_____________________________________________________________________________ Table of Contents State/Territory Name: Georgia State Plan Amendment (SPA) #: GA-13-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-26-12 t . M Ls

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAY 2 0 2015

Ms. Sheila Alexander

Program Director, Peach Care for Kids Georgia Department Community Health 2 Peachtree, N.W., 37" Floor

Atlanta, GA 30303

Dear Ms. Alexander:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number GA-13-0016 submitted on November 14, 2013, with additional information provided on May 19, 2015. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

In SPA number GA-13-0016, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. Page CS10 allows the state to cover children who have access to public employee coverage and updates the supporting documentation. The first CS10 page uses the maintenance of agency contribution criteria to allow CHIP coverage for children of State Health Benefit Plan employees, and the second CS10 page uses the hardship exception criteria to allow CHIP coverage for children of the Board of Regents employees. Page CS13 indicates that the state elects to cover as deemed newborns children born to mothers enrolled as targeted low- income children in CHIP and children deemed eligible in another state. These approved pages are attached to this letter and should be incorporated into the current CHIP state plan according to the table below. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

New State Plan Page Impact on Current State Plan Section

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

CS7: Targeted Low-Income Children Sections 4.1.1, 4.1.2, 4.1.3: Supersede all CS10: Children Who Have Access to Public Section 4.4.1: Supersede information on Employee Coverage dependents of employees of a public agency CS10: Maintenance of Agency Contribution Appendix: Supersede current documentation (State Health Benefit Plan Employees) CS10: Children Who Have Access to Public Section 4.4.1: Supersede information on Employee Coverage dependents of employees of a public agency

Page 2 - Ms. Sheila Alexander CSlO: Hardship Exception (Board of Regents Appendix: Supersede current documentation Employees) CS13: Deemed Newborns Section 4.3: Add new subsection Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Lagorio's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-4554 Facsimile: (410) 786-5882 E-mail: Cassandra.Lagorio@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Jackie Glaze, Associate Regional Administrator (ARA) in our Atlanta Regional Office. Ms. Glaze's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Atlanta Federal Center, 4th Floor 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs, at (410) 786-0719. We look forward to continuing to work with you and your staff. Enclosures cc: Sincerely, // .
5----- Eliot Fishman Director Ms. Jackie Glaze, ARA, CMS Region IV, Atlanta

Children’s Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children’s Health Insurance Program Eligibility: Summary Page

State/Territory Georgia

name: 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. |GA 13-0016

Type of SPA: ¥| MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility

Proposed Effective Date

(nn/aa/yvyy)

Federal Statute/ Regulation Citation

[42 CFR A§ A§ 457.310, 457.315, 457.320.457.360,

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count:43 out of 2000 CHIP MAGI Eligibility State Plan Amendments

Signature of State Agency Official

Submitted By: Sheila Alexander

Last Revision May 19, 2015 Date: Submit Date: Nov 14, 2013

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

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

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

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

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. @ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (1 Include a prorated portion of the reasonably predictable increase in future income and/or family size. (J Account for a reasonably predictable decrease in future income and/or family size.

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

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

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

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

1 attachment is submitted. a

PRA Disclosure Statement

SPA# GA-13-0016 Approval pate__ MAY 20 2015 —

Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

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

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

SPA# GA-13-0016 Approval vate, MAY 20 2015

Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

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

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

The CHIP Agency operates this covered group in accordance with the following provisions: Age Must be under age 19.

Income Standards

Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) . + Ilo 1 205 247 + : 1 6 149 247 + (le 19 133 247

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

For children ages 1, 6, 19, eligibility ends at the end of the month in which the child's birthday occurs.

Special Program for Children with Disabilities

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

MAY 2 0 2015

SPA# GA-13-0016 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

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

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

V.20130709

MAY 2.0 2015 SPA# GA-13-0016 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

State Name:|Georgia | OMB Control Number: 0938-1148

Transmittal Number: GA - 13 - 0016 Expiration date: 10/31/2014

S10

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

aw Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: @ Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. C Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act.

Coverage under this option is extended to children whose household income is:

Select one of the options for the income standard when compared to Targeted Low Income Children

@ The same as the standards for Targeted Low-Income Children

C Lower than the income standards for Targeted Low-Income Children

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

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

Employees of certain public agencies.

Type of agency

State Health Benefit Plan Employees x

(] Certain types of public employees.

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

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

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

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

MAY 20 2015

SPA# GA-13-0016 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

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

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

V.20140415

MAY 20 2015

SPA# GA-13-0016 Approval Date:. Effective Date: January 1, 2014 Page 2 of 2

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CHIP Eligibility

State Name:|Georgia | OMB Control Number: 0938-1148 Transmittal Number: GA - 13 - 0016 Expiration date: 10/31/2014

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

wl Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: C Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA.

@ Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act.

Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children

@ The same as the standards for Targeted Low-Income Children C Lower than the income standards for Targeted Low-Income Children

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

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

Employees of certain public agencies.

Type of agency

F ||Board of Regents x

(C1 Certain types of public employees.

[m@] Attach methodology the state has used to calculate financial hardship.

"Am attachment is submitted.

The state provides assurance that the state will, on an annual basis, recalculate the financial status to determine if the hardship condition continues to be met.

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

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

MAY 2 6 2015

SPA# GA-13-0016 Approval Date: Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

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

V.20140415

MAY 20 2015 SPA# GA-13-0016 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

Average Annual Premium of Board of Regents Employee with Children in Health Care Plan*

Cost Sharing Total Annual Cost Sharing per Client

Family Size

DU PWN

Georgia Department of Community Health Hardship Exception for Children of Georgia Board of Regents Employees

FY2012 FY2013 S$ 2,284.33 $2,311.23 FY2012 FY2013 $ 707.15 S 665.82

FY2012 FY2013

Annual 235% Annual Annual

235% Annual 5% Premium + Income 5% Premium + Income FPL** Threshold Cost Sharing# FPL** Threshold Cost Sharing# S 26,249.50 S 1,312.48 $ 27,001.50 §$ 1,350.08 $ 35,555.50 $ 1,777.78 §$ 2,284.33 S$ 36,448.50 §$ 1,822.43 $ 2,311.23 $ 44,861.50 $ 2,243.08 $ 2,991.49 S 45,895.50 §$ 2,294.78 $ 2,977.05 $ 54,167.50 S 2,708.38 $ 3,698.64 $ 55,342.50 §$ 2,767.13 $ 3,642.87 $ 63,473.50 S 3,173.68 $ 4,405.79 S 64,789.50 $ 3,239.48 S$ 4,308.69 S 72,779.50 S 3,638.98 $ 5,112.94 $ 74,236.50 $ 3,711.83 $ 4,974.51

*- Georgia used the average premium of the different health plans offered based on membership in

each plan.

** ~ 2012 and 2013 FPL calculations were used.

# - Because Georgia used the average premium amounts, Georgia wanted to be more conservative in the calculation to ensure that the hardship criterion was met. Therefore, the calculation of annual total premium and cost sharing paid for a family of 2 did not include any cost sharing. The calculation of the annual total premium and cost sharing paid for a family of 3 included only 1 annual cost per client. For example, in 2012 fora family size of 3, the average premium was $2,284.33 + $707.15*1 = $2,991.49

SPA# GA-13-0016

Approval Date:

MAY 2 0 2015

Effective Date: January 1, 2014

CHIP Eligibility

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

3

Section 2112(e) of the SSA and 42 CFR 457.360

Cl Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CHIP or Medicaid until the child turns one.

The state operates this covered group in accordance with the following provisions: [m] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

a The child is deemed to have applied for and been found eligible for CHIP or Medicaid, as appropriate, as of the date of the child's birth, and remains eligible without regard to changes in circumstances until the child's first birthday.

The state elects the following option(s):

Ba The state elects to cover as a deemed newborn a child born to a mother who is covered as a targeted low-income child under the state's separate CHIP on the date of the newborn's birth.

The state elects to recognize a child's deemed newborn status from another state and provides benefits in accordance with the requirements of section 2112(e) of the SSA.

oO The state elects to cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the authority of the state’s section 1115 demonstration on the date of the newborn’s birth.

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

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

SPA# GA-13-0016 Approval vate, MAY 20 2615

Effective Date: January 1, 2014 Page | of |

_____________________________________________________________________________ Table of Contents State/Territory Name: Georgia State Plan Amendment (SPA) #: GA-13-0017 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

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

7500 Security Boulevard, Mail Stop: S2-01-16 CENTERS FOR MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 0 6 2014

Ms. Sheila Alexander

Program Director, Peach Care for Kids Georgia Department Community Health 2 Peachtree, N.W., 37" Floor

Atlanta, GA 30303

Dear Ms. Alexander:

Tam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number GA-13-0017 submitted on November 14, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number GA-13-0017 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Georgia’s approved CHIP state plan.

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

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

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

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

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

Official communications regarding program matters should be sent simultaneously to Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Page 2 — Ms. Sheila Alexander

Centers for Medicare & Medicaid Services

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

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Jackie Glaze, ARA, CMS Region IV, Atlanta Lynette Rhodes, Medicaid Operations, Department of Community Health

Children's Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Georgia

name: 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. |GA-13-0017

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion ¥ Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date

(nm/de/yyvy)

Federal Statute/ Regulation Citation

[42 CFR § 457.310(d)

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:23 out of 2000 Establish 2101(f) Group

Please provide a brief summary of SPA changes.

Character Count: 23 out of 2000 Establish 2101(f) Group

Signature of State Agency Official

Submitted By: Therese Brisco

Last Revision Jan 31, 2014 Date:

Submit Date: Nov 14, 2013

CHIP Eligibility

OMB Control Number: 0938-1148

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[i] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision,

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

A The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

first renewal applying MAGI methods. The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

% FPL.

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program.

@ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their

SPA# GA-13-0017 Approval Date: FEB 0 6 aura Effective Date: January 1, 2014

Page | of 2

Ms CHIP Eligibility

STONERS VOOR ASTOGNGE f AN INEC NED SEAN

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C.No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

C Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

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 $0 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# GA-13-0017 Approval vate FEB 06 2014

Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Georgia

State Plan Amendment (SPA) #: GA-13-0018

This file contains the following documents in the order listed:

1) Approval Letter 2) Companion Letter 3) SPA Summary Form 4) Approved SPA Pages 5) Additional Attachments that are Part of the State Plan

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

DEPARTMENT OF HEALTH & HUMAN SERVICES - Centers for Medicare & Medicaid Services CM Say, 7500 Security Boulevard, Mail Stop: S2-26-12

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 2 1 2014

Ms. Sheila Alexander

Program Director, Peach Care for Kids Georgia Department of Community Health 2 Peachtree, N.W., 37th Floor

Atlanta, GA 30303

Dear Ms. Alexander:

I am pleased to inform you that Georgia’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), GA-13-0018, submitted on November 14, 2013, has been approved. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA GA-13-0018 includes full approval of your state’s alternative multi-benefit paper application. The state is using an interim alternative single streamlined online application and by December 31, 2014, will implement a revised alternative single streamlined online application that addresses our concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the end of Georgia’s approved CHIP State Plan:

CS24 Attachment 1 — State of Georgia’s alternative multi-benefit paper application and health coverage addendum

e Attachment 2 — Statement of use with respect to the alternative single streamlined online application

This approval and the attachments supercede the following sections of the current CHIP State Plan:

e Section 4.3: Single, Streamlined Application Screen and Enroll Process ® Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

Page 2 — Ms. Sheila Alexander

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan

Amendment. Your Title XXI project officer is Ms. Lavern Baty. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

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

Official communications regarding program matters should be sent simultaneously to Ms. Baty

and to Ms. Jackie Glaze, Associate Regional Administrator (ARA) in our Atlanta Regional Office. Ms. Glaze’s address is:

Ms. Jackie Glaze

Office of the Regional Administrator Atlanta Federal Center

61 Forsyth Street, SW, Suite 4T20 Atlanta, Georgia 30303-8909

If you have additional questions, please contact Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

ce: Ms. Jackie Glaze, ARA, CMS Region IV, Atlanta

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 2 1 2014

Ms. Sheila Alexander

Program Director, Peach Care for Kids Georgia Department of Community Health 2 Peachtree, N.W., 37th Floor

Atlanta, GA 30303

RE: C824 — Eligibility Process State Plan Amendment (SPA), GA-13-0018

Dear Ms. Alexander:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Georgia’s state plan amendment (SPA) transmittal GA-13-0018, which was submitted to CMS on November 14, 2013. Our review of this submission included a review of the online alternative single streamlined application developed by the state.

Until December 31, 2014, the state is using an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following changes.

Necessary Changes

Date by which changes will be completed:

Reference to 6 months in Former Foster Care questions will be removed in the next revision.

July 1, 2014

Questions regarding access to employer- sponsored coverage, beyond what is needed for Medicaid and CHIP, will only be asked of applicants above the income limit for Medicaid and CHIP. The information collected regarding access to employer-sponsored coverage will be updated in accordance with the model CMS application.

December 31, 2014

Page 2 — Ms. Sheila Alexander

Please submit the revised alternative single streamline online application to CMS for review no later than December 1, 2014, to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

We look forward to continuing to work with you and your staff.

Sincerely,

Linda Nablo Director, Division of State Coverage Programs

ce: Ms. Jackie Glaze, ARA, CMS Region IV, Atlanta

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility GA.0507.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Georgia State Funds: $ Federal Funds: $ Submitted By: Sheila Alexander Last Revision Date: Oct 14, 2014 Submit Date: Nov 14, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. GA13-0018 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR § 457 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:0 out of 2000 Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/30/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/30/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

GA-13-0018 Georgia

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 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.

CHIP Eligibility

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

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457. subpart C for application processing, eligibility screening and enrollment.

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:

P| The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single. stream lined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

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.

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 CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means. [2] Other electronic means: Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

wl Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs: and

fa] Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as otentially eligible for Medicaid or other insurance afforgabjlity programs based on household income; and p y elig fp vi ra ais

SPA# GA-13-0018 Approval Date: Effective Date: October 1, 2013 Page | of 2

cms CHIP Eligibility

A A

Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the plicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. Yes

Redetermination Processing

Redeterm inations 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 457.343:

[MH] Once every 12 months.

mw 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 [Mf] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals

screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.34 8(b)-and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering

oO insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

‘esta nt

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

V.20130709

FEB 2 1 2014

SPA# GA-13-0018 Approval Date: Effective Date: October 1, 2013 Page 2 of 2

Georgia Department of Human Services

Application for Benefits

cit

‘Georgia Department ‘of uman Services

If you need help filling out this application, ask us or call 1-877-423-4746. If you have a hearing impairment, call GA Relay at 1-800-255-0135. Our services are free.

What Services Do We Offer at the Division of Family and Children Services (DFCS)?

DFCS offers the following services:

Food Assistance

Food Stamps are benefits that you can use to buy food at any store that has the EBT/Quest sign. We will subtract the price of your food purchase from your Food Stamp account.

Cash Assistance/Employment Support Services Temporary Assistance for Needy Families (TANF) provides cash assistance to families with dependent children for a limited time. Parents or caretakers who are included in the grant are required to participate in a work program.

Cash Assistance program also provides financial assistance to refugee households who are not eligible for the TANF program.

Medical Assistance Medicaid, for those who are eligible, may help pay medical bills, doctor's visits, and Medicare premiums.

Community Outreach Services

For more information about Community Outreach Services, please

visit our website at: http://www.dfcs.dhr.georgia.gov or call 1-877- 423-4746.

“Giessen How Do | Apply for Benefits? Step 1. Fill out the application.

Read the questions carefully and give accurate information. Sign and date the application.

Step 2. Turn in the application. You will need to tear off pages 1 and 2 and keep it for yourself.

Mail, fax, or bring in pages 3-6 of this application to your local Division of family & Children Services (DFCS) office. If you or the person for whom you are applying is eligible for benefits, Food Stamps or TANF benefits will be provided from the date thatwe receive the application with your name, address, and signature on it.

If you apply for Food Stamps, and/or Medicaid you can file an application for benefits with only your name, address and signature. However, it may help us to process your application quicker if you complete the entire form.

Step 3. Talk with us. You may need to complete an interview with a case manager. If so,

we will give you an appointment. This interview can be completed by phone.

Form 297 (Rev. 03/12) 1

“In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food and Nutrition Act of 2008 and USDA policy, discrimination is also prohibited on the basis of religion or political beliefs.”

To file a complaint of discrimination, you may contact USDA or HHS.

Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9411 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY).

Write HHS, Director, Office of Civil Rights, Room 509-F, 200 Independence Avenue, S.W., Washington, D.C., 20201 or call (202) 619- 0403 (voice) or (202) 619-3257 (TTY).

USDA and HHS are equal opportunity providers and employers

You may also file a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street, N.W., Suite 19- 248, Atlanta, Georgia 30303 or call (404) 657-3735 or fax (404) 463-3978.

Under the Department of Community Health (DCH) policy, Medicaid cannot deny you eligibility or benefits based on your race, age, sex, disability, national origin, or political or religious beliefs. To report Medicaid eligibility or provider discrimination, call the Georgia Department of Community Health's Office of Program Integrity (local 404-463-7590) (toll free) 800-533-0686.

What Do the Words Used in this Application Mean? This chart explains the words we have used in this application.

Caretaker

Aparent, relative or legal guardian who applies for and receives TANF with children in his or her care.

Grantee Relative

A parent, relative or legal guardian who applies for and receives TANF in his or her name on behalf of the children.

Disqualified

The action taken to remove an individual from a Food Stamp or TANF case because they did not tell the truth and received benefits that they should not have received.

Electronic Benefit Transfer (EBT)

The system used in Georgia to pay benefits to individuals who are eligible for Food Stamps or TANF. Individuals receiving assistance are issued an EBT debit card, which is used to withdraw cash benefits and to access their food stamp accounts.

Household Members

Individuals who live in your home.

