pay in excess of established Medicare rates for clinical diagnostic laboratory services performed by a physician/practitioner, independent laboratory or hospital. 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐿𝐿𝐿𝐿𝐿𝐿 𝐹𝐹𝐹𝐹𝐹𝐹= 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝑇𝑇𝑇𝑇 ∙0.60 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐿𝐿𝐿𝐿𝐿𝐿 𝑃𝑃𝑃𝑃= 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐿𝐿𝐿𝐿𝐿𝐿 𝐹𝐹𝐹𝐹𝐹𝐹 ∙0.20 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐿𝐿𝐿𝐿𝐿𝐿 𝑇𝑇𝑇𝑇= 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐿𝐿𝐿𝐿𝐿𝐿 𝐹𝐹𝐹𝐹𝐹𝐹 ∙0.80 Note: The PC and TC are only calculated when the fee includes a PC or TC component. (d) Independent laboratory services Rates are 10% less than the practitioner laboratory services. The Agency cannot pay in excess of established Medicare rates for clinical diagnostic laboratory services performed by a physician/practitioner, independent laboratory or hospital. 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼 𝐿𝐿𝐿𝐿𝐿𝐿 𝐹𝐹𝐹𝐹𝐹𝐹= 𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀𝑀 𝑇𝑇𝐶𝐶 ∙0.60 ∙0.90 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼 𝐿𝐿𝐿𝐿𝐿𝐿 𝑃𝑃𝑃𝑃= 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼 𝐿𝐿𝐿𝐿𝐿𝐿 𝐹𝐹𝐹𝐹𝐹𝐹 ∙0.20 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼 𝐿𝐿𝐿𝐿𝐿𝐿 𝑇𝑇𝑇𝑇= 𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼𝐼 𝐿𝐿𝐿𝐿𝐿𝐿 𝐹𝐹𝐹𝐹𝐹𝐹 ∙0.80 Note: The PC and TC are only calculated when the fee includes a PC or TC component E. Rates for services that do not have Medicare RVUs, and do not have locales from FCSO utilize the below calculations. 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 6 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ (a) For services without a FS or TC component from FCSO, Florida Medicaid rates are determined based upon other state’s Medicaid rates utilizing Purchasing Power Parities (PPP) and other states’ Regional Price Parities. F. When none of the data in A. – E. is available or the code is unlisted, a like-code coverage for Florida is subject to review for applicability to the new code. If Florida does not cover a similar code, PPP will be used for other state rates coverage of like-codes. G. When none of the data in A. – F. are available, the code is priced manually. Manual pricing is rare and evaluates codes that are in the same service type subset of the national coding manual. The code is subject to review the next year to determine data availability for A. – F. for an updated rate. H. Florida Medicaid reimburses physician assistants and advanced practice registered nurses at 80% of the FSI reimbursement of a physician who provides the same services. III. Resource Based Relative Value Scale Annual Rebalancing This section defines the method of determining the Resource Based Relative Value Scale and the Agency Conversion Factor calculation. Updated information is obtained including updated RVUs and prior complete state fiscal year (July – June) utilization data. The conversion factor is calculated through an optimization equation. At the end of each calendar year, utilization data from the previous state fiscal year is collected for all procedure codes on relevant fee schedules. For codes with utilization, the updated RVUs will also be utilized for that code, if available. The conversion factor is calculated through the below equations: 1. Total Expenditures 1.1. Total Expenditures is calculated by taking the FS for each code and multiplying it by its utilization: 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸= 𝐹𝐹𝐹𝐹𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐 ∙𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈 2. Total Adjusted Expenditures 2.1. Total Adjusted Expenditures is calculated by calculating new rates based on new RVU’s and multiplying the rate by its utilization. The formula for FS adjusted (the estimated new fee schedule rate) is conditional: If 𝐹𝐹𝐹𝐹𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐∙0.9 < 𝑅𝑅𝑅𝑅𝑅𝑅 ∙𝐶𝐶𝐶𝐶 < 𝐹𝐹𝐹𝐹𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐∙1.1, then 𝐹𝐹𝐹𝐹𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎= 𝑅𝑅𝑅𝑅𝑅𝑅 ∙𝐶𝐶𝐶𝐶 If 𝑅𝑅𝑅𝑅𝑅𝑅 ∙𝐶𝐶𝐶𝐶< 𝐹𝐹𝐹𝐹𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐 ∙0.9, then 𝐹𝐹𝐹𝐹𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎= 𝐹𝐹𝐹𝐹𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐 ∙0.9 If 𝑅𝑅𝑅𝑅𝑅𝑅 ∙𝐶𝐶𝐶𝐶> 𝐹𝐹𝐹𝐹𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐 ∙1.1, then 𝐹𝐹𝐹𝐹𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎= 𝐹𝐹𝐹𝐹𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐∙1.1 These conditions ensure that the rate does not increase or decrease by more than 10%. Once the adjusted rates are calculated, Total Adjusted Expenditures can be calculated, 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 7 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸= 𝐹𝐹𝐹𝐹𝑎𝑎𝑎𝑎𝑎𝑎𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢∙𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈𝑈 The conversion factor is calculated through the below equation: Min ∑𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸− ∑𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸 ∋ ∑𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸− ∑𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸≥0. A. Exclusions (a) Facility fees for services have the flexibility to increase by more than 10% to align with Medicare’s implementation of the facility fee. (b) Fee calculations based upon Medicare’s RVU definitions have the flexibility to increase by more than 10% to align with Medicare RVUs. (c) Rate increases or decreases may exceed 10% in order to correct an error made by the Agency. (d) Laboratory services rates may decrease by more than 10% to align with Medicare’s RVUs. The Agency cannot reimburse more than Medicare for laboratory services. IV. Recurring Rate Increases to the Methodology Reimbursement increases noted above do not apply to the following services: supplies, devices and laboratory/pathology services.. The Agency ensures recurring rate increases are included for each service and service increase throughout future years. (a) Pediatric Primary Care (Primary Care Evaluation and Management Rate Increase) The increase of fees for the three most common utilized office visit procedure codes for beneficiaries ages 0-19, for evaluation and management service codes 99212, 99213 