Income

Payments such as wages, salaries, commissions, bonuses, worker's compensation, disability, pension, retirement benefits, interest, child support or any other form of money received

Migrant Farm Workers

Individuals who are seasonal farm workers and move from one home base to another to work or look for farm work

Resources

Cash, property, or assets such as bank accounts, vehicles, stocks, bonds, and life insurance

Seasonal Farm Workers

Individuals who work at certain times of the year planting, picking or packing produce. They are hired on a temporary basis when a job requires more workers than the farm employs on a regular basis

Trafficking

Selling or trading Food Stamp benefits for profit

Qualified Alien/Immigrant

A qualified alienimmigrant is a person who is legally residing in the U.S. who falls within one of the following categories: a person lawfully admitted for permanent residence (LPR) under the Immigration and Nationality Act (INA); Amerasian immigrant under section 584 of the Foreign Operations, Export Financing and Related Program Appropriations Act of 1988; a person who is granted asylum under section 208 of the INA; Refugees, admitted under section 207 of the INA; A person paroled into the US under section 212(d)(5) of the INA for at least one year; A person whose deportation is being withheld under section 243(h) of the INA as in effect prior to April 1, 1997 , or section 241(b)(3) of the INA, as amended; a person who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980; Cuban or Haitian immigrants as defined in section 501(e) of the Refugee Education Assistance Act of 1980; victims of human trafficking under section 107(b)(1) of the Trafficking Victims Protection Act of 2000; battered immigrants who meet the conditions set forth in section 431 (c) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, as amended; Afghan or Iraqi immigrants granted special immigrant status under section 101(a)(27) of the INA (subject to specified conditions); American Indians born in Canada living in the U.S. under section 289 of the INA or non-citizens of federally-recognized Indian tribe under Section 4(e) of the Indian Self-Determination and Education Assistance Act and Hmong or Highland Laotian tribal members that rendered assistance to U.S. personnel by taking part in military or rescue operation during Vietnam Era (8/05/1964 — 5/07/1975).

Applicant

An individual who chooses to apply for or to receive public assistance/benefits

Non-applicant

An Individual who chooses NOT to apply for or to receive public assistance/benefits; non-applicants are not required to provide an SSN, citizenship or immigration status.

Assistance Unit

An assistance unit includes eligible individuals who live together and receive public assistance/benefits together.

Form 297 (Rev. 03/12)

‘Georgia Deparumes ‘of Wuman Services

Georgia Department of Human Services

Application for Benefits

mt

What Am I Applying For? Check all that apply:

Q

Q

Food Stamps The Food Stamp program helps meet the food and nutritional needs of eligible households.

Temporary Assistance for Needy Families (TANF)

Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash payments, or other support services, to strengthen eligible families with children. If you are the child’s parent, or the caretaker who would like to be included in the grant, we will require you to participate in a work program.

Refugee Cash Assistance

The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible for the TANF program. The term refugee includes refugees, Cuban/ Haitian Entrants, victims of human trafficking, Amerasians, and unaccompanied refugee minors.

Medicaid

Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families. When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.

Tell Us About The Applicant

Does the applicant or person applying on behalf of the applicant need assistance when communicating with us? If so check all that apply.

() TTY () Braille () Large Print () E-mail (_) Video Relay) ( ) Sign Language Interpreter

() Foreign Language Interpreter (specify language) () Other

Please fill out the chart below about the applicant. First Name Middle Initial Last Name Suffix Street Address Where You Live Apt City State Zip Code

Mailing Address (if different)

City State Zip Code Home Telephone Number Other Contact Number E-Mail address Signature Date

Witness Signature if signed by ‘X’ Date

Form 297 (Rev. 03/12) 3

Do | Qualify to Get Food Stamps Faster? Answer these questions about the applicant and all household members to see if you can get Food

Stamps within 7 days. 1. Are you or any household member a migrant or seasonal farm worker? QO Yes OQ No 2. Total Gross earned income that will be received for this month: $. Employer Name Employment Begin Date Employment End Date Rate of Pay Hours Worked Weekly wk/bi-wk/semi-mo/mo (circle one) 3. Total Gross unearned income that will be received for this month: $. Type of Unearned Income Amount wk/bi-wk/semi-mo/mo (circle one) Type of Unearned Income Amount wk/bi-wk/semi-mo/mo (circle one) 4. Total earned and unearned income for this month: $ 5. How much money do you and all household members have in cash or in the bank? $ 6. How much do you and all household members pay for rent or mortgage? $ 7. How much do you and all household members pay for electric, water, gas, etc.? $

Can | Choose Someone to Apply for Food Stamps or Medicaid for me?

Complete this section only if you want someone to fill out your application, and/or complete your interview, and/or use your EBT card to buy food when you cannot go to the store. You can choose more than one person.

Name: Phone:

Address: Apt:

City: State: Zip: Name: Phone:

Address: Apt:

City: State: Zip:

For Medicaid, do you want this individual to have a copy of your Medicaid card? O Yes O No

Tell Us about the Applicant and All Household Members

Please fill out the chart below about the applicant and all household members. The following federal laws and regulations: The Food and Nutrition Act of 2008, 7 U.S.C. § 2011-2036, 7. C.F.R. § 273.2, 45 C.F.R. § 205.52, 42 C.F.R. § 435.910, and 42 C.F.R. § 435.920, authorize DFCS to request your and your household members social security number(s).If anyone in your household does not want to give us

Form 297 (Rev. 03/12)

information about his or her citizenship, immigration status, or social security numbers, then that person can be designated as a non-applicant. This means that the person will not be considered an applicant and will not be eligible for benefits. However, other household members may still be able to receive benefits, if they are otherwise eligible. If you want us to decide whether any household members are eligible for benefits, you will still need to tell us about their citizenship or immigration status and give us their SSN. You will still need to tell us about your income and resources to determine the eligibility and benefit level of the household. Individuals will not be reported to the United States Citizenship and Immigration Services if they do not give us their citizenship or immigration status.

NAME Relation Is this Birth Social Security | Sex Hispanic/ Race Are you a U.S -ship person Date Number Latino? Code citizen, qualified First Middle Initial Last to You applying alien/immigrant for or benefits? (Optional) | (Optional) | Hmong/Highland Laotian Immigrant? (Applicants only) (Y/N) Format (Applicants (See codes (--1--1--) Only) (MIF) (YIN) Below) (YIN) SELF

Race Codes (Choose all that apply): : Al — American Indian/Alaska Native AS — Asian BL — Black/African American HP — Native Hawaiian/Pacific Islander WH — White

By providing Race/Ethnicity information, you will assist us in administering our programs in a non-discriminatory manner. Your household is not required to give us this information and it will not affect your eligibility or benefit level.

Tell Us More about the Applicant and All Household Members

We need more information about the applicant and all household members in order to decide who is eligible for benefits. Please answer only the questions about the benefits you want to receive on the page below.

1. Has anyone received any benefits in another county or state? Q Yes O No Who: What: Where: When:

2. Did anyone in your house hold voluntarily quit a job or voluntarily reduce his/her work hours below 30 hours per week since the last application or review? Q Yes Q No

If yes, who quit? Why did he/she quit?

Form 297 (Rev. 03/12) 5

3. Is anyone pregnant? For TANF, please provide proof of pregnancy if available. Q Yes QO) No

(This question does not apply to Food Stamp only applicants) Who: Due Date:

4. Is anyone disqualified from the Food Stamp or TANF Program? Q Yes O No a. Who: b. Where:

5. Is anyone trying to avoid prosecution or jail for a felony? (For TANF and FS only) QO Yes ONo Who:

6. Is anyone violating conditions of probation or parole? (For TANF and FS only) QO Yes ONo Who:

7. Has anyone been convicted of a drug felony (For TANF and FS only) or violent felony (For TANF only)? Q Yes ONo

Who: When:

| have read and completed everything on this form that applies to the applicant and the applicant’s household. | certify, under penalty of perjury, all the information that | provided is true and complete as far as | know. | understand | can be punished by law if | do not tell the complete truth.

Applicant's Signature Date Authorized Representative’s Signature Date Case Manager's Name and Signature Date

Form 297 (Rev. 03/12) 6

_____________________________________________________________________________ Table of Contents State/Territory Name: Georgia State Plan Amendment (SPA) #: GA-13-0019 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

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

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

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 0 6 2014

Ms. Sheila Alexander

Program Director, Peach Care for Kids Georgia Department Community Health 2 Peachtree, N.W., 37" Floor

Atlanta, GA 30303

Dear Ms. Alexander:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPAs) numbered GA-13-0019 submitted on November 14, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an

effective date of January 1, 2014.

SPA number GA-13-0019 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, and non-payment of premiums. Copies of the approved state plan pages are attached and these approved pages supersede sections of Georgia’s current state plan as detailed below:

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security

Section 4.1.9.1

Number

CS20: Non-Financial Eligibility — Substitution of | Section 4.4.4 Coverage

CS21: Non-Payment of Premiums Section 8.7

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

Centers for Medicare and Medicaid Services Center for Medicaid & CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16

Baltimore, MD 21244-1850 Telephone: (410) 786-5480 Facsimile: (410) 786-5882

Page 2 - Ms. Sheila Alexander Official communications regarding program matters should be sent simultaneously to Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Division of Medicaid and Children's Health Operations. Ms. Glaze's address 1s: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Atlanta Federal Center, 4 th Floor 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. Enclosures cc: Jackie Glaze, ARA, CMS Region IV Sincerely, Eliot Fishman Director Lynette Rhodes, Medicaid Operations, Department of Comm.unity Health

Children's Health Insurance Program Eligibility

Control P ] . ” PUNT tine ae Children's Health Insurance Program Eligibility:

Summary Page

General

Information

File Management name: Transmittal Number:

carina fn inert a a Please enter the Transmittal Number (TN) in the format ST- Tribal Input 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. |GA13-0019 |

Summary

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion (| Establish 2101(f) Group (| Eligibility Processing “ Non-Financial Eligibility Proposed Effective Date

(nn/ da/yvyy)

Federal Statute/ Regulation Citation

[42 CFR § § 320, 380, 340, 350, 805, 342, 355; 42 CFR § § 435.926, 1102

Federal Budget Impact

|| This SPA has a budget impact. Total budget impact: State Funds: $

Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:0 out of 2000

Signature of State Agency Official

Submitted By: Therese Brisco

Last Revision Dec 11, 2013 Date:

Submit Date: Nov 14, 2013

Cems. CHIP Eligibility

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

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Approval Date: FEB 0 6 2014

SPA# GA-13-0019

Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. fo |

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

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

FEB 0 6 2014

SPA# GA-13-0019 Approval Date:

Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

S18

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

Citizenship

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

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

Who are citizens or nationals of the United States; or

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

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

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

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

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

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

The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

(@ Other date, as described:

The month following the date that all other eligibility requirements are met and any required premiums are paid. (Citations: Georgia State Plan: Section 2.2, Page 6, Section 4.3, Page 3)

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing No in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

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

Income Pregnant Women. FEB it] 6 2014

SPA# GA-13-0019 Approval Date:

Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

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

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

FEB 0 6 2014

SPA# GA-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems. CHIP Eligibility

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

42 CFR 457.340(b)

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

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

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

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

[| The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

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

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

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

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

SSN. [yes

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

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

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

PRA Disclosure Statement

FEB 0 6 2014

SPA# GA-13-0019 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

ccms CHIP Eligibility

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

FEB 0 6 2014

SPA# GA-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccmMs. CHIP Eligibility

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

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

Substitution of Coverage

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

[Mi] Substitution of coverage prevention strategy:

Name of policy Description

Waiting Period A member must wait 2 months

A waiting period during which an individual is ineligible due to having dropped group health coverage. How long is the waiting period?

C One month (@ Two months C 90 days

C Other

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

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

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

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

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

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

[BH] The child has special health care needs.

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

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

FEB 0 6 2014

SPA# GA-13-0019 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

aa

cms CHIP Eligibility

TRAE

Describe

* Employer cancellation of the entire group plan;

+ Leave of absence without pay, or reduction of work hours;

* Cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; x «Cancellation of COBRA or an individual insurance policy. ¢ A child born during the two month waiting period.

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

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

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

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

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

V.20130718

FEB 0 6 2014

SPA# GA-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccms CHIP Eligibility

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

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

A member’s coverage can be cancelled due to premium non payment or at the parent’s request. When a member’s coverage is canceled due to non payment they become “Not Enrolled” with reason of lock out or non payment. The lock out period occurs after the member does not pay premiums for a period of two months, which is also known as the grace period. If the account is cancelled due to non payment, the member’s coverage can be reinstated after the one month lockout period or payment of past due premiums, whichever occurs first.

What is the length of the time premium lock-out period? Select a length of time:

@ One month

C Two months

C 90 days

( Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

Individual's income decreased to a level where no premium is required or within Medicaid standards (11 Other financial hardship (2 Other

The state assures that:

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

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

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

PRA Disclosure Statement

FEB 0 6 2014

SPA# GA-13-0019 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CCoMS CHIP Eligibility

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

V.20130917

FEB 0 6 2014

SPA# GA-13-0019 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Georgia State Plan Amendment (SPA) #: GA-13-0025 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Massachusetts consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

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

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

(CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 25 2014

Sheila Alexander .

Program Director, Peach Care for Kids Georgia Department of Community Health 2 Peachtree Street, N.W., 37" Floor Atlanta, GA 30303

Dear Ms. Alexander:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbered GA-13-0025 submitted on December 11, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

SPA number GA13-0025 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XX1-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

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

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

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

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

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

Official communications regarding program matters should be sent simultaneously to

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

Page 2 - Ms. Sheila Alexander Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Atlanta Federal Center, 4th Floor 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. Enclosures cc: Jackie Glaze, ARA, CMS Region IV Sincerely, Eliot Fishman Director Lynette Rhodes, Medicaid Operations, Department of Community Health

Children's Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Georgia

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- ¥YY-0000 where ST= the state abbreviation, YY = the last twa digits of the submission year, and OOOO = a four digit number

with leading zeros. The dashes must also be entered. |GA13-0025

Type of SPA: MAGI Eligibility & Methods ¥ XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility

Proposed Effective Date

(nm/aa/ yyy)

Federal Statute/ Regulation Citation

[42 CFR 457.320{a)(2) -(aj(3)

Federal Budget Impact

This SPA has a budget impact. Total budget impact: State Funds: $

Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:0 out of 2000

Signature of State Agency Official

Submitted By: Therese Brisco

Last Revision Dec 11, 2013 Date:

Submit Date: Dec 11, 2013

CHIP Eligibility

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

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

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

Age and Household Income Ranges

‘

From Age To Age Above (% FPL) Up to & including (% FPL)

19 113 133 xX

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1 148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

FEB 25 2014

SPA# GA13-0025 Approval Date: Effective Date: January 1, 2014

Page | of |

_____________________________________________________________________________ Table of Contents State/Territory Name: Georgia State Plan Amendments (SPA) #: GA-15-0021 This file contains the following documents in the order listed: 1) Approval Letter 2) Final Approved State Plan

ornate a

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services jn C* M Ss

7500 Security Boulevard, Mail Stop S2-01-16 CENTER om MEDICARE & MEDION vices Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 0 3 2016

Dr. Linda Wiant

Chief of the Medicaid Assistance Plans

State of Georgia, Department of Community Health 2 Peachtree Street, NW, Suite 36450

Atlanta, GA 30303

Dear Dr. Wiant:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) GA-15-0021, submitted on December 31, 2015, has been approved. Through this SPA, Georgia eliminates its Express Lane Eligibility (ELE) program. This SPA has an effective date of April 1,2016. ELE is also eliminated in Medicaid, effective March 31, 2016.

Georgia implemented ELE on April 1, 2011 through a partnership with the Special Nutritional Assistance Program for Women, Infants, and Children (WIC). Georgia’s ELE program is no longer needed due to the implementation of the state’s integrated human services and health programs eligibility system, which assesses individuals’ eligibility for Medicaid, CHIP, WIC and other programs through a single application.

Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Lagorio’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-4554

Facsimile: (410) 786-5943

E-mail: Cassandra.Lagorio@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Jackie Glaze, Associate Regional Administrator in our Atlanta Regional Office. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909 + |

Page 2 - Dr. Linda Wiant If you have additional questions, please contact Mr. Manning Pellanda, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff. cc: Jackie Glaze, ARA, CMS Region IV 8?LMrt@ Anne Marie Costello Acting Director •

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998

Form CMS-R-211

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

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

State/Territory:

Georgia

(Name of State/Territory)

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

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

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Clyde Reese Position/Title: Commissioner, Georgia Department of Community Health Name: Position/Title: Name: Position/Title:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 1 Page: 1

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1  Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.  Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3.  A combination of both of the above.

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

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

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date: September 1, 1998

Implementation date: November 1, 1998

State Plan Amendment #1: (Reinstatement policy) Submitted: January 6, 2000 Approved: April 20, 2000 Effective: October 1, 1999

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 1 Page: 2

State Plan Amendment #2: (Clarification of Renewal Process) Submitted: January 31, 2001 Approved: June 1, 2001 Effective: July 1, 2001

State Plan Amendment #3: (Increase eligibility to 235% FPL) Submitted: February 6, 2001 Approved: June 1, 2001 Effective: July 1, 2000

Amendment #4: (Change in enrollment process to cover the month of application) Submitted: June 15, 2001 Approved: August 31, 2001 Effective: April 1, 2001

Amendment #5: (Exempt families spending in excess of 5% of income on private coverage from the crowd-out waiting period) Submitted: September 28, 2001 Approved: February 11, 2002 Effective: October 1, 2001

Amendment #6: (Compliance Amendment) Submitted: July 30, 2002 Approved: January 17, 2003 Effective: August 1, 2002

Amendment #7: (Cost-sharing increase) Submitted: July 3, 2003 Approved: September 25, 2003 Effective: July 1, 2003

Amendment #8: (Administrative policy changes) Submitted: July 18, 2003 RESCINDED

Amendment #9: (Change to single late notice) Submitted: February 13, 2004 Approved: Pending Effective: January 1, 2004

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 1 Page: 3

Amendment #10: (Change to premiums and administrative policy changes) Submitted: June 21, 2004 Approved: September 17, 2004 Effective: July 1, 2004

Amendment #11: (Change to premium policy, Dental benefit, and Managed Care delivery system) Submitted: July 7, 2005 Approved: September 30, 2005 Effective: Dental Benefit effective July 1, 2005 Premium Policy effective August 1, 2005 Managed Care delivery system effective January 1, 2006

Amendment #12: (Change Dental Benefit) Submitted: August 29, 2006 Approved: November 2, 2006 Effective: Dental Benefit effective in accordance with Georgia Families Roll out. Effective June 1, 2006 in Atlanta and Central Region; September 1, 2006 Statewide.

Amendment #13: (Adopt Enrollment Freeze) Submitted: March 20, 2007 Approved: June 15, 2007 Effective: Close program to new enrollments effective March 11, 2007 and add CMOS Quality assessment fees as a new source of state funds effective March 20, 2007. Updated name change of Georgia Healthy Families to Georgia Families.

Amendment #14: (Implement Full Verification of Income, Citizenship and Identity and Open Enrollment) Submitted: July 5, 2007 Approved: October 25, 2007 Effective: Require full verification of income, citizenship and identity for all PeachCare applicants and members effective July 1, 2007. Resume

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 1 Page: 4

enrollment in program effective July 12, 2007 until enrollment reaches 295,000 children.

Amendment #15: (Grace Period, Income, Citizenship and Identity updates) Submitted: July 13, 2010 Approved: February 10, 2011 Effective: Grace Period Change effective July 31, 2010 Citizenship Changes effective January 1, 2010 Income documentation changes to further align with Medicaid effective June 1, 2010

Amendment 16: Designate Express Lane Eligibility agency as the Special Nutritional Assistance Program for Women, Infants and Children (WIC) Submitted: February 7, 2011 Approved: April 13, 2011 Effective : April 1, 2011

Amendment #17: (Implement new co-payments for PeachCare for Kids®) Submitted: June 27, 2011 Approved: September 28, 2011 Effective: November 1, 2011

Amendment 18: Enrollment of Children of Public Agency Employees Submitted: August 30, 2011 Approved: November 18, 2011 Effective : January 1, 2012

Amendment #19: (Implement co-payment changes for PeachCare for Kids®) Submitted: March 1, 2012 Approved: April 9, 2012 Effective: April 1, 2012

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 1 Page: 5

Amendment 20: Update Premium amounts and delete outdated information Submitted: May 2, 2014 Approved: March 31, 2015 Effective: January 1, 2014

Amendment 21: End Express Lane Eligibility Submitted: December 31, 2015 Approved: February 3, 2016 Effective: April 1, 2016

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 1 Page: 6

Superseding Pages of MAGI CHIP State Plan Material State: Georgia

Transmittal Number SPA Group PDF# Description Superseded Plan Section(s) GA-13-0016

Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS10

CS10

CS10

CS10

CS13

CS15 Eligibility – Targeted Low Income Children

Children Who Have Access to Public Employee Coverage

Maintenance of Agency Contribution (State Health Benefit Plan Employees)

Children Who Have Access to Public Employee Coverage

Hardship Exception (Board of Regents Employees)

Deemed Newborns

MAGI-Based Income Methodologies Supersedes the current sections 4.1.1; 4.1.2; 4.1.3

Supersedes the current section 4.4.1 information on dependents of employees of a public agency

Supersedes current documentation in Appendix

Supersedes the current section 4.4.1 information on dependents of employees of a public agency

Supersedes current documentation in Appendix

Adds new subsection in Section 4.3

Adds new subsection in Section 4.3 and supersedes information on income counting

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 1 Page: 7

GA-13-0025

Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 GA-13-0017

Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 GA-13-0018

Effective/Implementation Date: October 1, 2013 Eligibility Process Group CS24 Eligibility Processing Supersedes the current section 4.3; 4.4 GA-14-0019

Effective/Implementation Date: January 1, 2014 Non- Financial Eligibility CS17

CS18

CS19

CS20

CS21

Non-Financial Eligibility – Residency

Non-Financial – Citizenship

Non-Financial – Social Security Number

Substitution of Coverage

Non-Payment of Premiums

Supersedes the current section 4.1.5

Supersedes the current sections 4.1.0; 4.1-LR; 4.1.1-LR

Supersedes the current section 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.1 Page: 1

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

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

Of the 2,219,179 children in the state, Georgia estimates (using the Current Population Survey data from 2000) that 193,558 are without any creditable coverage. Of the 2.03 million who do have creditable coverage, 912,116 (almost half) have coverage through Georgia Medicaid. The 193,558 without coverage includes 141,489 children with income below 235% of the FPL. Of these children, 104,446 could be eligible for the Medicaid program. The other 37,043 are potentially eligible for PeachCare for Kids. FPL changed to 247% of FPL January 2014.

When compared to figures from the 1993-1995 period, the current data show that while the number of children in the state has grown by about 10%, the number of children without coverage has declined by about 40%. Part of this improvement is due to a decrease in the number of Medicaid eligible uninsured children from 39% to 24%, and a decrease in the number of PeachCare eligible uninsured children form 32% to 6%. The remaining uninsured children, whether eligible for PeachCare or Medicaid, will be targeted for enrollment through the state’s marketing and outreach efforts.

The estimates of children with creditable coverage in the following table are based on the Current Population Survey and are submitted as requested to allow comparisons to be made between states and on a nationwide basis. The sources of the data are the Current Population Survey for the year 2000, and the combined tape 1994, 1995, 1996 (data for years 1993, 1994, 1995).

Unfortunately at this time we are unable to examine the insurance status of children in Georgia by income level, age, race, and location for the year 2000. The Census has only released a small sample of records for Georgia at this time. Due to the small sample size it is unadvisable to estimate the numbers of uninsured eligible children within each demographic grouping. The Census is

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.1 Page: 2

expected to release an expanded sample shortly. Upon release, these figures will be updated.

Calculations were made by William S. Custer, Ph.D. and Patricia Ketsche, Center for Risk Management and Insurance Research, Georgia State University. The sample size for some categories is very small, and the numbers should be used with caution.

Insurance Status of Children in Georgia Attributes of Population Current Medicaid Enrollees Children without Creditable Coverage* TOTAL (2000) TOTAL (1993,1994,1995) Income Level (1993,1994,1995) <100% 100-133% 134-185% 186-200% >=200% Age (1993,1994,1995) 0 to1 1 through 5 6 through 12 13 through 18 Race/Ethnicity (1993,1994,1995) Black, non-Hispanic Hispanic White, non-Hispanic Other**** Location (1993,1994,1995) MSA non-MSA 753,114 759,023 ** ** ** 0 0 107,591 256,618 243,021 151,793 429,690 32,006 262,585 34,742 425,174 333,849 Total 193,558 320,243 112,449 47,928 56,718 10,508 92,640 16,037 67,165 119,112 117,929 164,500 14,009 135,817 5,827 181,618 138,625 Eligible for Medicaid Eligible for CHIP 104,446 124,621 112,449 7,061 5,111 0 0 7,744 28,938 38,634 49,305 74,298 7,844 42,281 198 67,993 56,627 24% 39% 100% 15% 9% 0% 0% 48% 43% 32% 42% 50% 60% 35% 3% 37% 41% 37,043 102,982 *** 40,867 51,607 10,508 0 *** 14,901 54,199 33,882 54,455 3,113 43,619 1,795 53,843 49,138 6% 32 % 0% 85 % 91 % 100 % 0% 0% 22 % 46 % 29 % 33 %

*The percentages of children without creditable coverage do not add to 100% in

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.1 Page: 3

the age, race/ethnicity and location categories because children over 200% of poverty are not included, since they were not eligible for Medicaid or for PeachCare for Kids. **The current Medicaid information system does not have income data on non- SSI Medicaid eligibles. However, Medicaid has no enrollees at income levels above 185% of poverty ***CPS did not identify any individuals in this cell. ****Other racial/ethnic groups cannot be reported for GA from CPS due to very small sample size.

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 1

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

Currently, Georgia’s public child health insurance plans include PeachCare for Kids® and the Medicaid program administered by the Georgia Department of Community Health (DCH), Division of Medical Assistance (DMA). The Department has several approaches to identifying and enrolling eligible children. These approaches are described in the following paragraphs.

PeachCare for Kids®

PeachCare for Kids’ outreach effort was launched in September 1998. Outreach initiatives have included a wide array of mass-media and local grassroots efforts. PeachCare for Kids has had massive advertising, in both English and Spanish, through television, radio, newspaper, and outdoor billboard and transit advertising. In 2001 and 2002, PeachCare has teamed up with WSB Channel 2’s, Atlanta’s ABC affiliate, Family 2 Family Community Program. Through this partnership, PeachCare for Kids is able to participate in hundreds of family-oriented community events in the metro Atlanta area. PeachCare also benefits from the extensive public service campaigns.

In 2000, the Department created a “minigrant” program to facilitate grassroots efforts to educate targeted populations about PeachCare for Kids and Medicaid. The grantee organizations were diverse in the populations they served, including African-American, Hispanic, Asian and rural communities. An evaluation of the grantees showed a 16% increase in applications submitted over other similar counties during the same time, and a 19% increase in applications for the targeted populations.

In 2000, 2001, and 2002, the Department has teamed up with the Department of Education, Division of School Nutrition Services to distribute flyers, in English and Spanish, to each student during Back-to- School registration. The Right from the Start Medicaid (RSM) outreach

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 2

staff worked with many elementary schools to be on site promoting PeachCare for Kids and Medicaid to the parents.

PeachCare for Kids®, RSM, March of Dimes and Kmart stores partnered in 1999 and 2000 to promote PeachCare for Kids and Medicaid. In 1999, outreach workers were at each Kmart store on the Saturday before Halloween educating parents while their children shopped for costumes and treats. In 2000, the outreach workers returned to Kmarts on the Saturday before school started to talk to parents as they were getting their kids ready for the new school year.

The Department has created a simple, one-page mail-in application for PeachCare for Kids, available in English, Spanish, Vietnamese, Chinese, Korean and Somalian. The application is distributed by request through the PeachCare for Kids call center and throughout the state in many hospitals, provider offices, Department of Families and Children offices, health departments, and libraries.

In 2001, the Department launched www.peachcare.org, a web-based application designed to provide parents with instant access to complete the enrollment process. In its first year, applications have been received for nearly 40,000 children through the website. The site has also been successful reaching families of Medicaid-eligible children. Nearly half of all web-based applicants have been eligible for the Medicaid program. The advantages of the website are numerous. It eliminates mail delays. It provides parents with instant confirmation that the application has been received and gives parents an estimation of potential eligibility. The website also generates a list of participating primary care physicians to assist parents in the selection of a doctor for their child.

Division of Family and Children Services (DFCS)

The Department of Medical Assistance has an interagency agreement with the Department of Human Resources (DHR) to provide, through its Division of Family and Children Services (DFCS), Medicaid eligibility determinations for all Medicaid coverage groups other than SSI cash assistance. For pregnant women and children, these coverage groups include: Low Income Medicaid, Medically Needy, Right From the Start Medicaid (RSM - Georgia’s poverty level Medicaid program), and the Katie Beckett Deeming Waiver programs. These programs are offered in conjunction with other entitlement programs and supportive services that

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 3

are offered by DFCS. DFCS is also responsible for Food Stamps, Temporary Assistance for Needy Families (TANF), Child Protective Services and Foster Care. The Medicaid application process is coordinated with that for cash assistance and employment related services available through TANF. Children in families seeking these services also have their Medicaid eligibility determined. The State of Georgia has 159 counties. Each county has at least one DFCS office, and some counties have multiple sites for Medicaid eligibility intake. Some workers from these local DFCS offices are assigned to Federally Qualified Health Centers (FQHCs) and Disproportionate Share Hospitals.

While the bulk of the state’s Medicaid determinations are made locally at the county DFCS offices, the RSM Outreach Project is an aggressive outreach program targeted at enrolling uninsured and underinsured poverty level pregnant women and children in Medicaid and PeachCare. This project operates under a separate interagency agreement between the Department of Community Health and the Department of Human Resources. The eligibility workers who are part of this project are housed in locations other than the local DFCS offices.

Public Health Departments and Federally Qualified Health Centers

DCH also coordinates Medicaid enrollment efforts with the activities of the Division of Public Health, a part of the Department of Human Resources. Across the state, perinatal case management services and the Medicaid application process are linked. At the public health departments and federally qualified health centers, a pregnant woman can apply for Presumptive Medicaid eligibility, and begin receiving prenatal services immediately. As part of this process, the pregnant woman applies for RSM Medicaid to ensure ongoing Medicaid eligibility. When the pregnant woman applies for RSM, any children in the family are also included on the application form and the form with the children’s names are routed to

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 4

DFCS for a determination of their eligibility along with that of the pregnant woman.

The Division of Public Health, through its local health departments, and the federally qualified health centers administer the Special Nutritional Program for Women, Infants and Children (WIC). This program provides nutritious food to supplement the regular diet of pregnant women, breast- feeding women, infants, and children under age five who meet state income standards. Generally, on the initial visit to either of these facilities, the pregnant woman is certified for Presumptive Medicaid eligibility, applies for regular Medicaid for herself and her children, and receives WIC for herself and any children under the age of five (5). The PeachCare for Kids® program also recognizes the WIC program as an Express Lane agency.

Express Lane Eligibility was implemented effective April 1, 2011 and ended April 1, 2016

(1902 (e) (13) of the Social Security Act). The program partnered with the Special Nutritional Assistance Program for Women, Infants, and Children (WIC) to implement the program.

Other State Initiatives For Special Needs Children

The following programs are some of the State’s own initiatives to provide health care to special needs children. All are administered by the Department of Human Resources, three by the Division of Public Health, two by the Division of Mental Health, Mental Retardation and Substance Abuse and one by an interagency team. As mentioned previously, RSM outreach workers are stationed in many county public health departments or visit on a routine basis to process Medicaid applications. Uninsured children who present to these programs for their services are referred to outreach workers or county DFCS offices to have a Medicaid eligibility determination completed.

Division of Public Health “Babies Can’t Wait”

“Babies Can’t Wait” or the Early Intervention Program is Georgia’s statewide interagency service delivery system for children from birth to three years who have developmental delays or disabilities. This program guarantees that all children, regardless of their disability, have access to services that will enhance their development. Services are provided by agencies and

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 5

individuals from both the public and private sectors. Some are offered at no cost. For others, state funds are available to assist families that have been determined unable to pay. Medicaid eligible children may participate in this program.

Children’s Medical Services

Children’s Medical Services (CMS), formerly the Crippled Children’s Program, provides medical care to low income children with disabling conditions or chronic diseases. It also provides specialized health care for certain disorders, e.g., chronic lung disease, craniofacial anomalies, and cystic fibrosis. Eligibility is based on the age of the child ( 0-21 years), type of medical condition, Georgia residency and annual family income. Some services are covered by Medicaid and Medicaid eligible children may participate in this program. CMS serves approximately 15,000 to 16,000 children yearly.

Department of Behavioral Health and Developmental Disabilities

Core and Specialty Services include evaluation/assessment, diagnosis, counseling and medication, therapy (individual, group, and family), community support services, crisis assessments, and physician services. These services are provided in clinics and other locations as needed, including homes, schools, detention facilities, and other community settings.

Crisis Services include crisis stabilization and mobile crisis response services.

Mobile Crisis Response Services (MCRS) provides community-based, face-to-face crisis response 24 hours a day, seven days a week to individuals in an active state of crisis. MCRS offers short-term, behavioral health services for persons in need who may have been unable to successfully maintain stability.

Psychiatric Residential Treatment (PRTF) Services provide comprehensive mental health and substance abuse treatment to children, adolescents, and young adults ages 5-21 who, due to severe emotional disturbance, are in need of quality active treatment that can only be provided in an inpatient treatment setting and for whom alternative, less restrictive forms of treatment have been tried and found unsuccessful or are not medically indicated.

Uninsured children who present to these programs for their services are

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.2 Page: 6

referred for a Medicaid eligibility determination, but services are provided to uninsured or underinsured children on a sliding fee scale and are not denied due to inability to pay.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

The State of Georgia has one public-private program designed to provide health care to uninsured children; however, this program does not offer “creditable coverage.” The PeachCare for Kids and Medicaid program’s eligibility processes have a significant role in the efforts of the program. The application process for The Georgia Partnership for Caring Program begins with the RSM Outreach Project worker.

Georgia Partnership for Caring Foundation

The Georgia Partnership for Caring Foundation (GPCF) was established in 1994 and represents a unique partnership between state government and the private sector. The mission of GPCF is to establish a free health care referral program for Georgians who cannot afford private health insurance but are not eligible for governmental medical assistance such as PeachCare for Kids, Medicaid or Medicare. Funding has been provided by grants from individuals, associations, and the Departments of Human Resources and Community Health.

The program includes the limited voluntary services of physicians, nurse practitioners, dentists, ophthalmologists, optometrists, physician’s assistants, hospitals, pharmacists, pharmaceutical manufacturers, and many health provider groups and agencies. These volunteers are not paid for their services or products, but are committed to assisting Georgians obtain access to needed health care coverage. The program is available in about three-fifths of Georgia’s counties. GPCF is not insurance coverage. It is not for emergencies or urgent care situations. Application processing time averages 1 month. As previously stated, RSM outreach workers are involved in the referral and application process for GPCF. They perform the screening function to determine that individuals who are referred to GPCF are not eligible for Medicaid.

The Georgia Partnership for Caring Program ended in 2010.

Effective Date: September 1, 1998 Revision Effective Date: August 1, 2002 Approval Date: September 3, 1998 State: Georgia Section: 2.3 Page: 1

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

As part of its effort to decrease the number of uninsured children, Georgia targets children who are under the age of nineteen (19), who have family income that is at or below 235% of the Federal Poverty Level (FPL), and who do not have other creditable health coverage. PeachCare for Kids health benefit coverage is provided to these children through a state child health insurance program that is administered by the DCH, the same agency that administers the Medicaid program.

PeachCare enrolls only eligible, targeted low-income children because marketing, outreach and eligibility determination efforts will be completely coordinated for PeachCare for Kids and Medicaid, so that those children who are eligible for Medicaid will be enrolled in Medicaid rather than PeachCare. The marketing and outreach efforts target all children at or below 235% of the FPL. RSM outreach workers have available all pertinent information for both Medicaid and PeachCare for Kids. The outreach workers have a variety of program information on both creditable and non-creditable coverage and other ways to access health care services. The order of priority for the outreach workers is first to locate uninsured children, second to determine eligibility for Medicaid, third to provide information and assistance regarding enrollment in PeachCare for Kids, fourth to provide information on the Georgia Partnership for Caring Foundation, and DHR public health care programs and services. The marketing and outreach efforts are coordinated with community based organizations and health care providers.

Applications for PeachCare for Kids contain the information necessary to determine eligibility for Medicaid as well as for PeachCare for Kids. Applications are mailed to and processed by a Third Party Administrator (TPA) at a centralized location. As part of the eligibility determination process, the TPA screens applications for Medicaid eligibility before determining eligibility for PeachCare for Kids. If a child or children on the application appear to possibly be eligible for Medicaid, the application for that child or those children is processed by RSM workers. The processing provides for investigation and verification of both the financial and non- financial requirements for the Medicaid program. If the child or

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children are eligible for Medicaid, Medicaid enrollment will occur, rather than eligibility determination for PeachCare for Kids. If the RSM worker finds the child or children ineligible for Medicaid, then the TPA determines eligibility for PeachCare for Kids.