and 99214. These three CPT codes continue to receive set rates as detailed below: CPT Code Rate 99212 26.45 99213 32.56 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 8 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ 99214 48.27 (b) Physician Services Fee: The 4% increase in physician service rates, known as the FSI rate in Florida Medicaid Managed Information System (FLMMIS). The following provider types were included in this increase in physician services per the line item budget: 25 physician; 26 osteopathic physician; 27 podiatrist; 28 chiropractor; 29 physician assistant; 30 advanced registered nurse practitioner; 35 dentist and 62 optometrist, including all age groups. (c) Pediatric Services: The separate 4% increase in rates for physician services provided to beneficiaries under age 21. This is calculated as an added 4% to the FSI in the reimbursement rules in the Agency’s FLMMIS. (d) Pediatric Physician Specialty: Funds to increase reimbursement rates to physicians for services provided to individuals under age 21 with emphasis on pediatric specialty care for those services deemed by the Agency to be the most difficult to secure under the reimbursement methodology. There are 29 specialty types that receive an enhanced fee of 24% over the base fee to other physician providers for the same services. These specialty types are: 002, 003, 004, 005, 008, 010, 014, 015, 017, 020, 021, 022, 023, 029, 030, 031, 036, 037, 038, 039, 043, 046, 051, 053, 055, 057, 058, 060, and 062. (e) Pediatric Rate Increase: The Agency identifies the CPT code range of 99201-99496 and 13 physician specialty types that receive an enhanced fee of 10.2% over the FSI rate. They are 01, 19, 23, 35, 36, 37, 38, 39, 43, 49, 59, 101, and 102. (f) Total increases for Pediatric Specialty Codes: When all criteria are met and the 4%, 24% and 10.2% increases are applicable, to calculate the specialty fee for those certain pediatrician specialty codes, multiply the base fee by 1.04, then multiply that result by 1.24, and then multiply that result by 1.102. The highest rate following the inclusion of all applicable fee schedule increases is reimbursed. (g) Critical Pediatric Neonatal Intensive Care (NICU)/Pediatric Intensive Care Unit (PICU) Rate increase: $3,470,437 are provided for a rate increase for NICU/PICU services. 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 9 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ (h) Epidural rate increase: For the 2018/19 Fiscal Year, $1,285,347 are provided for a rate increase for epidural services. V. Glossary This section details a glossary of terms, alongside acronyms, used throughout the practitioner methodology. A. Agency - In Florida, the Agency for Health Care Administration is responsible for Medicaid. Medicaid is the medical assistance program that provides access to health care for low-income families and individuals. Medicaid also assists the elderly and people with disabilities with the costs of nursing facility care and other medical and long-term care expenses. B. Anesthesia Time Rate - Anesthesia is reported in total minutes and reimbursed through the anesthesia rate calculation. Qualified non-physician providers, within their scope of practice, are reimbursed at 80%. C. Base Fee (FS) - Fee set by the Agency prior to the application of legislatively mandated increases, on which all reimbursement is based. D. Existing Covered Service – Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes that are included on a current Agency fee schedule. E. Newly Covered Service – CPT and HCPCS codes that are added to an Agency fee schedule that were not on the previous fee schedule. F. Facility Fee - Fee paid to the practitioner when the service is performed in the following places of service: 19 (outpatient hospital off-campus), 21 (inpatient hospital), 22 (outpatient hospital), 23 (emergency room hospital), and 24 (ambulatory surgical center). G. Fee Schedule Increase (FSI) - Base fee plus an additional four percent for services to Medicaid recipients of all ages, based upon provider type. H. Medicare First Coast Services Options (FCSO), Inc. -the current Medicare Administrative Contractor (MAC) for Jurisdiction N (JN), which includes Florida, Puerto Rico and the U.S. Virgin Islands. 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 10 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ I. Florida Medicaid Management Information System (FLMMIS) - The information system currently utilized to enroll providers, reimburse providers, and maintain eligibility and provider enrollment data. J. Agency’s Conversion Factor (CF) - Defined annually based upon Florida Medicaid service utilization, rebalancing, and available budget. Florida’s CF is a value used in this reimbursement methodology to turn Relative Value Units into payable rate (i.e., actual fees). K. Like-Code Coverage - Code that is similar in nature, scope, and direction to an existing covered code in Florida Medicaid. L. Medicaid Fee Schedule (Medicaid FS) – A fee schedule is a complete listing of fees used by Medicaid to pay doctors or other providers and suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis. M. Medicare Physician Fee Schedule - Florida Medicaid utilizes the most current Medicare Physician Fee Schedule available, along with cost RVUs to set rates as detailed in this exhibit. N. Medicare Geographic Practice Index (GPCI) for Florida - Florida Medicaid utilizes the Geographic Practice Cost Index along with Medicare Relative Value Units to determine allowable payment amounts for medical procedures. The Agency utilizes a standard GPCI of 1 across all locales for all RVU components for Medicare’s reported geographic variances. O. Professional Component (PC, modifier 26) - Used for reimbursement for the interpretation and report of a procedure. P. Professional Component Increase (PCI) - Base PC fee plus an additional four percent. Q. Purchasing Power Parodies (PPP) - Ratio of other state service-level coverage set by the United States Department of Commerce Bureau of Economic Analysis. R. Relative Value Units (RVUs) - The Agency adopts Medicare’s RVUs. There are three components of the RVU, which include (1) Work RVU, (2) Facility Practice Expense (FAC PE RVU) or Non- Facility Practice Expense (NON FAC PE RVU), and (3) Malpractice RVU. 4/20/21