If the child or children are found to be income eligible and under age 5, they are notified of their eligibility to enroll in the Georgia Women, Infants and Children (WIC) program. Because the Georgia WIC program serves a significant number of children younger than 5 years, it is often called on to assess immunization status and screen for child health problems. Prospective participants in the WIC program must undergo a variety of nutritional screenings to determine eligibility. These include assessments of height, weight, diet, and health history.

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Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

The PeachCare for Kids® legislation mandates that “Any health care provider who is enrolled in the Medicaid program shall be deemed to be enrolled in the program.” Therefore, the current Medicaid health assistance delivery and utilization control system is the system used for PeachCare for Kids. Service delivery is accomplished through a variety of relationships and agreements with private medical providers and state agencies.

The PeachCare for Kids legislation allows the DCH to contract with licensed care management organizations (CMOs) as a condition of receiving coverage under the program. As a condition of participation, all enrolled providers in each category of service must be fully licensed and/or certified under all applicable state and federal laws to perform the services provided to participants.

Georgia Families

PeachCare for Kids® members will be enrolled in a commercially licensed care management organization (CMO) that is contracted by DCH. Membership in Georgia Families (GF) is mandatory for all PeachCare for Kids® members and most pregnant women and children eligible for Medicaid.

Through GF, each CMO contracts with primary care physicians, specialists and other providers to deliver and coordinate health care services for PeachCare for Kids members. The CMO receives a per member per month capitation rate for providing and coordinating members’ health care services, regardless of whether the member is seen.

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Five key goals of the program are to (1) improve the health care status of enrolled populations (2) Establish a “provider home” for Members through its use of assigned Primary Care Providers (PCPs) (3) Establish contractual accountability for access to, and quality of, healthcare (4) Slow the rate of growth in PeachCare costs (4) Implement an intelligent health system where members have accurate, timely knowledge of their health needs, access to the best information about how to maintain their health, knowledge of who and where to go if they have health needs, and an assurance that their health providers will be using best practices based on the most recent understanding of outcomes based medicine.

Members are given an opportunity to select a CMO in his or her area as well as a PCP within that CMO. For those who do not make a selection, a computer algorithm is used to assign a member to a CMO. Conditioned on continued eligibility, all members will be enrolled in a CMO plan for a period of twelve (12) consecutive months. The member has 90 days to change CMO plans before the continuous enrollment period or lock-in period begins.

The contracted CMOs must assure that PeachCare for Kids members are offered freedom of choice in selecting a PCP. Each contracted CMO includes in its network of PCPs physicians who routinely provide primary care services in the areas of Family Practice, General Practice, or Internal Medicine. Also, Nurse Practitioners Certified (NP-C) specializing in Family Practice or Pediatrics may enroll as PCPs. Finally, Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) may be included as PCPs.

In the event a PCP is auto-assigned, the member may change to another PCP by making a PCP selection and requesting the change. The contracted enrollment broker handles the CMO assignment functions (both self-selection and auto-assignment).

Payment Methodologies of FQHC/RHC Unit

Our providers are paid the Prospective Payment Method (PPS) or Alternative Payment plan method. When a Federal Qualified Health Center (FQHC) and/or Rural Health Clinic (RHC) application is received from DCH Enrollment unit, they are paid utilizing the PPS method. Only the Critical Access Hospital RHC’s (CAH RHC) are given the option of choosing the PPS method or the Alternative method of payment.

PPS Rate Method

The basis of the PPS reimbursement is providing for “core” services and other ambulatory services per encounter visit cost during FY 1999 and FY 2000. This

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baseline rate, effective January 2001, is utilized as the basis for rates in succeeding years. Annually, each FQHC/RHC’s per visit rate is calculated by adjusting the prior year’s rate by the Medical Economic Index (MEI). The MEI is announced in Recurring Update Notifications (RUNs) issued by Centers for Medicare and Medicaid Services (CMS) each year.

For newly qualified FQHCs and RHCs that participate in PPS payments after FY 2000 have their rates established by a statewide average for similar centers. Similar meaning, all FQHCs, hospital based RHCs, and free standing RHCs; each have an average state rate. After the initial year, payment will be set using the MEI and change of scope methods used for other clinics.

Change of Scope

A change in scope of services for a FQHC and RHC is defined as a change in the type, intensity, duration and/or amount of services. It is the clinics responsibility to recognize any changes in their scope of services and to notify the Department of those changes and to provide documentation and projections of the cost and volume impact of the change. Once all documents are received, a review of clinic activity is completed. This may happen once a year.

Alternative Payment Method

This method is only available to critical access hospital RHCs; they have the choice of the PPS method of payment listed above or the Alternative Payment Method (APM). The APM is a cost based reimbursement method. The Department will calculate the settlement based on the hospital cost report. If the hospital cost is lower than the equivalent PPS rate, the Department will make the additional payment up to the equivalent of PPS rate. This information is derived from the latest cost report and the critical access hospital reports (HS&R reports) for the same period. The Department reviews CAH-RHC activity annually to determine if payment is due to the hospital from the Department or if the hospital owes the Department for over payment.

Settlement Calculation

Annually the department obtains the latest available cost report as well as the hospital statistical and reimbursement report (HS&R reports) from each CAH-RHC. The new percentage is derived from the information from the cost report annually. The comparison of cost to expenses is obtained from the HS&R reports. The amount the Department paid to the CAH-RHC as well as the number of visits are obtained from the HS&R reports. The visits are multiplied by the PPS rate (normally the state average) to determine what the PPS total amount would have been if chosen by the clinic. The reimbursement amount is compared to the PPS amount

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to determine if the clinic was paid at least the PPS. If not, the department will reimburse the hospital.

CMO’s (Care Management Organization)

When an FQHC or RHC provides services pursuant to a contract between the clinic and a Care Management Organization, the State shall perform a reconciliation at least annually, and as needed to ensure that CMO payment equivalent to the amount calculated under the PPS rate. The State is responsible based on the contract between the department and CMO equal to the amount by which the PPS rate exceeds the amount of the payments provided by the CMO on an aggregate annual base. Any such supplemental payments shall be made pursuant to a payment schedule agreed to by the State and the clinic.

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3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Reimbursement Limitations

The federal government allows DCH to place appropriate limits in regard to medical necessity and utilization control. Reimbursement limitations such as prior approval requirements, service limitations, non-covered procedures, and eligibility limitations are used by DCH to guarantee appropriate utilization of funds.

Georgia Families

The CMO provides assistance to Members and Providers to ensure the appropriate utilization of resources, using the following program components: prior authorization and pre- certification, prospective review, concurrent review, retrospective review, ambulatory review, second opinion, discharge planning and case management. Specifically, the CMO has written Utilization Management Policies and Procedures that:

• Include protocols and criteria for evaluating Medical Necessity, authorizing services, and detecting and addressing over-utilization and under- utilization. Such protocols and criteria comply with Federal and State laws and regulations. • Address which services require PCP Referral; which services require Prior-Authorization and how requests for initial and continuing services are processed, and which services will be subject to concurrent, retrospective or prospective review. • Describe mechanisms in place that ensure consistent application of review criteria for authorization decisions. • Require that all Medical Necessity determinations be made in accordance with DCH’s Medical Necessity definition.

Georgia Families also provides care coordination, case management, disease management, clinical outcome studies, and physician incentive programming.

Specifically, each CMO must provide individual needs assessment and diagnostic assessments; develop individual treatment plans, as necessary, based on the needs assessment; establish treatment objectives; monitor outcomes; and maintain a process to ensure that treatment plans are revised as necessary. The CMOs must also guarantee a strategy is in place to ensure that

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all Members and/or family members or guardians are involved in treatment planning.

The CMO is required to develop disease management programs for individuals with chronic conditions such as diabetes and asthma. Additionally, each CMO must have programs for at least two additional conditions including: Perinatal case management, obesity, hypertension, Sickle cell disease; or HIV/AIDS.

By looking at other State’s experiences with Medicaid and SCHIP managed care, DCH expects that the GF program will save State and Federal dollars by appropriately controlling utilization, improving access to primary care services and enhancing continuity of care. Numerous studies support the theory that improving members’ access to primary care and providing appropriate disease management standards reduce the rate of growth in expenditures and ultimately result in savings through reduced likelihood of hospitalization for serious illnesses, reduced number of unnecessary visits to emergency rooms for non- emergency care, and reduced visits to specialists for care that could be provided through a primary care physician.

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Superseded by ACA SPA

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 21 02)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.0.  Non-Financial Eligibility – Citizenship

4.1.1.  Geographic area served by the Plan: Georgia’s Title XXI plan is available statewide to children in all 159 Georgia counties

4.1.2.  Age: The plan will be available to children 0 through 18 years of age. If the child is otherwise eligible, coverage will continue through the month of his/her nineteenth birthday.

4.1.3.  Income: Eligible children will have family income that is at or below 235% of the federal poverty level and will not be eligible for Medicaid.

4.1.4.  Resources (including any standards relating to spend downs and disposition of resources): There is no resource test.

4.1.5.  Residency (so long as residency requirement is not based on length of time in state): Georgia residency is required. Residency is based on current circumstances. There is no requirement that a child must live in Georgia a specified length of time prior to application.

Non-Financial Eligibility – Residency

4.1.6.  Disability Status (so long as any standard relating to disability status does not restrict eligibility): No child will be denied eligibility based on disability status.

4.1.7.  Access to or coverage under other health coverage: A child will be denied eligibility if it is determined that he or she: 1) is covered

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Superseded by ACA SPA under a group health plan or under health insurance coverage as

defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) voluntarily dropped coverage under an employer plan during the past six months. (Voluntary termination of coverage does NOT include the following: employer cancellation of the entire group plan; loss of eligibility due to parent’s layoff, resignation of parent from employment, employment termination; leave of absence without pay, or reduction of work hours; cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; cancellation of an individual within a family policy due to meeting lifetime maximum of benefits; or cancellation of COBRA or an individual insurance policy. A child born during the six month waiting period would be eligible.) The CHIP application will contain questions about current and past coverage under group health plans. Access to State health benefits will be verified through monthly matches with the State Merit System and the Board of Regents. In addition, as claims are paid, if the providers report coverage under other health plans, eligibility will be terminated if the coverage meets any of the three criteria listed above.

4.1.8.  Duration of eligibility: With the approval of the PeachCare application, a child will be eligible for twelve months as long as eligibility criteria continue to be met. The family will be notified of its responsibility to report changes in income, residency or health insurance coverage. There will be monthly matches with the Medicaid MMIS to ensure that Title XXI children have not been certified for Medicaid. At the end of the twelve-month eligibility period, the family will be sent a letter detailing the information on the family’s account pertinent to eligibility. The family will be required to report any changes to the information and provide verification of all sources of income at this time. Eligibility will be redetermined for another twelve-month period so long as the family provides the required documentation within the requested timeframe.

4.1.9.  Other standards (identify and describe):

• Consistent with 42 CFR 457.340(b), PeachCare does not require Social Security numbers for any applicant. Eligibility is not denied for failure to provide a Social Security Number; however, Social Security Numbers are requested of individuals listed on the application.

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4.1.9.1  Non-Financial Eligibility – Social Security Number

See Attachment 5

4.1.10 Children’s Health Insurance Program Eligibility – Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards

See ACA pages at end of SPA document

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4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.  These standards do not discriminate on the basis of diagnosis. 4.2.2.  Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.  These standards do not deny eligibility based on a child having a pre-existing medical condition.

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4.3. Describe the methods of establishing eligibility and continuing entart Medicaid program (Title XIX Poverty Level Group).

DCH contracts with a Third Party Administrator (TPA) who is responsible for receiving PeachCare applications, screening for Medicaid eligibility, determining PeachCare eligibility, processing monthly premium payments and coordinating coverage between PeachCare and Medicaid for applicant children who qualify for either the Title XIX or Title XXI program.

Customer Service is a major component of the functions required of the Third Party Administrator. The TPA’s telephone customer service staff is expected to furnish PeachCare applications upon request, provide assistance to potential applicants who may have questions about the program in general or who may need assistance in the completion of the form. The following process is used to establish eligibility and continuing enrollment:

APPLICATION

PeachCare for Kids has a single-page mail-in application form and a web-based enrollment process that is available for families to quickly and easily apply for health care coverage for their children. Both the mail-in and web-based applications can be used to enroll children in either Medicaid or PeachCare for Kids, depending on each child’s eligibility. The PeachCare application gathers information about the applicant children and their parents. Requested information includes:

• Documentation of amount, frequency and source of earned and unearned income • Amount, frequency and source of child care expenses • Health insurance status of family members • Current address • U. S. Citizen/Lawful Alien Status of children

VERIFICATION OF INCOME, CITIZENSHIP/LEGAL RESIDENCY AND IDENTITY

Beginning July 1, 2007, all PeachCare applicants are required to provide verification of income, citizenship/legal residency and identity. The application

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directs families to send in the most recent proof of all earned and unearned income sources. The following documentation is requested:

A. Earned Income - money anyone in the household received from providing a service. • Weekly pay – (4) weeks of pay stubs (one week after the other) • Bi-Weekly pay – (2) pay stubs received every other week (one after the other) • Semi-Monthly – (2) pay stubs received two times a month (one after the other) • Monthly – (2) pay stubs received one time a month (one month after another) • Yearly – Federal Tax Form • Paid in cash-letter from Employer provided by an Officer of the Company. Must be provided on Company letterhead.

Self-employment documents: • business ledger/receipts • tax forms- 1040, 1040A, 1040EZ • bank deposits • applicant/recipient's signed statement if neither of the above is available.

NOTE: Assume that any deductions taken on a tax return or business record is allowable by the Internal Revenue Service.

Document the case record as to why federal income tax returns or business records were not used if the A/R’s statement was accepted as verification.

B. Unearned Income –money anyone in the household received from any agencies, parents or relatives, friends, or any other sources. a. SSI or SSA – Current year or most recent award letter b. Unemployment check – (4) weeks of pay stubs (one week after the other) or award letter c. Workman’s Compensation – letter from insurance company stating amount received and how often received, provide contact name and number d. Child Support (paid through court) – court papers or letter stating amount of income received and how often it is received. e. Contributions – written statement from the person who gives you money. Provide name, address, and contact number. Provide amount received and how often received f. Child Support (paid directly to custodial parent) – written statement from

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the parent who pays the child support to the applicant/recipient-. Provide the name, address, and contact number. Provide amount received and how often received. g. Other Unearned Income – letter from the source stating amount received and how often received. Provide name, address, and contact number or (4) weeks of pay stubs (one week after the other)

C. Citizenship/Identity/Legal Residency

Georgia follows the DRA provisions regarding citizenship/nationality and as of January 1, 2010, has updated its process to comply with section 211 of CHIPRA. PeachCare for Kids applicants must declare their citizenship or alien status and provide documentation, as described in CFR 435.407, that verify they are in an eligible status to receive benefits. As required in CHIPRA section 211, the State will not deny, delay, reduce, or terminate benefits while the documentation is gathered during a reasonable opportunity period. If an applicant is determined to be eligible for PeachCare for Kids, but citizenship documentation is still outstanding, the State will continue to provide PeachCare for Kids benefits until the end of the reasonable opportunity period.

For determining deemed newborn status, the TPA performs a data match with Georgia’s MMIS files to determine whether the applicant’s mother was Medicaid eligible per the date of the child’s birth. If citizenship cannot be verified through data match with vital records or MMIS records, the applicant is then required to submit a form of acceptable documentation as outlined in CFR 435.407.

The following groups of individuals are exempt from the requirements:

• Individuals receiving SSI benefits under title XVI of the Act. • Individuals entitled to or enrolled in any part of Medicare. • Individuals receiving disability insurance benefits under section 223 of the Act or monthly benefits under section 202 of the Act, based on the individual's disability (as defined in section 223(d) of the Act). • Individuals who are in foster care and who are assisted under Title IV-B of the Act, and individuals who are recipients of foster care maintenance or adoption assistance payments under Title IV–E of the Act.

Types of acceptable documentary evidence of citizenship.

For purposes of this section, the term “citizenship” includes status as a “national of the United States” as defined by section 101(a)(22) of the Immigration and Nationality Act

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(8 U.S.C. 1101(a)(22)) to include both citizens of the United States and non-citizen nationals of the United States.

(a) Primary evidence of citizenship and identity. The following evidence must be accepted as satisfactory documentary evidence of both identity and citizenship:

(1) A U.S. passport. The Department of State issues this. A U.S. passport does not have to be currently valid to be accepted as evidence of U.S. citizenship, as long as it was originally issued without limitation .Note: Spouses and children were sometimes included on one passport through 1980. U.S. passports issued after 1980 show only one person. Consequently, the citizenship and identity of the included person can be established when one of these passports is presented. Exception: Do not accept any passport as evidence of U.S. citizenship when it was issued with a limitation. However, such a passport may be used as proof of identity.

(2) A Certificate of Naturalization (DHS Forms N–550 or N–570.) Department of Homeland Security issues for naturalization.

(3) A Certificate of U.S. Citizenship (DHS Forms N–560 or N–561.) Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent.

(4) A valid State-issued driver's license, but only if the State issuing the license requires proof of U.S. citizenship before issuance of such license or obtains a social security number from the applicant and verifies before certification that such number is valid and assigned to the applicant who is a citizen. (This provision is not effective until such time as a State makes providing evidence of citizenship a condition of issuing a driver's license and evidence that the license holder is a citizen is included on the license or in a system of records available to the Medicaid agency. The State must ensure that the process complies with this statutory provision in section 6036 of the Deficit Reduction Act of 2005. CMS will monitor compliance of States implementing this provision.).

(5) A Tribal document issued by a federally recognized Indian tribe evidencing membership, enrollment in, or affiliation with such Tribe is satisfactory documentary evidence of an individual’s U.S. citizenship or nationality.

(b) Secondary evidence of citizenship. If primary evidence from the list in paragraph (a) of this section is unavailable, an applicant or recipient should provide satisfactory documentary evidence of citizenship from the list specified in this section to establish citizenship and satisfactory documentary evidence from paragraph (e) of this section to establish identity, in accordance with the rules specified in this section.

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(1) A U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (if born on or after January 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after January 17, 1917), American Samoa, Swain's Island, or the Northern Mariana Islands (after November 4, 1986 (NMI local time)). A State, at its option, may use a cross match with a State vital statistics agency to document a birth record. The birth record document may be issued by the State, Commonwealth, Territory, or local jurisdiction. It must have been recorded before the person was 5 years of age. A delayed birth record document that is recorded at or after 5 years of age is considered fourth level evidence of citizenship. (Note: If the document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S., or the Northern Mariana Islands before these areas became part of the U.S., the individual may be a collectively naturalized citizen. Collective naturalization occurred on certain dates listed for each of the territories.) The following will establish U.S. citizenship for collectively naturalized individuals:

(2) A Certification of Report of Birth (DS–1350). The Department of State issues a DS– 1350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired U.S. citizenship at birth, based on the information shown on the FS–240. When the birth was recorded as a Consular Report of Birth (FS–240), certified copies of the Certification of Report of Birth Abroad (DS–1350) can be issued by the Department of State in Washington, DC. The DS–1350 contains the same information as that on the current version of Consular Report of Birth FS–240. The DS–1350 is not issued outside the U.S.

(3) A Report of Birth Abroad of a U.S. Citizen (Form FS–240). The Department of State consular office prepares and issues this. A Consular Report of Birth can be prepared only at an American consular office overseas while the child is under the age of 18. Children born outside the U.S. to U.S. military personnel usually have one of these.

(4) A Certification of birth issued by the Department of State (Form FS–545 or DS– 1350). Before November 1, 1990, Department of State consulates also issued Form FS–545 along with the prior version of the FS–240. In 1990, U.S. consulates ceased to issue Form FS–545. Treat an FS–545 the same as the DS–1350.

(5) A U.S. Citizen I.D. card. (This form was issued until the 1980s by INS. Although no longer issued, holders of this document may still use it consistent with the provisions of section 1903(x) of the Act.) INS issued the I–179 from 1960 until 1973. It revised the form and renumbered it as Form I–197. INS issued the I–197 from 1973 until April 7, 1983. INS issued Form I–179 and I–197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid.

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(6) A Northern Mariana Identification Card (I–873). (Issued by the DHS to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 4, 1986.) The former Immigration and Naturalization Service (INS) issued the I–873 to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986. The card is no longer issued, but those previously issued are still valid.

(7) A final adoption decree showing the child's name and U.S. place of birth. The adoption decree must show the child's name and U.S. place of birth. In situations where an adoption is not finalized and the State in which the child was born will not release a birth certificate prior to final adoption, a statement from a State approved adoption agency that shows the child's name and U.S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate.

(8) Evidence of U.S. Civil Service employment before June 1, 1976. The document must show employment by the U.S. government before June 1, 1976. Individuals employed by the U.S. Civil Service prior to June 1, 1976 had to be U.S. citizens.

(9) U.S. Military Record showing a U.S. place of birth. The document must show a U.S. place of birth (for example a DD–214 or similar official document showing a U.S. place of birth.) Alien Verification for Entitlements (SAVE) Program for naturalized citizens. A Stat (10) A data verification with the Systematic e may conduct a verification with SAVE to determine if an individual is a naturalized citizen, provided that such verification is conducted consistent with the terms of a Memorandum of Understanding or other agreement with the Department of Homeland Security (DHS) authorizing verification of claims to U.S. citizenship through SAVE, including but not limited to provision of the individual's alien registration number if required by DHS.

(11) Child Citizenship Act. Adopted or biological children born outside the United States may establish citizenship obtained automatically under section 320 of the Immigration and Nationality Act (8 U.S.C. 1431), as amended by the Child Citizenship Act of 2000 (Pub. L. 106–395, enacted on October 30, 2000). The State must obtain documentary evidence that verifies that at any time on or after February 27, 2001, the following conditions have been met:

(i) At least one parent of the child is a United States citizen by either birth or naturalization (as verified under the requirements of this Part);

(ii) The child is under the age of 18;

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(iii) The child is residing in the United States in the legal and physical custody of the U.S. citizen parent;

(iv) The child was admitted to the United States for lawful permanent residence (as verified under the requirements of 8 U.S.C. 1641 pertaining to verification of qualified alien status); and

(v) If adopted, the child satisfies the requirements of section 101(b) (1) of the Immigration and Nationality Act (8 U.S.C. 1101(b) (1) pertaining to international adoptions (admission for lawful permanent residence as IR–3 (child adopted outside the United States)), or as IR–4 (child coming to the United States to be adopted) with final adoption having subsequently occurred).

(c) Third level evidence of citizenship. Third level evidence of U.S. citizenship is documentary evidence of satisfactory reliability that is used when both primary and secondary evidence is unavailable. Third level evidence may be used only when the applicant or recipient alleges being born in the U.S. A second document from paragraph (e) of this section to establish identity must also be presented:

(1) Extract of a hospital record on hospital letterhead established at the time of the person's birth that was created 5 years before the initial application date and that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) Do not accept a souvenir “birth certificate” issued by the hospital.

(2) Life, health, or other insurance record showing a U.S. place of birth that was created at least 5 years before the initial application date that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) Life or health insurance records may show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth.

(3) Religious record recorded in the U.S. within 3 months of birth showing the birth occurred in the U.S. and showing either the date of the birth or the individual's age at the time the record was made. The record must be an official record recorded with the religious organization. CAUTION: In questionable cases (for example, where the child's religious record was recorded near a U.S. international border and the child may have been born outside the U.S.), the State must verify the religious record and/or document that the mother was in the U.S. at the time of birth.

(4) Early school record showing a U.S. place of birth. The school record must show the name of the child, the date of admission to the school, the date of birth, a U.S. place of birth, and the name(s) and place(s) of birth of the applicant's parents.

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(d) Fourth level evidence of citizenship. Fourth level evidence of citizenship is documentary evidence of the lowest reliability. Fourth level evidence should only be used in the rarest of circumstances. This level of evidence is used only when primary, secondary and third level evidence is unavailable. With the exception of the affidavit process described in paragraph (d) (5) of this section, the applicant may only use fourth level evidence of citizenship if alleging a U.S. place of birth. In addition, a second document establishing identity must be presented as described in paragraph (e) of this section.

(1) Federal or State census record showing U.S. citizenship or a U.S. place of birth. (Generally for persons born 1900 through 1950.) The census record must also show the applicant's age. Note: Census records from 1900 through 1950 contain certain citizenship information. To secure this information the applicant, recipient or State should complete a Form BC–600, Application for Search of Census Records for Proof of Age. Add in the remarks portion “U.S. citizenship data requested.” Also add that the purpose is for PeachCare for Kids® eligibility. This form requires a fee.

(2) One of the following documents that show a U.S. place of birth and was created at least 5 years before the application for PeachCare for Kids® (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) This document must be one of the following and show a U.S. place of birth:

(i) A delayed U.S. public birth record that is recorded more than 5 years after the person's birth.

(ii) Statement signed by the physician or midwife who was in attendance at the time of birth.

(3) Institutional admission papers from a nursing facility, skilled care facility or other institution created at least 5 years before the initial application date that indicates a U.S. place of birth. Admission papers generally show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth.

(4) Medical (clinic, doctor, or hospital) record created at least 5 years before the initial application date that indicates a U.S. place of birth. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.)

Medical records generally show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth. (Note: An immunization record is not considered a medical record for purposes of establishing U.S. citizenship.)

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(5) Written affidavit. Affidavits should ONLY be used in rare circumstances. If the documentation requirement needs to be met through affidavits, the following rules apply:

(i) There must be at least two affidavits by two individuals who have personal knowledge of the event(s) establishing the applicant's or recipient's claim of citizenship (the two affidavits could be combined in a joint affidavit).

(ii) At least one of the individuals making the affidavit cannot be related to the applicant or recipient. Neither of the two individuals can be the applicant or recipient.

(iii) In order for the affidavit to be acceptable the persons making them must be able to provide proof of their own citizenship and identity.

(iv) If the individual(s) making the affidavit has (have) information which explains why documentary evidence establishing the applicant's claim or citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well.

(v) The State must obtain a separate affidavit from the applicant/recipient or other knowledgeable individual (guardian or representative) explaining why the evidence does not exist or cannot be obtained.

(vi) The affidavits must be signed under penalty of perjury and need not be notarized.

(e) Evidence of identity. The following documents may be accepted as proof of identity and must accompany a document establishing citizenship from the groups of documentary evidence of citizenship in the groups in paragraphs (b) through (d) of this section.

(1) Identity documents described in 8 CFR 274a.2 (b) (1) (v) (B) (1).

(i) Driver's license issued by State or Territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight or eye color.

(ii) School identification card with a photograph of the individual. (iii) U.S. military card or draft record. (iv) Identification card issued by the Federal, State, or local government with the same information included on drivers' licenses.

(v) Military dependent's identification card.

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Page: 10

(vi) U.S. Coast Guard Merchant Mariner card.

Note to paragraph (e) (1): Exception: Do not accept a voter's registration card or Canadian driver's license as listed in 8 CFR 274a.2 (b) (1) (v) (B) (1). CMS does not view these as reliable for identity.

(2) The TPA may use a cross match with a Federal or State governmental, public assistance, law enforcement or corrections agency's data system to establish identity if the agency establishes and certifies true identity of individuals. Such agencies may include child support, corrections, including juvenile detention, motor vehicle, or child protective services.

(3) The TPA may also accept three or more documents that together reasonably corroborate the identity of an individual provided such documents have not been used to establish the individual's citizenship and the individual submitted second or third tier evidence of citizenship. The State must first ensure that no other evidence of identity is available to the individual prior to accepting such documents. Such documents must at a minimum contain the individual's name, plus any additional information establishing the individual's identity. All documents used must contain consistent identifying information. These documents include employer identification cards, high school and college diplomas from accredited institutions (including general education and high school equivalency diplomas), marriage certificates, divorce decrees and property deeds/titles.

(f) Special identity rules for children. For children under 16, a clinic, doctor, hospital or school record may be accepted for purposes of establishing identity. School records may include nursery or daycare records and report cards. If the State accepts such records, it must verify them with the issuing school. If none of the above documents in the preceding groups are available, an affidavit may be used. An affidavit is only acceptable if it is signed under penalty of perjury by a parent, guardian or caretaker relative (as defined in the regulations at 45 CFR 233.90(c) (v) stating the date and place of the birth of the child and cannot be used if an affidavit for citizenship was provided. The affidavit is not required to be notarized. The state may accept an identity affidavit on behalf of a child under the age of 18 in instances when school ID cards and drivers' licenses are not available to the individual in that area until that age.

For PeachCare for Kids® applicants, the affidavit requirement can be met when the parent attests to the to the child’s identity under penalty of perjury when the application is signed and submitted or certified when the information is entered online.

(g) Special identity rules for disabled individuals in institutional care facilities. The State may accept an identity affidavit signed under penalty of perjury by a residential care facility director or administrator on behalf of an institutionalized

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individual in the facility. States should first pursue all other means of verifying identity prior to accepting an affidavit. The affidavit is not required to be notarized.

(h) Special populations needing assistance. The state must assist individuals to secure satisfactory documentary evidence of citizenship when because of incapacity of mind or body the individual would be unable to comply with the requirement to present satisfactory documentary evidence of citizenship in a timely manner and the individual lacks a representative to assist him or her.

(i) Documentary evidence. (1) All documents must be either originals or copies certified by the issuing agency. Uncertified copies, including notarized copies, shall not be accepted.

(2) States must maintain copies of citizenship and identification documents in the case record or electronic data base and make these copies available for compliance audits.

(3) States may permit applicants and recipients to submit such documentary evidence without appearing in person at a PeachCare for Kids® office. States may accept original documents in person, by mail, or by a guardian or authorized representative.

(4) If documents are determined to be inconsistent with pre-existing information, are counterfeit, or altered, States should investigate for potential fraud and abuse, including but not limited to, referral to the appropriate State and Federal law enforcement agencies.

(5) Presentation of documentary evidence of citizenship is a one time activity; once a person's citizenship is documented and recorded in a State database subsequent changes in eligibility should not require repeating the documentation of citizenship unless later evidence raises a question of the person's citizenship. The State need only check its databases to verify that the individual already established citizenship.

(j) Record retention. The State must retain documents in accordance with 45 CFR 74.53.

(k) Reasonable opportunity to present satisfactory documentary evidence of citizenship. Eligible individuals who declare to be U.S. citizens or nationals must be provided a reasonable opportunity to present satisfactory documentation of citizenship or nationality and must be enrolled in coverage pending the reasonable opportunity to document that claim. New applicants are asked to provide citizenship verification after the application is received if they are not exempt from providing documents or there is no data match or other acceptable verification on file. (See §435.930 and §435.911.) Applicants are given up to 90 days to provide documents and their eligibility may be extended as long as they are making a good faith effort to comply. If an individual has

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Superseded by ACA SPA

not provided satisfactory documentation of citizenship by the end of the reasonable opportunity period, and any extension period, States may terminate that individual’s eligibility for Medicaid or CHIP benefits in accordance with Medicaid rules at 42 CFR 435.919 and 42 CFR 431 Subpart E (regarding timely notice and opportunity for a fair hearing).

APPLICATION PROCESSING

Upon receipt of the PeachCare application, the TPA screens the application for potential Medicaid eligibility. Potentially Medicaid eligible cases will be referred to Medicaid once income has been verified. The TPA provides the TPA Specialist with an electronic file of the application for eligibility determination. Since the income verification requirements for PeachCare for Kids are the same as in Medicaid, families will not have to go through the process again unless they report a change in income. The TPA Specialists reports back the eligibility and enrollment status for all referred children. If a child comes back to the TPA as not Medicaid eligible, the account will not be required to go through income verification. The case will be updated using information provided by the TPA Specialist. For children who are not Medicaid eligible, the TPA determines if net family income (gross income minus disregards) is at or below the 247% federal poverty level; the child is covered by a group health plan (either currently or in the past six months); the child is eligible for health benefits through a family member’s employment with a state agency; and if the child is a U.S. citizen or lawfully admitted alien. The TPA is also required to use customer service personnel to follow up on incomplete or unclear information found in the application.

The TPA checks Medicaid’s information system for enrollment in the Medicaid program and conducts matches with the State Health Benefit Plan and Board of Regents for enrollment in or eligibility for state-sponsored health benefit plans. If a child is determined to be ineligible for PeachCare for Kids®, the family receives a written notice describing the reason for ineligibility. The notice specifies the reason for the denial (e.g. excess income, age over eighteen years etc.) The notice also specifies the applicant’s opportunity to request a reconsideration of the decision and related procedures to accomplish this. This may include submission of additional or clarifying information to allow a review of the application decision. If the applicant is not satisfied with the final decision of the TPA, the case is sent to the Department of Community Health for further review.

If a child is found to be eligible for the PeachCare for Kids® program, the family receives a PeachCare for Kids® handbook that describes the program’s benefits, instructions on how to submit premium payments and a number to contact the

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TPA to report changes. The family is also contacted by the Georgia Families (GF) enrollment broker and receives a new enrollment package that explains the GF program and choices about CMO plans in the Member’s service region. The enrollment broker also provides information regarding how to access services through the GF CMO selected by, or assigned to the family.

CONTINUING ENROLLMENT

At the time of application approval, the family receives information requiring them to report changes in their income, place of residence or household size to the TPA. If a family reports a decrease in income, verification of all income is required. If the family remains PeachCare for Kids® eligible and is within 90 days of their annual renewal, the income verification process will be held until that time. The verification request for renewal is sent two months prior to the renewal month. If these changes result in ineligibility, the TPA reviews the account information for potential eligibility for the Medicaid program. If the child is potentially Medicaid eligible, the account information is sent immediately to the State Medicaid staff for review, just as the new applications are handled.

If the child is screened as ineligible for Medicaid and PeachCare for Kids® based on the information provided, the TPA sends the member a notice of termination and closes the case. The notice specifies the reason for termination (e.g. excess income, etc.) The notice also specifies the applicant’s opportunity to request a reconsideration of the decision and related procedures to submit any necessary documentation.

As long as the family continues to meet all eligibility requirements and continues to pay the monthly premium as required, the child(ren) may be eligible for coverage for twelve (12) months.

PREMIUM COLLECTION and REINSTATEMENT PROCESS

• Premiums: Premiums are not required for children ages 0 through 5 years. For children ages 6 through 18, the premiums are detailed in the table below. • The applicant must submit one (1) month's premium, if required, with the application for it to be complete. Once determined eligible, enrollment becomes effective the first day of month the application is determined complete. • When the applicant is enrolled, the TPA sends a coupon payment book (or other payment mechanism) to the member for use in making regular premium payments. Members may send in premiums for multiple months. • The first two months’ coverage will be funded with state/federal funds. The premium received with the application will be applied to the third month's coverage. With this model, the collection process will be one month ahead of coverage and a member has 45 days after being late with a payment to

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submit it before coverage is terminated. • If payments are late, the notification/cancellation process will begin. A letter will be sent before cancellation occurs.

An example follows:

Date Event January 6th Applicant submits complete application. January 15th Eligibility is determined. January 1st New applicant is enrolled, if eligible. Child is eligible to receive benefits effective January 1st. State/federal dollars fund January’s coverage. February 1st or March 1st. Child is enrolled in a Care Management Organization (CMO). State/federal dollars fund January and February’s coverage. March 1st Premium submitted with application is applied to March’s coverage. April premium is due.

RENEWAL PROCESS

Sixty days prior to a member’s annual anniversary date, PeachCare for Kids® sends a letter to the family detailing enrollment-related information on the account, including demographic information, children enrolled, and premiums required. Families are notified of the requirement to send in the appropriate verification documents. All families will be required to provide income verification at the annual renewal. A form detailing the required documentation will be sent with the renewal notice. After 3 weeks, a reminder notice will be sent. If a family makes an effort to comply with the verification process prior to the renewal date but needs additional time to provide the necessary documents, a thirty (30) day grace period will be granted. In circumstances where there is intent to comply, an additional (30) days of coverage can be granted manually by a supervisor with the TPA.

Children who remain eligible after the 12-month renewal period will continue coverage. If a change in income or household composition is reported, the account will be reprocessed, similar to a new application with the children being screened for potential Medicaid eligibility, referred if appropriate and then evaluated for continued eligibility for PeachCare for Kids®.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

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Page: 15

Due to a lack of funding, effective March 11, 2007, DCH closed PeachCare for Kids to new enrollment. Receipt of federal funds from FFY2004 and FFY2005 redistribution and supplemental appropriations, provided sufficient resources to open enrollment. On June 14, 2007, a public notice was issued announcing the Department’s intent to resume enrollment. Upon DCH Board approval, enrollment resumed effective July 12, 2007. However, enrollment is limited to 295,000 children. The enrollment limit will be reassessed based on the availability of federal funding once SCHIP is reauthorized.

While the cap is in place, enrollment will be monitored weekly. Children will only be activated for coverage when the number of active children is under the cap (295,000). Once the cap is reached, no pending accounts whether they are new or reinstatements will be activated to receive coverage. In the chance occurrence that the cap is reached during the processing of a family group, all eligible children will be given coverage. The eligibility system will include notes and updated correspondence that will be “turned on” if the cap is reached. Public notice on the enrollment cap was issued.