Practitioner Reimbursement Methodology Attachment 4.19-B Exhibit II Page 11 of 11 Amendment: 2019-003 Effective Date: 12/1/2019 Supersedes: New Approval Date: __________ S. Resource-Based Relative Value Scale (RBRVS) Methodology - the Agency’s methodology to assign practitioner procedures a relative value which is multiplied by an annual fixed conversion factor to determine each procedure’s rate. T. Technical Component (TC) - The increase for the technical portion (i.e., staff and equipment costs) of a test. U. Technical Component Increase (TCI) - Base TC fee plus an additional four percent. 4/20/21

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State/Territory Name: Florida State Plan Amendment (SPA) #: 19-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 Financial Management Group September 19, 2019 Ms. Beth Kidder Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, MS #8 Tallahassee, Florida 32308 RE: State Plan Amendment (SPA) FL 19-0006 Dear Ms. Kidder: CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEOICAIO & CHIP SERVICES We have reviewed the proposed amendment to Attachments 4.19-A and 4.19-B of your Medicaid State plan submitted under transmittal number 19-0006. This amendment proposes to continue UPL supplemental payments for eligible Cancer hospitals. The two qualified hospitals will be reimbursed for services rendered to Medicaid recipients who are not enrolled in a managed care plan and who are not dually eligible Medicare and Medicaid recipients. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(13), 1902(a)(l3), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR Part 447. We have found that the proposed reimbursement methodology complies with applicable requirements and therefore have approved them with an effective date of June 28, 2019. We are enclosing the CMS-179 and the amended approved plan pages. If you have any questions, please call Anna Dubois at (850) 878-0916. cc: Anna Dubois Dan Yablochnikov Sincerely, Kristin Fan Director /s/