In the event that the enrollment cap of 295,000 children is reached before adequate FFY08 is available and enrollment must be closed again, the following procedures will be in place:

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• All correspondence, as well as the PeachCare for Kids website, will be updated to indicate the capped enrollment status and explain what it will mean for members and potential members.

• Members whose participation in the program is suspended for failure to timely pay premiums or for failure to provide required income verification will be precluded from re-enrollment during any closed enrollment period.. These members will receive additional notice by direct mail informing them of their review rights as required by governing regulations.

• Members enrolled and/or determined eligible prior to any closed enrollment period will not be impacted by this particular change so long as they continue to pay premiums timely and comply with any requests for information, including income, citizenship and identity verification.

• Members who are suspended during a closed enrollment period will be able to re-instate their accounts once enrollment is open so long as they bring their account into balance. They will not be required to submit a new application. These accounts will be given a special designation in the eligibility system as “pending closed enrollment.”

• All individuals who submit an application during a closed enrollment period will receive a notice stating that PeachCare for Kids is in closed enrollment but that they will be notified once the program is open to new enrollment.

• PeachCare will continue to accept applications during any closed enrollment period. The TPA would enter them into the system and continue to screen for potential Medicaid eligibility. Upon re-opening of enrollment, applications would continue processing based on date of application or reinstatement request.

Applications received during any enrollment freeze will be retained based on original date of receipt. For children referred to Medicaid, the original date of receipt will be the date the application was received by PeachCare for Kids.

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4.3.2 Deemed Newborns

See Attachment 5

4.3.3 MAGI-Based Income Methodologies

See Attachment 5

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Superseded by ACA SPA

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

PeachCare for Kids utilizes the same income methodologies as are used for its Right from the Start Medicaid program (Title XIX Poverty Level Group), ensuring that there are no gaps or overlap in income eligibility for PeachCare for Kids and Medicaid based on income sources or income disregards.

Upon receipt of the completed application, including verification of income, citizenship and identity, the TPA screens the application for potential Medicaid eligibility. If the child is potentially Medicaid eligible based on verified income, the TPA will route the application to centralized Right from the Start Medicaid (RSM) staff for a determination of Medicaid eligibility. The child’s application is entered into SUCCESS, the state’s eligibility system for Medicaid, Food Stamps, and TANF. The RSM staff notifies the TPA of the outcome of all applications. The denial reasons and any additional income information are included for the TPA to reevaluate the application for potential eligibility for PeachCare for Kids. If it is determined that the income is within the PeachCare eligibility guidelines, the TPA will enroll the child in PeachCare for Kids without requiring the parent to complete an additional application.

Prior to enrollment, each child who is screened for potential PeachCare eligibility is checked against the Medicaid information system for enrollment in Medicaid. The record of each child is also checked with the State Health Benefit plan and Board of Regents for enrollment of the child or a parent in the state health insurance plan.

Effective January 1, 2012, PeachCare for Kids®’ eligibility rule will allow the enrollment of children of employees of a public agency who meet all eligibility requirements. This change is made in compliance with section 10203 (d) (2) (D) of the Patient Protection and Affordable Care Act which allows exceptions to the exclusion of children of employees of a public agency from enrolling in CHIP.

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Superseded by ACA SPA

This condition is met through the Maintenance of Agency Contribution provision. Georgia’s public agency expenditures for health coverage for

employees that have dependent coverage is not less than the amount of such expenditures in the 1997 State fiscal year, increased by the percentage increase of the medical care expenditure category of the Consumer Price Index (CPI-M) for All Urban Consumers. The state monitors, on an annual basis, agency expenditures or the cost-sharing rules applicable to the coverage offered through the State health benefits plan to ensure that it continues to meet one of the conditions. Please see Attachment A.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Upon receipt of the application, the TPA screens the application for potential Medicaid eligibility. This process will continue during the PeachCare enrollment freeze. If the child is potentially Medicaid eligible based on reported income, the TPA will route the application to centralized Right from the Start Medicaid (RSM) staff for a determination of Medicaid eligibility. The child’s application is entered into SUCCESS, the state’s eligibility system for Medicaid, Food Stamps, and TANF. The RSM staff notifies the TPA of the outcome of all applications. The denial reasons and any additional income information are included for the TPA to reevaluate the application for potential eligibility for PeachCare for Kids. If it is determined that the income is within the PeachCare eligibility guidelines, the TPA will enroll the child in PeachCare for Kids without requiring the parent to complete an additional application.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Since the inception of PeachCare for Kids DCH has worked closely with Department of Family & Children Services to promote the program.The PeachCare for Kids application requests all of the information necessary to determine Medicaid eligibility for a child. DFCS offices use this application for parents who are only seeking coverage for their children. If the children

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are determined to be ineligible for Medicaid, the caseworker mails the application to PeachCare for processing, without requiring the family to complete an additional form or application.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

Non-Financial – Substitution of Coverage

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Superseded by ACA SPA

See ACA pages at end of SPA document

4.4.4.1.  Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

A child will be denied eligibility if it is determined that he or she: 1) is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act; or 2) is eligible for Medicaid; or 3) is a member of a family that is eligible for health benefits coverage under a State health benefit plan based on a family member’s employment with a public agency in the State; or 4) voluntarily dropped coverage under an employer plan during the past six months. (Voluntary termination of coverage does NOT include the following: employer cancellation of the entire group plan; loss of eligibility due to parent’s layoff, resignation of parent from employment, employment termination; leave of absence without pay, or reduction of work hours; cancellation of a private health plan in which cost-sharing is expected to exceed 5% of the family’s annual income; cancellation of an individual within a family policy due to meeting lifetime maximum of benefits; or cancellation of COBRA or an individual insurance policy. A child born during the six month waiting period would be eligible.) The PeachCare application contains questions about current and past coverage under group health plans and family member’s employment with State agencies. The application also contains questions about current and past coverage under group health plans. In addition to self- declaration of other coverage, providers report coverage under other health plans and PeachCare enrollment is terminated if the other coverage meets any of the four criteria listed above. Children who are currently insured, regardless of the amount of cost-sharing required by their policy will be ineligible for PeachCare for Kids. PeachCare also requires children to be uninsured for six months prior to being eligible to enroll, with exceptions for non-voluntary cancellations of coverage. The application asks parents to report if their children have cancelled insurance within the previous six months and provides an opportunity to report the reason the insurance is cancelled. Once a month, these applications are manually

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Superseded by ACA SPA reviewed by PeachCare for Kids staff to determine if the reason given meets one of the exceptions defined in Georgia’s state plan (such as change in employment, employer dropped coverage, etc.)

Effective January 1, 2012, children of state employees will be allowed to enroll in PeachCare for Kids® if they meet the other technical eligibility requirements including limits and lack of health insurance.

At this time, the application does not ask the parent to report the cost sharing required under their previous private policy. A letter is generated to request such information before a determination of the 5% of household income can be made.

To calculate the cost sharing imposed on a household and the 5% threshold, the enrollment system for PeachCare will have to be modified. With this information stored on the system, PeachCare for Kids will be able to monitor on an ongoing basis the number of letters sent, the number of families providing the information about their previous coverage, and the number of children who are exempted from the waiting period.

Once the revision has been made to collect this data on the application, PeachCare will continue to monitor the number of applications requesting to be exempted from the six- month wait due to the cost of their previous insurance and the number of children who are ultimately exempted.

The average percentage of children who had reported canceling private insurance due to excessive costs was 5.06% of the new eligibles for the 1st Federal Fiscal Quarter in 2002. If there are two consecutive quarters in which the percentage of new eligible who report losing coverage due to cost exceeds 5%, the Department of Community Health will increase the cost-sharing threshold from 5% to 7.5% before an exemption from the six-month wait is granted.

4.4.4.2.  Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

See 4.4.4.1

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. 4.4.4.3.  Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

N/A

4.4.4.4.  If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution. The cost-effectiveness determination. 4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

There are no federally-recognized tribes in Georgia. Recognizing that a member of a tribe may re-locate to the State, CHIP will exempt children who are members of federally-recognized tribes from the cost-sharing requirements as stipulated in Section 2103(e)(1)(A). Children who identify themselves as American Indian or Native Alaskan on the CHIP application will be notified that, upon receipt of documentation of tribal membership, they will no longer be required to submit monthly premiums. Any premiums paid after October 1, 1999 will be reimbursed within 45 days of receipt of documentation of tribal membership.

The materials sent to all new enrollees will include information on the cost-sharing exemption for members of federally-recognized American Indian or Native Alaskan tribes to ensure that those not indicating race on the application will be notified of this exemption.

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Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish: Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

PeachCare for Kids Outreach Through RSM Outreach

Outreach efforts are completely coordinated for PeachCare for Kids and Medicaid, so that those children who are eligible for Medicaid will be reached and enrolled in Medicaid and those children eligible for PeachCare can be reached and enrolled in PeachCare. The outreach efforts target all children at or below 247% of the FPL. To build on and enhance our outreach efforts, Georgia utilizes our nationally recognized RSM outreach strategies for PeachCare for Kids. With over 143 representatives statewide, RSM outreach workers have been specifically trained in doing outreach for PeachCare for Kids. RSM outreach workers have available all pertinent information for both Medicaid and PeachCare for Kids. The outreach workers also have a variety of program information on both creditable and non-creditable coverage and other ways to access health care services. The order of priority for the outreach workers are first to locate uninsured children, second to determine eligibility for Medicaid, third to provide information and assistance regarding enrollment in PeachCare for Kids, fourth to provide information on the Georgia Partnership for Caring Foundation and DHR public health care programs and services. The outreach efforts are also coordinated with community- based organizations, health care providers, GF CMO plans and the enrollment broker.

RSM Outreach Project

The Right From the Start Medicaid (RSM) Project began in July 1993 as Georgia’s response to the high infant mortality rate and to improve health care access for all children and pregnant women.

The Department of Community Health (DCH) and the Department of Human Resources (DHR) entered into an agreement to place eligibility

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Superseded by ACA SPA

workers in community settings. The agreement provides for 143 eligibility workers. This staffs currently have offices in health departments, hospitals, clinics, day care centers, schools, community action agencies and other locations in the community. A major feature of the program is the availability of staff during non-traditional work hours so that clients may apply for RSM without having to lose time from their jobs or from school. Non- traditional hours are defined as any time other than 8 a.m. to 5 p.m. Monday through Friday.

Outreach staffs are housed throughout Georgia and, although not housed in all 159 counties, provide Medicaid enrollment information and access to the Medicaid application process in every county. This involvement with potential Medicaid clients on a local level greatly enhances Georgia’s outreach efforts. Outreach staff also actively pursue collaboration with other agencies and groups in their communities in order to maximize involvement at the local level and to educate other agencies in the basics of Medicaid eligibility and the availability of Medicaid services and to provide for mutual referral systems. Most of the local RSM project staff has partnerships with the county health departments, local schools, pregnancy centers, battered women’s shelters, Head Start programs and the health care community in their areas.

Workers and supervisory staff make presentations regularly to community groups, medical providers and employers. RSM project staffs often participate in health fairs and other local activities in order to reach potential Medicaid clients. Staffs have utilized creative techniques for distributing information to the public. Medicaid flyers have been sent home with school age children and workers have visited day care centers to pass out brochures. Employer contacts have resulted in opportunities to distribute literature through personnel offices and at employee forums, and to accept applications at job sites.

Simplified PeachCare for Kids Application

PeachCare for Kids has developed a simplified paper and web-based application in both English and Spanish for use by families who apply for the PeachCare for Kids program. The paper application is a one page, two-sided form designed to be submitted to PeachCare by mail. (Attachment 1)

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Superseded by ACA SPA

The web-based application is available on-line at www.peachcare.org. It was created to allow parents to apply quickly and easily at local libraries, community centers, hospitals and in their homes. When an application is submitted online, a cover form with the application confirmation number will be generated. Parents will be instructed to print out this form and attach required documents for income and/or citizenship and identity verification to then be mailed or faxed to the TPA. Both applications are designed to gather information needed to determine eligibility for both PeachCare and Medicaid. Marketing and Public Awareness

Advertising Campaign

The PeachCare for Kids outreach campaign includes television, radio, outdoor and transit advertising. The advertising campaign follows the theme, “Now You Can Afford Peace of Mind,” addressing the practical and the emotional needs of potential PeachCare families. Creatively, advertising is intended to evoke the heroism of the working-class parent, recognizing their love and dedication to their child. The radio commercial, “Vicky,” tells the story of a father and his daughter, and the TV commercial, “Emma,” spotlights a mother and her son.

Outreach Publications

PeachCare for Kids published informational brochures in both English and Spanish to educate and encourage enrollment. The brochures give a brief description of benefits available through PeachCare and a summary of PeachCare eligibility requirements. The brochures are distributed at outreach activities throughout the state and are available at doctor’s offices, DFACS, Department of Labor career centers, health departments, community centers, and daycare centers.

Outreach Video

The Georgia Department of Community Health produced a short promotional video, which details the benefits of PeachCare to parents and community outreach workers. It features two women talking about their experience with the program. The video explains how to apply, premiums, benefits and accessing services. For bilingual viewers, it is available with Spanish subtitles. The video is especially designed for broadcast in hospital and physician waiting rooms, health departments, and community health fairs.

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Back-to-School Outreach

To enhance back to school outreach activities, PeachCare for Kids partners with the Georgia Department of Education to distribute a program flyer to every child in the public school system. Through this effort, nearly every parent of a school-age child in the state receives information about PeachCare for Kids. To date, we distribute over 1.6 million brochures at the beginning of each school year.

Community Outreach Mini-grants

In 1999, the Georgia Department of Community Health created a minigrant program, “Improving Health Care Access: Innovations in Medicaid and PeachCare for Kids Outreach, to assist local efforts to raise awareness of both PeachCare and Medicaid programs among hard-to- reach populations. Twenty-four community organizations were awarded grants to conduct grassroots outreach activities specifically designed for their communities.

The minigrant outreach program had a positive impact on the number of applications submitted to PeachCare for Kids and Medicaid. The grantees were responsible for producing between 30,000 and 40,000 new applications between October 1999 and June 2000.

An evaluation performed by the Health Policy Center at Georgia State University looked at various differences by race and county size, as part of our goal was to reach the underserved hard-to-reach population. The evaluation found:

• An increase of 16% in new applications compared to non-outreach counties; • An increase of 18% in smaller counties (fewer than 42,000 people); • An increase of 11% in larger counties (more than 90,000 people); and • An increase of 19% in minority applications.

The activity level of the grantees produced the following results:

• 427,315 pieces of PeachCare for Kids informational materials were distributed; • 445 PeachCare for Kids presentations were conducted; and

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• 6,000 families were assisted with applications.

Local Media Partnerships

PeachCare for Kids became one of five partner organizations in Georgia’s largest and most comprehensive community service campaign, WSB-TV’s Family 2 Family Project. WSB-TV, the highest ranked television station in the state and has established partnerships with community and family organizations throughout Georgia to address family issues. As part of its partnership, PeachCare participates in several major events such as the Baby & Kid Expo, CPR Saturday trainings by the American Red Cross, the Susan B. Komen Foundation’s Race for the Cure, the Salute 2 America Fourth of July parade, and Give Kids a Boost. PeachCare brochures are also always on display in the other Family 2 Family sponsor locations, including Haverty’s Furniture, Verizon Wireless, Promina Health Systems, and Southtrust Bank.

The news and advertising exposure on one of Georgia’s most popular television stations, community event participation across northern Georgia, and exclusive program opportunities will continue to help us reach even more eligible families.

Georgia Families

The Georgia Families Care Management Organizations (CMOs)

The CMO plans are permitted to perform the following marketing activities:

• Distribute general information through mass media (i.e. newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising, and other media outlets); • Make telephone calls, mailings and home visits only to Members currently enrolled in the Contractor’s plan, for the sole purpose of educating them about services offered by or available through the Contractor; • Distribute brochures and display posters at Provider offices and clinics that inform patients that the clinic or Provider is part of the CMO plan’s Provider network, provided that all CMO plans in which the Provider participates have an equal opportunity to be represented; and • Activities that benefit the entire community such as health fairs or

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other health education and promotion activities.

If the CMO performs an allowable activity, the CMO shall conduct these activities in the entire Service Region. The State must approve all CMO marketing materials prior to their use. All materials are in compliance with the information requirements in 42 CFR 438.10.

The GF Enrollment Broker (EB)

The GF EB conducts an outreach and educational campaign to promote community awareness of GF and inform Potential Members about the managed care benefits available, including preventive care and Health Check services. The EB ensures that outreach activities reach non- English speaking populations, populations with hearing impairments, and populations with vision impairments.

Outreach Materials

The EB develops print ads, public service announcements, post card mailings and other outreach materials targeted to GF eligible populations in each Service Region.

The outreach materials are designed to be understandable to GF eligible populations and written at a 5th grade reading level.

The outreach materials are also available in Spanish and as determined by DCH, other non-English prevalent languages spoken by five percent (5%) of the Medicaid population in a Service Region.

Collaboration with Others

The EB regularly collaborates with other State agencies and community- based advocacy and service groups that are involved in programs and activities targeted at GF eligible population.

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Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.  Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1.  FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2.  State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3.  HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

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

6.1.3.  Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state- based coverage.

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6.1.4.  Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.  Coverage the same as Medicaid State plan 6.1.4.2.  Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3.  Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4.  Coverage that includes benchmark coverage plus additional coverage The BlueChoice Health Care Plan, the state’s HMO with the largest enrollment, is the benchmark plan. The benefit plan for PeachCare for Kids is the benchmark coverage with added services to bring the coverage to equal a Medicaid look-alike, with the exceptions of non- emergency transportation, targeted case management, services solely for persons over age 19, and some services that to be needed require a level of disability that would qualify the child for Medicaid. 6.1.4.5.  Coverage that is the same as defined by “existing comprehensive state-based coverage” 6.1.4.6.  Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.  Other (Describe)

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

These services are the same as the services in the Georgia Medicaid Plan with the exceptions of non-emergency transportation, targeted case management, services solely for persons over age 19, and some services that to be needed require a level of disability that would qualify the child for Medicaid. All these services are subject to the same limitations and prior approvals as they are in the Georgia Medicaid Plan.

6.2.1.  Inpatient services (Section 2110(a)(1))

Inpatient services include medical and surgical services delivered during a hospital stay. Inpatient services are covered in full. See 6.2.10 for coverage for psychiatric hospital services. Prior approval is needed for some services.

6.2.2.  Outpatient services (Section 2110(a)(2))

Outpatient services include outpatient surgery, clinic services and emergency room care. Outpatient services are covered in full. Prior approval is needed for some services.

6.2.3.  Physician services (Section 2110(a)(3))

Physician services include services provided by a participating physician for the diagnosis and treatment of an illness or an injury. Physician services are covered in full. Prior approval is needed for some services.

6.2.4.  Surgical services (Section 2110(a)(4))

Surgical services are covered in full. See 6.2.1 for inpatient surgical services and 6.2.2 for outpatient surgical services. Prior approval is needed for certain procedures.

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

Rural Health Clinic Services (RHC) and Federally Qualified Health Center Services

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Rural Health Clinic (RHC) Services are defined in section 1905(a)(2)(B) of the Social Security Act (the Act). Federally Qualified Health Center (FQHC) Services are defined in section 1905(a)(2)(C) of the Social Security Act (the Act). FQHC and RHC services include services provided by physicians, nurse practitioners, physician assistants, nurse midwives, clinical psychologists, clinical social workers and visiting nurses and other ambulatory services included in the state plan. RHC services also include services and supplies that are furnished as an incident to professional services furnished by a physician, physician assistant, nurse practitioner, or nurse midwife, and, for visiting nurse care, and related medical supplies other than drugs and biologicals.

EPSDT limitations may be exceeded if medically necessary. Medical necessity must be properly documented.

Limitations

Services are subject to retrospective reduction or denial if adequate medical justification is not provided in medical records. Preventive health visits for individuals under the age of 21 must align with the EPSDT Program’s requirements. Additional office visits must be based on medical necessity that is properly documented.

Non-Covered Services

1. Ancillary services unrelated to the establishment of a diagnosis or treatment of the patient. 2. Routine physical examination or immunization unless in conjunction with the EPSDT Program. 3. Experimental services or procedures or those not recognized by the profession or the U.S. Public Health Service as universally accepted treatment. 4. Additional non-covered services are listed in the Part II, Policies and Procedures for Rural Health Clinic Services Manual.

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See 6.2.2 above.

6.2.6.  Prescription drugs (Section 2110(a)(6))

Prescribed drugs (from participating rebate manufacturers) and supplies approved by DMA and dispensed by an enrolled pharmacist are covered in full. Some drugs require prior approval or have therapy limitations. Prescriptions or refills are limited to six per month per enrollee. There are procedures in place that allow a member to receive medically necessary prescriptions in excess of six (6) per month.

6.2.7.  Over-the-counter medications (Section 2110(a)(7))

The following non-prescription drugs are covered up to a maximum allowable cost: Multi-vitamins and multiple vitamins with iron, enteric coated aspirin, diphenhydramine, insulin, NIX, iron, meclizine, insulin syringes, insulin delivery unit systems (NOVO pen for example) and urine test strips. No other over-the-counter medications are covered.

6.2.8.  Laboratory and radiological services (Section 2110(a)(8))

Radiology services are covered in a hospital setting or in a physician’s office only. Note: laboratory and radiological services are covered as two separate services.

6.2.9.  Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

These services are covered in full. This includes Childbirth Education Services, a series of 8 classes regarding the birth experience and tools to prepare for a healthier pregnancy, birth and postpartum period.

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

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Provides both medical/surgical benefits and mental health or substance use disorder benefits in the same manner. Ensures that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder benefits are not more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits.

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

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

Durable medical equipment and supplies prescribed by a physician are covered. Prior approval is required for custom molded shoes and for repairs to certain prosthetic devices. Hearing aids are allowed every three years without prior approval. Medical necessity for hearing aids must be approved by Children’s Medical Services. This prior approval is based upon the completion of a hearing evaluation by the prescribing physician or other licensed practitioner. Medical equipment purchases and one-way mileage for delivery in excess of $200.00 require prior approval. See Vision Care under 6.2.28 for eyeglasses.

6.2.13.  Disposable medical supplies (Section 2110(a)(13))

6.2.14.  Home and community-based health care services (See instructions) (Section 2110(a)(14))

Home health services, ordered by a physician and provided in the enrollee’s home, including part-time nursing services, physical, speech and occupational therapy, and home health aide services are covered for 75 visits per calendar year. Home health services exceeding 75 visits per calendar year may be covered when requested by a physician and determined to be medically necessary by DMA.

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6.2.15.  Nursing care services (See instructions) (Section 2110(a)(15))

Nursing care services are covered as follows. The Nurse Practitioner Services Program reimburses for a broad range of medical services provided by participating Pediatric, Family, Adult, and OB/GYN Nurse Practitioners, as well as Certified Registered Nurse Anesthetists (CRNA). Nurse Midwife services are also covered and include primary care services in addition to obstetrical care.

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

6.2.17.  Dental services (Section 2110(a)(17))

Dental and oral surgical services are covered as follows: 2 visits (initial or periodic) for dental exams/screens and 2 emergency exams during office hours and two emergency exams after office hours per calendar year are allowed; 2 cleanings per calendar year; 1 restorative (filling) procedure per tooth per restoration; the maximum number of surfaces covered is four (4); sealants for first and second permanent molars only; orthodontic services with prior approval.

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

Inpatient substance abuse treatment services are covered only for short-term acute care in general acute care hospitals up to 30 days per admission. Services furnished in a state-operated mental hospital are not covered. Services furnished in an Institution for Mental Disease (IMD) are not covered.

6.2.19.  Outpatient substance abuse treatment services (Section 2110(a)(19))

Outpatient substance abuse treatment services are covered through Community Mental Health Centers, subject to limitations specified in DHR standards. Outpatient short term acute care and substance abuse treatment services are covered in general acute care hospitals.

6.2.20. 

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

6.2.21. 

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

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

Physical, occupational and speech pathology therapy are covered as follows: 1 hour per day up to 10 hours per calendar month for physical therapy; 1 hour per day up to 10 hours per calendar month for occupational therapy; 1 session per day up to 10 sessions per month for individual speech therapy. With prior approval these limits may be exceeded. See also Children’s Intervention Services below.

6.2.23.  Hospice care (Section 2110(a)(23))

Covered under a plan of care when provided by an enrolled hospice provider.

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

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

6.2.26.  Medical transportation (Section 2110(a)(26))

Emergency ambulance services are covered for an enrollee whose life and/or health are in danger. Non-emergency transportation is not covered.

6.2.27.  Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

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

Health Check: Regular physical examinations (screening), health tests, immunizations and treatment for diagnosed problems are covered. Screening requirements are based on the recommendations for preventive pediatric health care adopted by the American Academy of Pediatrics. Treatment is covered within the limitations on covered services.

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Vision Care: Services including eyeglasses, refractions, dispensing fees, and other refractive services are covered. Medically necessary diagnostic services are also covered. Limitations are: 1 refractive exam, optical device, fitting, and dispensing fee within a calendar year; additional such services require prior approval. Prior approval is also required for other services including but not limited to: contact lenses, trifocal lenses, oversized frames, hi-index and polycarbonate lenses.

Children’s Intervention Services: Services covered for children from birth through 18 years of age are audiology, nursing, nutrition, occupational therapy, physical therapy, social work, speech- language pathology and developmental therapy instruction. Written prior approval is required for medically necessary Children’s Intervention Services once the annual service limitations listed in the Policy and Procedure Manual have been reached. Individualized Family Service Plan is required to document medical necessity for amount, duration and scope of services. Note that children 18 years of age are not covered under these program services.

Family Planning: Covered services include initial and annual examinations, follow-up, brief and comprehensive visits, pregnancy testing, birth control supplies, and infertility assessment.

Pregnancy-Related Services: Covered services help reduce infant mortality by providing home visits that assess the mother and child and teach the mother about specific subjects that will reduce infant mortality.

Podiatry: Services covered are diagnosis, medical, surgical, mechanical, manipulative and electrical treatment of ailments of the foot or leg as authorized within the Georgia statute governing podiatric services.

Physicians Assistant Services: Covered services are limited to primary care services and anesthesiologist’s assistant services authorized in the basic primary care job description, approved by the Georgia Composite State Board of Medical Examiners.

End Stage Renal Disease (ESRD) Dialysis: Services and procedures designed to promote and maintain the functioning of the kidney and related organs are covered when provided by a provider enrolled in the ESRD program. Acute renal dialysis services are covered under other programs.

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6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.  The state shall not permit the imposition of any pre- existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2. 

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

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6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1.  Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii))

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(42CFR 457.1005(a))

6.4.2.  Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

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Section 7. Quality and Appropriateness of Care

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.  Quality standards 7.1.2.  Performance measurement 7.1.3.  Information strategies 7.1.4.  Quality improvement strategies

The monitoring for 7.1.1-7.1.4 is detailed in Section 7.2 and in Section 9 “Strategic Objectives and Performance Goals and Plan Administration.”

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7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

To encourage utilization of primary and preventive care, PeachCare for Kids does not have any co-payments for services. Additionally, premiums are not required for children under the age of six, ensuring that all children up to the age of six in households with incomes up to 235% of the federal poverty level have access to care without any cost to the family.

PeachCare for Kids sends each child a birthday postcard each year that wishes them a healthy year and reminds their parents of the well-child care available through PeachCare.

PeachCare for Kids monitors the members’ appropriate Early Periodic Screening, Diagnostic and Testing (EPSDT) utilization. Each CMO must provide quarterly reports to DCH documenting the number of initial newborn visits, the number of members who received all scheduled EPSDT services on the periodicity schedule, the number of members who received any dental services, number of members that received an initial health visit and screening within 90 days of enrollment, the number of diagnostic and treatment services, including referrals, and the number and rate of lead screening for children.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

All members are enrolled in Georgia Families (GF), a managed care program. GF PCPs are required to have care accessible to their members 24 hours a day.

Members are informed in member handbooks mailed to each family upon enrollment, “If your child is in an emergency situation, call 911 or go immediately to the nearest hospital emergency room. You do not need prior approval from your child’s doctor if your child has a serious or disabling illness or injury. Be sure to call your doctor if your child has a serious or disabling illness or injury. Be sure to call your doctor as soon as you can after your child has received care.”

The Georgia Health Policy Center (GHPC), Georgia State University, has

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done an annual evaluation of the claims submitted for services received by PeachCare for Kids members. The results of the survey are shared with DCH staff and analyzed to monitor access, utilization and trends in utilization as the program matures. The GHPC has also conducted the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey on behalf of PeachCare for Kids. This survey assesses the parents’ perceptions about the availability and quality of care their children have received.

Additionally, each CMO is required to provide quarterly timely access reports that monitor the time lapsed between a Member’s initial request for an office appointment and the date of the appointment. The CMOs are also required to submit a Provider Network Adequacy and Capacity Report that demonstrates that the Contractor offers an appropriate range of preventive, Primary Care and specialty services that is adequate for the anticipated number of enrollees for the service are and that its network of providers is sufficient in number, mix and geographic distribution to meet the needs of the anticipated number of enrollees in the service area. Additionally, on an ad hoc basis DCH can request of each CMO a report of the availability of certain services and the coverage and authorization of services.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The Georgia Health Policy Center (GHPC), Georgia State University, has done an annual evaluation of the claims submitted for services received by PeachCare for Kids members. The results of the survey are shared with DCH staff and analyzed to monitor access, utilization and trends in utilization as the program matures. The GHPC also conducts the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey on behalf of PeachCare for Kids. This survey assesses the parents’ perceptions about the availability and quality of care their children have received, including access to specialist care. Through these evaluations, PeachCare monitors access to specialist care for all members, including those with special or chronic conditions.

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All children enrolled in PeachCare for Kids are assigned a CMO and primary care provider (PCP) through GF. The PCP’s role is to assess, treat, and coordinate specialty care for the PeachCare members under their care.

PeachCare for Kids members who are identified as in need of special health care services by receiving care through CMS or Georgia Pediatric Program (GAPP) are excluded from GF and covered under PeachCare for Kids on a fee for service basis.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

As mentioned earlier, each CMO has written Utilization Management Policies and Procedures that have been reviewed and approved by DCH. Also, on a monthly basis CMO will provide to DCH a report of the availability of certain services and the coverage and authorization of services.

The CMO must submit Prior Authorization and Pre-Certification Reports that summarize all requests in the preceding month for Prior Authorization and Pre-Certification. The Report includes, at a minimum, the following information: • Total number of requests for Prior Authorization and Pre- Certification requested by type of service; • Total number of requests for Prior Authorization and Pre-

Certification processed within fourteen (14) Calendar Days for standard Service Authorizations; • Total number of requests for extension of the fourteen (14) Calendar Days for standard Service Authorizations; • Total number of requests for Prior Authorization and Pre- Certification processed within twenty-four (24) hours for expedited Service Authorizations; • Total number of requests for the extension of the twenty-four (24) hours for expedited Service Authorizations; • Total number of requests for authorization processed within thirty (30) Calendar Days for determination for services that have been delivered; • Total number of requests approved by type of service; and • Total number of requests denied by type of service.

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Section 8. Cost Sharing and Payment (Section 2103(e))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.  YES 8.1.2.  NO, skip to question 8.8.

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

8.2.1 Premiums: Premiums are not required for children ages 0 through 5 years. American Indian/Alaska Natives and children in Foster Care are also exempt from paying a premium. For children ages 6 through 18, the premiums are detailed in the table below.

FPL One Child Family Cap 139%-158% 11.00 $16.00 159%-170% 22.00 $44.00 171%-190% 24.00 $49.00 191%-210% 29.00 $58.00 211%-231% 32.00 $64.00 232%-247% 36.00 $72.00

8.2.2. Deductibles: None

8.2.3. Coinsurance or co-payments: Coinsurance or co-payments: There are no coinsurance payments required. For children ages 6 and over, the following co-payments apply:

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Category of Service Co-Payment Ambulatory Surgical Centers / Birthing $3.00 Durable Medical Equipment $1.00 and $3.00 Federally Qualified Health Centers $2.00 Free Standing Rural Health Clinic $2.00 Home Health Services $3.00 Hospital-based Rural Health Center $2.00 Inpatient Hospital Services $12.50 Oral Maxillofacial Surgery Cost-Based Orthotics and Prosthetics $3.00 Outpatient Hospital Services $3.00 Pharmacy - Preferred Drugs $0.50 Pharmacy - Non-Preferred Drugs Cost-Based Physician Assistant Services Cost-Based Physician Services Cost-Based Podiatry Cost-Based Vision Care Cost-Based

Cost-Based Co-Payment Schedule Cost of Service $10.00 or less $0.50 $10.01 to $25.00 $1.00 $25.01 to $50.00 $2.00 $50.01 or more $3.00

*There are no co-payments for children below the age of 6 years old, for children in Foster Care, or for children who are American Indians or Alaska Natives.

8.2.4. Other: None

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8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

PeachCare for Kids® publicizes the cost sharing requirements in its brochures, applications, website, mass media campaigns and other outreach materials. If a parent applies for a child and does not include a premium payment with the application, if applicable, a letter is sent indicating that a payment must be received for the children to be enrolled in the program. The letter includes the specific amount due, depending on the number of children over 6 in the household, and the due date for premium payments for enrollment to be initiated and maintained monthly.

The Board of Community Health, a nine-person board appointed by the Governor, governs the Department of Community Health. The board meets regularly on a monthly basis and is open to the public. The FY 04-05 cost sharing changes were presented to and approved by the board on May 12, 2004.

Effective November 1, 2011, Families will be required to make co-payments for certain services for children ages 6 and above.

The PeachCare for Kids® Third Party Administrator will issue notices to all currently enrolled families regarding the new co-payments prior to July 18, 2011. Once the co-pay amounts are finalized, the information will be included in letters routinely generated to new enrollees by the Third Party Administrator when they are approved, re-instated and at redetermination.

A public notice will be issued and posted at the Department of Family and Children Services offices state-wide. The notice will also be sent to regional newspapers and posted on the Department of Community Health website. See Attachment #3

Prior to implementation of co-pays, the Board decided to change the co-pay amounts. Effective April 1, 2012, co-payment amounts previously approved were changed to lower amounts. A banner message will be sent to PeachCare for Kids® providers statewide to inform them of the new co-pay amounts required for children 6 and older.

The PeachCare for Kids® Third Party Administrator will issue notices to all currently enrolled families regarding the new co-payments prior to March 10, 2012. The co-pay information will be included in letters routinely generated to new enrollees by the Third Party Administrator when they are approved, re- instated and at redetermination.

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A public notice was issued and posted on December 8, 2011 at the local county Division of Family and Children Services offices state-wide. The notice was sent to regional newspapers and posted on the Department of Community Health website. See Attachment #4

A banner message will be sent to PeachCare for Kids® providers statewide to inform them of the co-pay amounts required for children 6 and older.

PeachCare for Kids® will emphasize cost-sharing rules and regulations in its provider education and communications. Out of pocket expenses that exceed the 5% cap will be reimbursed to the family after review of all cost sharing documentation for the family. At the end of the first 12 months of eligibility, eligibility will be re-determined. The 5% cap will be recalculated for the family and the monitoring cycle will start over again. At the point of application approval and review, families will be informed, by mail, of the 5% cost sharing maximum and their responsibility for tracking costs.

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8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.  Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.  No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3  No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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8.5. Describe how the state will ensure that the annual aggregate cost sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Effective April 1, 2012

To protect families against excessive medical expenses and comply with the statutory limit of no more than five percent of family income being expended on cost sharing expenses, the state keeps the co-pays and premiums the families are required to pay minimal. Because of the low premium and low co-payment, very few families are likely to exceed the limit and would not approach the 5 percent limit. The MMIS, Third Party Administrator and the Care Management Organization (CMO) will implement system changes designed to track all cost- sharing. When a family reaches 4.5% of their income for the eligibility period, the system will send the family a notice that no further cost-sharing is required for the remainder of the eligibility period. Each year consists of 12 months beginning with the approval month or the month of eligibility redetermination.

If out of pocket expenses still somehow manage to exceed 5% of the cap, the overage will be reimbursed to the family.

Families are notified of the premiums and co-pays when their applications are initially approved and when changes are reported that result in premium changes. Information about premiums and co-pays, including the 5% cap, is posted on the PeachCare for Kids® website, the Department of Community Health web-site and the Care Management Organization websites.

Families are not required to keep track of their expenses since they are tracked electronically by the agency, but if at any point, the family believes that their out of pocket expenses have exceeded 5% for the year, they may contact the PeachCare for Kids® Third Party Administrator to request a review of their expenses.