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 2019-0006 2. STATE FL 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE June 28, 2019 5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN x AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 42CFR 447 7. FEDERAL BUDGET IMPACT: a. FFY 2018-2019 $10,306 b. FFY 2019-2020 $30,917 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 4.19-A Part IV Attachment 419-B, pg48 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 4.19-A Part IV Attachment 419-B, pg48 10. SUBJECT OF AMENDMENT: Florida Cancer Hospital Reimbursement Methodology

11. GOVERNOR’S REVIEW (Check One):

GOVERNOR’S OFFICE REPORTED NO COMMENT x OTHER, AS SPECIFIED:

COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Reviewed by the Deputy Secretary for Medicaid

NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL who is the Governor’s designee 12. SIGNATURE OF STATE AGENCY OFFICIAL: //s// 16. RETURN TO: Ms. Beth Kidder Agency Secretary for Medicaid 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Attention: Cole Giering 13. TYPED NAMEMs. Beth Kidder 14. TITLE: Deputy Secretary for Medicaid 15. DATE SUBMITTED:

17. DATE RECEIVED: 06/30/19 18. DATE APPROVED: 09/19/19 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 06/28/19 20. SIGNATURE OF REGIONAL OFFICIAL: //s// 21. TYPED NAME: Kristin Fan

22. TITLE: Director, FMG

23. REMARKS:

Attâchment 4.1 9-A Part lV CANCER HOSPITALS REIMBURSEMENT METHODOLOGY REIMBURSEMENT - Eligible providers specified below will be reimbursed for Florida Med¡caid reimbursable services rendered to Flor¡da Medica¡d recipients who are not enrolled in a managed care plan and who are not dually eligible Medicare and Medicaid recipients. Eligible providers shall be reimbursed up to the¡r respective ind¡v¡dual UPLS based on the upper payment limits described in 42 CFR 447.272 for inpat¡ent hospital serv¡ces. These supplemental payments shall be calculated quarterly and be based on the prev¡ous three months' worth of valid claims. These supplemental payments shall be made by the last day of the following quarter. An additional one{ime payment will be made to University of Miam¡ Hospital and Clinics dibla Sylvester Comprehensive Cancer Center in the amount of $5,917,930 for the quarter ending on 6/30/2019 and will be paid by 9i30l2019. ELIGIBLE PROVIDERS - Cancer hospitals that meet the criteria under 42 USC s. 1395ww(d)(f )(BXv) including only H. Lee Moffitt Cancer Center and Un¡vers¡ty of Miami Hospital and Clinics d/bia Sylvester Comprehensive Cancer Center, will receive the enhanced reimbursement for services rendered at these facilit¡es. Eligible providers shall be enrolled Florida Medica¡d providers. Amendment 2019-0006 Effective 06/28/2019 Supersedes 2017-013 Approvar:-+t++F¿0lg

Attachment 4.19-B CANCER HOSPITALS REIMBURSEMENT METHODOLOGY REIMBURSEMENT - Eligible providers specified below will be reimbursed for Florida Medicaid re¡mbursable services rendered to Flor¡da Medicaid recipients who are not enrolled in a managed care plan and who are not dually eligible Medicare and Medicaid recipients. Eligible providers shall be reimbursed up to their respective ind¡vidual UPLs based on the upper payment limits described in 42 CFR 447.321 for outpatient serv¡ces. These supplemental payments shall be made by the last day of the following quarter. An addit¡onal one-time payment will be made to University of Miami Hospital and Clinics d/b/a Sylvester Comprehensive Cancer Center in the amount of $l,590,974 during the quarter ending on 613012019 and will be pa¡d by 9/30/2019. ELIGIBLE PROVIDERS - Cancer hospitals that meet the criteria under 42 USC s. 1395ww(d)(1XB)(v), including only H. Lee Moffitt Cancer Center and University of Miami Hospital and Clinics d/b/a Sylvester Comprehensive Cancer Center, will receive the enhanced reimbursement for services rendered at these facilities. Eligible providers shall be enrolled Florida Medicaid providers. Amendment 2019-0006 Effective 06/28/2019 SuDersedes 2017-013 Ap'proval: SEP l9 2019 48

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

FL - FL-20-0001 - Eligibility Package ID FL2020MS0001O Program Name N/A SPA ID FL-20-0001 Version Number 2 Submitted By Cole Giering Package Disposition Priority Code P2 Submission Type OŰcial State FL Region Atlanta, GA Package Status Approved Submission Date 1/17/2020 Approval Date 4/2/2020 11:50 AM EDT

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid & CHIP Operations Group 601 East 12th Street Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services April 02, 2020 Beth Kidder Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Mail Stop #20 Tallahassee, FL 32308 Re: Approval of State Plan Amendment FL-20-0001 Dear Beth Kidder: On January 17, 2020, the Centers for Medicare and Medicaid Services (CMS) received Florida State Plan Amendment (SPA) FL-20-0001 to apply an income disregard for the eligibility determination process for individuals with disabilities with earned income through paid employment.. We approve Florida State Plan Amendment (SPA) FL-20-0001 on April 02, 2020 with an eſective date(s) of January 01, 2020. Name Date Created No items available If you have any questions regarding this amendment, please contact Tandra Hodges at Tandra.Hodges@cms.hhs.gov. Sincerely, James Scott Director Division of Program Operations Center for Medicaid & CHIP Services Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID N/A SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date N/A State Information State/Territory Name: Florida Medicaid Agency Name: Agency for Health Care Administration Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID N/A SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date N/A SPA ID and Eſective Date SPA ID FL-20-0001 Reviewable Unit Proposed Eſective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 1/1/2020 NEW Non-MAGI Methodologies 1/1/2020 NEW Mandatory Eligibility Groups 1/1/2020 FL-13-0015 Optional Eligibility Groups 1/1/2020 FL-13-0015 Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules 1/1/2020 2009-026 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID N/A SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives The amendment seeks approval to apply an income disregard for the eligibility determination process for individuals with disabilities with earned income through paid employment. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $0 Second 2020 $0 Federal Statute / Regulation Citation 42 CFR 435.222 &1902(r)(2) of the Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

7 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID N/A SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date N/A Governor's OŰce Review Describe Medicaid Director review and approval No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID N/A SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: Upload copies of public notices and other documents used Name Date Created 2019-013 FAR Notice 1/17/2020 11:49 AM EST Upload with this application a written summary of public comments received (optional) Name Date Created No items available Indicate the key issues raised during the public comment period (optional) Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Public Hearing or Meeting Other method Access Quality Cost Payment methodology Eligibility Beneţts Service delivery Other issue

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID N/A SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct eſect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 12/13/2019 Tribal Letters The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created 2019-013 Seminole Tribal letter SIGNED 1/17/2020 11:52 AM EST 2019-013 Miccosukee Tribal letter SIGNED 1/17/2020 11:52 AM EST Indicate the key issues raised (optional) Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes Access Quality Cost Payment methodology Eligibility Beneţts Service delivery Other issue

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID NEW User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneţciaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) 1. SSA Eligibility Determination State (1634 State) 2. State Eligibility Determination (SSI Criteria State) 3. State Eligibility Determination (209(b) State)

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID NEW User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831. A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the ţnancial methodologies of either the SSI program or the AFDC program in eſect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID NEW User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 C. Financial Responsibility of Relatives 1. In determining ţnancial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in eſect as of July 16, 1996. (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID NEW User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identiţed below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state deţnes family size for one or more of the following FPL eligibility groups to include others beyond those identiţed in D.1. and D.2. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID NEW User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 E. Use of MAGI-like Methodologies 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in eſect as of July 16, 1996. 2. The election to use MAGI-like methodologies is described on the RU for each applicable eligibility group. 3. The MAGI-like methodology is consistent with 42 CFR 435.603(b) through (f) with respect to deţnitions, household income, and deţnition of household, except: a. The agency elects to use the MAGI deţnition of parent when considering the ţnancial responsibility of relatives, which includes natural or biological parents, as well as adopted parents and stepparents. b. Less restrictive methodologies can be used, as described in section B. c. The ţnancial responsibility requirements for relatives are applicable, as described in section C. d. The countable income deductions for the medically needy are applicable, when the MAGI-like methodologies are applied to the medically needy, as described in section F. Yes No Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID NEW User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that would be deducted in determining eligibility under SSI. 2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID NEW User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 G. Additional Information (optional)

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID FL-13-0015 System-Derived SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneţciaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualiţed Medicare Beneţciaries NEW Qualiţed Disabled and Working Individuals NEW Speciţed Low Income Medicare Beneţciaries NEW

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Qualifying Individuals NEW

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID FL-13-0015 System-Derived SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 B. The state elects the Adult Group, described at 42 CFR 435.119. C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Yes No

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID FL-13-0015 System-Derived SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children NEW Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Yes No

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

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID FL-13-0015 System-Derived SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women NEW Medically Needy Children under Age 18 NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classiţcations of Individuals under Age 21 NEW Medically Needy Parents and Other Caretaker Relatives NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Populations Based on Age, Blindness or Disability NEW Yes No

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID FL-13-0015 System-Derived SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Individuals who would be eligible for Medicaid if they were in an institution and who receive home and community-based services. Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID 2009-026 User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 The state operates the Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would be eligible for Medicaid if in a medical institution. 2. But for the provision of home and community-based services under a waiver granted under section 1915(c), (d) or (e) of the Act: a. For waivers granted under 1915(c), the individuals would otherwise require the level of care furnished in a hospital, a nursing facility or an intermediate care facility for individuals with intellectual disabilities. b. For waivers granted under 1915(d) or (e), the individuals would otherwise require the level of care furnished in a hospital or nursing facitlity. 3. Will receive the waivered services.

Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID 2009-026 User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 B. Income and Resource Methodologies 1. The income and resource methodologies used for this group are those used to determine eligibility for a state plan group under which the individual would be eligible if in an institution. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Percentage: 550.00% Description of disregard: 550 percent of the Federal Beneţt Rate 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Cash Asset Resource Disregard Cash assets can be up to the amount of $13,000 for a single individual and $24,000 for a couple. Monthly Status If resources are below the applicable standard at any time during the month, the individual is eligible on the factor of resources for that month. Description of disregard: Pursuant to 42 CFR 435.601(d) and (f) (2), the value of property which exceeds the $2,000 asset limit may be excluded if the applicant or recipient provides evidence of good faith eſort to sell the property. Proceeds from the sale of the property will be countable resources to the individual unless the individual plans to use them to buy an excluded home within three calendar months of receiving them. Coverage provided to children who have reached age 18 and are under 21 who were in foster care when they turned 18, or after reaching 16, were adopted from foster care or placed with a court-approved dependency guardian and spent a minimum of 6 months in foster care within the 12 months immediately preceding placement or adoption, without regard to a Yes No A percentage of earned income is disregarded. Yes No General resource disregard: Real property not otherwise excluded is disregarded.

resource test that is otherwise required. Name of methodology: Description: Burial Disregard Methodology The methodologies used in the SSI program in the determination of amounts set aside for burial shall be used with the following exceptions: - Up to $2500 of resources may be excluded if designated as burial funds. - Burial funds must be kept separate from, and not commingled with, non-burial resources unless the resources cannot be separated or it is unreasonable to require it. Burial fund accounts for prior months may be commingled with non-burial funds. - Resources may be designated as burial funds for any month including the three months prior to the month of application. - The $2500 exclusion is not reduced by the value of excluded life insurance policies or irrevocable burial contracts. Description: Participants can have a retirement account recognized by the Internal Revenue Service. The state uses a less restrictive methodology with respect to resources set aside for burial. Speciţed methodology for the treatment of resources set aside for burial: The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside for retirement Individual Retirement Accounts (IRA)

Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID 2009-026 User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 C. Income and Resource Standards The income and resource standards used for this group are those used to determine eligibility for a state plan group under which the individual would be eligible if in an institution.

Individuals Receiving Home and Community-Based Waiver Services under Institutional Rules MEDICAID | Medicaid State Plan | Eligibility | FL2020MS0001O | FL-20-0001 Package Header Package ID FL2020MS0001O Submission Type OŰcial Approval Date 4/2/2020 Superseded SPA ID 2009-026 User-Entered SPA ID FL-20-0001 Initial Submission Date 1/17/2020 Eſective Date 1/1/2020 D. Additional Information (optional)

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 6/11/2020 1:41 PM EDT

Table of Contents State/Territory Name: Florida State Plan Amendment (SPA) #: 20-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 November 2, 2020 Ms. Beth Kidder Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308 Re: Florida State Plan Amendment (SPA) FL 20-0004 Dear Ms. Kidder: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0004. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, asdetermined bythe Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such itemsandservicesingoodfaith,butareunableto complywithoneormoreofsuchrequirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exemptedfromsanctionsforsuchnoncompliance,absentanydeterminationoffraudorabuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.

Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of Florida requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of Florida also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Florida’s Medicaid SPA Transmittal Number 20-0004 is approved effective March 9, 2020. 3OHDVH QRWH WKDW WKH HIIHFWLYH GDWH IRU )ORULGD V QXUVLQJ IDFLOLW\ UDWHV LV HIIHFWLYH $SULO   WKURXJK -XQH   Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

Please contact Tandra Hodges at 404-562-7409 or by email at Tandra.Hodges@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Florida and the health care community.

Sincerely,

Alissa M. _ Qesvsapeo A Deboy-S Sateao-os00"

Alissa Mooney DeBoy

Acting Deputy Director

Center for Medicaid and CHIP Services

Enclosures

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED ‘OMB No. 0938-0193

1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF > oo el FL STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES __}}3- PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE

March 9, 2020

5. TYPE OF PLAN MATERIAL (Check One) (7 NEw STATE PLAN

CJ AMENDMENT TO BE CONSIDERED ASNEW PLAN

IH) AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION

Title XIX and Section 1135 of the Social Security Act, CFR 42

7. FEDERAL BUDGET IMPACT a. FFY20

b. FFY21

$_19,706,736 $ 9,282,267

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Pages 90-101 of Section 7

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

10. SUBJECT OF AMENDMENT COVID-19 Disaster Relief

11. GOVERNOR'S REVIEW (Check One)

(1 GoveRNor’s OFFICE REPORTED NO COMMENT C1 CoMMENTS OF GOVERNOR'S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED

12. SIGN. FFICIAL

13. TYPED NAME Beth Kidder

14. TITLE Deputy Secretary for Medicaid

15. DATE SUBMITTED 9-10-20

16. RETURN TO

Ms. Beth Kidder

Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #8 Tallahassee, FL 32308

Attention: Cole Giering

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED 09/10/2020

18. DATE APPROVED 11/24/2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL

20. SIGNATURE OF REGIONAAItSSachAL

M. Deboy -S 03/09/2020 Deboy -S ae 21. TYPED NAME 22. TITLE Alissa Mooney DeBoy Acting Deputy Director, CMCS 23. REMARKS

The State authorizes the following Pen & Ink changes for 20-0004 CMS 179:

Revise Block 1 to read — 20-0004

Revise Block 6 to read — Title XIX and Section 1135 of the Social Security Act, CFR 42

Revise Block 7a to read — FFY 20

Revise Block 7b to read — FFY 21

Revise Block 8 to read — Pages 90-101 of Section 7 Update Block 9 to read — New

FORM CMS-179 (07/92)