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8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

PeachCare for Kids notifies enrolled American Indian and Alaska Native families of the cost sharing exclusion by letter. The letter instructs families to mail their official tribal documentation to PeachCare for review. Once the documentation is reviewed, a letter is sent to families to confirm receipt. This letter also notifies the families that they are no longer required to pay a monthly premium or make co- pays. If official tribal documentation is not submitted, families must continue to make premium payments and co-pays.

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8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Non-Payment of Premiums

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:  State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, co-payments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))  The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))  In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost- sharing category as appropriate. (42CFR 457.570(b))  The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

Premiums are due the first of the month, prior to the month of coverage. If a premium payment is not received on the first, a late letter is sent to the family approximately four days after the late premium was due informing them that if payment is not received by the end of the month, they will be given 45 days of grace period before the coverage termination process begins, with coverage being canceled at the end of the 2nd month of the grace period. This notification also explains their option to opt out of receiving coverage for the grace period months. If the family does not pay the past due premium at the end of the month that it is due, the grace period begins the following month. The State will

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send a notice no later than the 8th of the first grace period month, informing the family that failure to make a premium by the 15th of the 2nd grace period month will initiate the termination process and coverage will ultimately be terminated at the end of the 2nd grace period month. A call campaign is launched on the 15th of the first grace period month to inform parents of the past due premium payments. If the premium is not paid by the 15th of the 2nd grace period month, then the coverage termination process begins and is ultimately terminated by the end of the 2nd grace period month. Payments received after the 15th day of the 2nd grace period month will not stop the termination process. Once coverage is terminated due to non-payment of premium, the family is ineligible to reinstate for the following month. Families who are canceled due to non-payment of premium are notified by mail and informed of their right to a review of the termination.

In the case that a premium payment is made during the grace period, but there is still an outstanding premium(s), the payment would apply to the first missed premium payment. The grace period would then start again based on the date of the second missed premium payment such that a family always has a grace period starting at the first of the month of a new coverage period and ending 45 days later.

For example, on January first the premium is due for February coverage. If a family missed the January 1st due date, a letter is sent to the family on approximately January 4th informing them that their payment is due and that if payment is not received by the end of January, the grace period will begin on February 1st and last until March 15th, after which the coverage termination process will begin. If the family does not pay the January 1st premium due for February coverage by the 15th of March, the family’s coverage is terminated at the end of March. In this case, the family would be ineligible for coverage during the month of April, unless the family opts out of February coverage by January 31.

In the case where a family missed the January 1st and the February 1st premium, but made a single premium payment by February 15th , the payment would apply to the January missed payment and the family would be offered a new premium grace period starting on March 1st and requiring payment by April 15th before coverage is terminated. In the case where a family missed the January 1st premium, the February 1st premium, but made a single premium payment by March 15th, the February 1st premium due for March coverage would be required by April 15, after which coverage would end April 30. This cycle will continue for each new month of coverage and each grace period, where premium payments are late. Any late premium payments will always apply to the earliest premiums due.

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If the family requests a review of the termination due to a claim of reduced income that disrupts their ability to pay the premium, coverage is extended to the child during the appeal process.

If the family reports a reduction in income during the cancellation period, as well as any other time, the application is screened for potential Medicaid eligibility. If it appears that the child is eligible for Medicaid, the application will be referred to Right from the Start Medicaid for a full determination. If it appears that the child still qualifies for PeachCare for Kids®, but at a lower premium amount, the family will be notified of the new premium requirement and will be issued a new coupon book.

Prior to August 1, 2005 a Member who was cancelled for late/non-payment of premium was ineligible to reinstate for a period of three (3) months. PeachCare for Kids® enrollees and the public at large were made aware of the policy change from a three-month period to a one-month period in a variety of methods. Those enrollees that were in a 3-month waiting period were notified via a letter that they were eligible for reinstatement effective August 1, 2005. All other members were notified of changes in correspondence mailed to households, the Frequently Asked Questions posted on our website (www.peachcare.org), and call center customer service representatives.

During closed enrollment, there will be no reinstatement period. Any family cancelled for late/non-payment of premium will be ineligible to reinstate so long as PeachCare enrollment is closed. All effected families will be notified of this change in policy by a mailing. It will be reiterated in the final notice letter that will also inform them of their right to seek a review within 30 days of receipt of the notice and to continue services during the review period.

There are no coinsurance or deductible fees for PeachCare for Kids®, but effective April 1, 2012, co-payments are required for children 6 years and older. Providers are responsible for collecting the co-payments at the time of service. A provider may not refuse to render services covered under the plan to an individual who is eligible for PeachCare for Kids® if they are unable to pay a co- pay. Providers can not send the account to collections nor can they deny additional services based upon the past failure to pay.

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8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.  No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.  No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.  No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.  Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5.  No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.  No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

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Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

The six strategic objectives of PeachCare for Kids are to:

1. Increase insurance coverage among Georgia’s low income children 2. Increase the percentage of low-income children with a regular source of care. 3. Promote utilization of Health Check (EPSDT) services. 4. Decrease unnecessary use of emergency departments for non-emergency services. 5. Minimize preventable hospitalizations. 6. Promote the appropriate use of health care services by children with asthma (as defined by national standards).

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9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c)) Objective 1: Increase insurance coverage of Georgia’s low-income children. Performance goals: 1.1 Enroll 75% of uninsured, non-Medicaid eligible children with family income below 235% of the federal poverty level. Measure: Percent of eligible children enrolled.

1.2 Employ marketing and outreach techniques that encourage parents of eligible, low-income children to enroll their children in PeachCare for Kids. Measure: Percent of eligible children enrolled and survey data of applicant families.

Baseline and Target Improvement Levels: Within one year, Georgia exceeded our two-year enrollment goal of 60,000 children, as indicated in our original state plan. For the upcoming fiscal year, we have set the goal of enrolling 85% of the estimated eligibles (169,142 children enrolled on June 30, 2003).

Objective 2: Increase the percentage of low-income children with a regular source of care.

Performance goals: 2.1 Over time, decrease the percent of children matched to a PCP through auto assignment. Measure: Percent of children who selected PCP on enrollment.

2.2 Encourage use of PCP through health plan policies and education. Measure: Percent of enrolled children who seek care from their assigned PCP.

2.3 Maximize the number of enrollees who stay with their PCP for 12 months. Measure: Percent of enrollees who stay with their PCP at least one year.

Baseline and Target Improvement Levels: As of November 30, 1999, there were 17,120 children who were matched to a PCP through auto assignment, and 41,713 (71%) who chose their own PCP. Our target improvement level is 80% by the end of federal fiscal year 2005.

Objective 3: Promote utilization of Health Check (EPSDT) services to achieve

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targets set by the Centers for Medicare and Medicaid Services and GF. These are 80% for screening and 90% for immunizations.

Performance goals: 3.1 Assess how many children receive recommended well visits and screenings. Measure: Percent of enrolled children receiving each screening on or about the recommended schedule.

3.2 Assess how many children receive immunizations. Measure: Percent of enrolled children receiving each immunization on or about the recommended schedule.

3.3 Increase provider and patient compliance with use of primary and preventive services by feeding back information to providers and health plans about their rates of screening for the enrolled population. Measure: Percent of PCP panels with improved screening rates in subsequent years.

Baseline and Target Improvement Level: From claims data for fiscal year 2000, 41% of all children enrolled 10 to 12 months had an EPSDT visit. Of the children ages 1 to 5, 55% had an EPSDT visit. Georgia’s goal is to increase this to 80% by the end of federal fiscal year 2005. With enhancements in our fiscal management system and the reporting provided by GF CMO plans, we anticipate being able to track services among children who have EPSDT services as their coverage changes among Medicaid and PeachCare for Kids. This will allow us to evaluate more children with 10 to 12 months of coverage and have a more complete picture of the percentage of children who are receiving these services, either through PeachCare exclusively or intermittent coverage through the Medicaid program.

Objective 4: Decrease unnecessary use of emergency departments for non- emergency services. A non-emergency service is one that does not meet the prudent layperson definition of emergency.

Performance goals: 4.1 Reduce the number of ED visits for non-emergency services. Measure: Rate of non-emergency ED visits per year for the population enrolled.

Baseline and Target Improvement Level: From claims data for fiscal year 2000,

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66% of visits to emergency departments met the criteria for an emergency. Georgia’s goal is to increase the percentage of emergency department visits for diagnoses considered to be medical emergencies to 70% by the end of federal fiscal year 2005. Objective 5: Reduce preventable hospitalizations. Performance goals: 5.1 Reduce preventable hospitalizations. Measure: Percentage of hospitalizations for preventable diagnoses.

Baseline and Target Improvement Level: From claims data for fiscal year 2000, 32% of hospitalizations were for diagnoses which could be considered preventable. Georgia’s goal is to decrease the percentage of preventable hospitalizations to 25% by the end of federal fiscal year 2005.

Objective 6: Promote the appropriate use of health care services by children with asthma (as defined by standards of the National Heart Lung and Blood Institute of the National Institutes of Health).

Performance goals: 6.1 Assess the number of children whose asthma is managed through appropriate outpatient care. Measure: Percent of children seeing PCP within two weeks of ER or hospital visit.

Baseline and Target Improvement Level: From claims data for fiscal year 2000, 93% of children had a follow-up visit within 2 weeks of a visit to an emergency department or a hospitalization. Georgia’s goal is to increase the percentage of children who have a follow-up visit within 2 weeks of a visit to an emergency department or a hospitalization due to asthma to 95% by 2005.

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9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops:

(Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1. 

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid.

9.3.2.  The reduction in the percentage of uninsured children. 9.3.3.  The increase in the percentage of children with a usual source of care. 9.3.4.  The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. 

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.  Other child appropriate measurement set. List or describe the set used. 9.3.7. 

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as:

9.3.7.1. 

Immunizations

9.3.7.2. 

Well child care

9.3.7.3. 

Adolescent well visits

9.3.7.4. 

Satisfaction with care

9.3.7.5. 

Mental health

9.3.7.6. 

Dental care

9.3.7.7. 

Other, please list:

9.3.8. 

Performance measures for special targeted populations.

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9.4.  The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

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9.5.  The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

PeachCare for Kids® will comply with the annual assessment by submitting a report, utilizing the Framework for Annual Evaluation developed by the National Academy for State Health Policy in conjunction with state SCHIP staff and CMS. This report will be completed by PeachCare staff. Independent evaluators will be responsible for measuring PeachCare’s progress in meeting the performance measures defined in Section 9 “Strategic Objectives and Performance Goals and Administration” and for nationally-mandated measures when they become available.

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9.6.  The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

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9.7.  The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

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9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.  Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.  Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.  Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.  Section 1132 (relating to periods within which claims must be filed)

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9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

Initial Public Involvement

In 1996, the Georgia Coalition for Health was asked by the Governor to examine approaches for reforming Medicaid in Georgia. The Coalition sponsored extensive research on the views of the stakeholders in the state’s Medicaid system – healthcare providers, Medicaid members and Georgia citizens. Three separate but complementary processes—focus groups, community forums and community dialogues—offered the opportunity for about 6,000 Georgians to express their views.

This unique process of obtaining stakeholder input served as a foundation for convening people with varied perspectives and expectations, raising awareness about those perspectives, identifying areas of agreement and disagreement, and working together to find solutions to difficult problems.

Georgia Health Decisions was commissioned by the Coalition to conduct research to learn what changes citizens would support in the state’s Medicaid program. Citizen input was gathered through focus groups in all areas of the state, with almost 500 people participating. Focus group participants were randomly chosen to represent all socio-economic segments of Georgia’s population. Eleven focus groups were composed of Medicaid members, and six others were made up of healthcare providers. Further, Georgia Health Decisions conducted 200 open community forums throughout the state in which 5,000 Georgians had the opportunity to express their concerns about Medicaid reform.

In addition, the Georgia Health Policy Center engaged 14 communities across Georgia in Medicaid community dialogues. The objectives of the dialogues were to ensure a process for obtaining input from Medicaid consumers and health care providers around the state; to clarify an understanding of the issues related to Medicaid reform and the ramifications of those issues; and, to identify examples of system disincentives that could be corrected by changes in policy.

The consumers and advocates participating in the dialogues were identified by a coalition of consumers and advocates incorporated under the name Healthcare for a Lifetime. This group represents the four primary populations that receive Medicaid: low income Mothers and children, older people, people with physical

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disabilities, and people with mental retardation, mental illness, or those with substance abuse problems. The providers were selected by the Healthcare Providers Council and included representation from hospitals, physicians, nursing, dentistry, nursing homes, home health, pharmacy, public health, community health and others. County Commissioners as well as members of the legislature were also invited to attend. Overall, 443 consumers and advocates and 234 providers participated for a total of 677 statewide participants. The meetings were open to the public and at every Dialogue there were observers who did not participate in the discussions yet had the advantage of moving among groups and hearing all four conversations.

These statewide, public conversations on Medicaid contributed to dispelling barriers between consumers and providers; the process also indicated where consumers, advocates and providers stand on major issues and where they are willing to negotiate. The main themes identified through the process are summarized below. These themes served as a reference and defining force for developing general Medicaid reform recommendations and many are reflected in Georgia’s proposal for implementing the Title XXI program.

Citizens

The citizens, both Medicaid members and members of the general public, expressed a wide variety of views, but agreed on a few basic themes.

• Vulnerable people should be protected. Citizens generally believe in the concept of a health care safety net and are willing to pay taxes to provide health care to people who need help.

• Only truly needy individuals should qualify for Medicaid. Citizens want to make sure that eligibility is strictly defined and enforced to stop abuse.

• Nothing should be free. Citizens want all adult Medicaid members to make some financial contribution toward their care, generally favoring a sliding scale based on income. They believe welfare recipients should work. They also want to make sure that families contribute to the cost of caring for disabled children and, perhaps, elderly parents.

• Health care should be accessible to all Georgians. Citizens worry about rising health care costs and their own ability to get affordable coverage, even if they now have health benefits, they worry about losing them. People are also concerned about the uninsured and would like to broaden Medicaid

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reform to also offer affordable coverage for this group.

Medicaid Members

In the community dialogues, Medicaid members generally shared the opinions of the general population, as described above, but also expressed some specific concerns.

• Medicaid costs should not be cut by reducing eligibility, since not enough truly needy people are covered today.

• There should be no stigma attached to receiving Medicaid, and any managed care plans used in the program should serve both Medicaid members and non-Medicaid patients.

• Prevention and education should be integral components of any benefits package.

Providers

In addition to participating in the focus groups and community dialogues, many health care providers were interviewed for a separate study as part of a detailed analysis of the current health care delivery system in Georgia. Key findings from that research are summarized below:

• The delivery system is in rapid transition. Organized health plans are widespread in the state, displacing traditional fee-for-service reimbursement plans. Hospitals and other providers are restructuring, merging and forming networks to compete with insurer-sponsored managed care organizations.

• A quick-budget-fix approach to Medicaid reform could harm public health and actually raise costs in the long run. Providers would support a serious, well- reasoned reform effort, developed through a fair process that listens to providers’ concerns, and includes realistic transition periods.

• Any reform plan should include performance standards, outcome measures, accountability, competition, and choice (for both members and providers). Providers should be able to at least break even financially if they participate in Medicaid, and a small profit would be appropriate as recompense for taking risk.

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• Providers who have traditionally served the Medicaid population with demonstrated quality should be included in a managed care or any other delivery system.

About six months after this public input process was completed, the Georgia Coalition for Health Board, concerned about the effects of Medicaid reform on uninsured children, asked the Health Policy Center to study mechanisms for providing coverage to this target population. In response to this charge, the Policy Center applied for (and was subsequently awarded) a Robert Wood Johnson Foundation grant to replicate the Florida Healthy Kids program. The Coalition also allocated funding to the Center to conduct preliminary planning activities so that Georgia could position itself for implementing the Healthy Kids program as well as the impending federal children’s health insurance legislation.

From May through December 1997, the Center established several advisory committees with representation from key agencies and organizations around the state. (It should also be noted that, according to the reviewers from the Robert Wood Johnson Foundation, one of the most impressive components of the initial grant and the subsequent planning efforts was the inclusive process for obtaining input from affected stakeholders into the design of the program.) The committee structure included a primary broad-based Children’s Health Insurance Advisory Committee and four subcommittees, each governed by specific charges that addressed the major programmatic issues of benefits package, eligibility criteria, program design, and local collaboration. There were a total of 40 individuals on the full advisory committee and four subcommittees, however, these meetings were open to and attended by several additional visitors and observers. There were about 25 meetings of the full advisory group and the subcommittees between April and December. Membership on these groups was comprised of representatives from the following agencies and organizations:

• Association of County Commissioners of Georgia • Augusta/Richmond County Community Partnership • Caring Program for Children • Chatham-Savannah Youth Futures Authority • Child Psychologist • Children’s Hospitals (Egleston, Hughes-Spalding, Scottish Rite) • Council on Maternal and Infant Health • Department of Education • Department of Medical Assistance (Division of Maternal and Child Health, Eligibility and Quality Control, and Strategic Planning) • Division of Family and Children Services

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• Division of Mental Health/Mental Retardation/Substance Abuse • Division of Public Health (Division Director, Child and Adolescent Health Unit, Gwinnett County Health District, DeKalb County Board of Health) • Georgia Academy of Family Physicians • Georgia Association for Primary Health Care • Georgia Chapter/American Academy of Pediatrics • Georgia Dental Association • Georgia Partnership for Caring • Georgia Policy Council for Children and Families • Georgians for Children • Governor’s Office of Planning and Budget • Healthy Mothers, Healthy Babies Coalition of Georgia • March of Dimes • Office of the Commissioner of Insurance • Tanner Medical Center • The Family Connection • United Healthcare • Wachovia Bank of Georgia Compensation and Benefits Branch • West Georgia Medical Center

In addition, separate group meetings were held with child advocates, health plan representatives, and public health district officers to explain the program and obtain input about specific components of the program design for CHIP. During December, January, February and March, several legislative hearings were held in both the Senate and House of Representatives. The hearings focused on the Governor’s proposal for implementing Title XXI in Georgia. At these hearings, child advocates, state agencies, pediatricians and other health care providers provided testimony.

Public Notice

At the regular meeting of the Board of Medical Assistance on April 8, 1998, DMA staff provided a public briefing for the Board on the status of the Georgia CHIP planning process. Again, at the regular meeting of the Board on May 13, 1998, the DMA presented detailed information to the Board and the public about the proposed Georgia CHIP, and gave opportunity for public comment. The May meeting had been extensively publicized with a notice mailed to a large mailing list of stakeholders in Medicaid and CHIP, in addition to regularly published meeting notices.

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Ongoing Public Involvement

The House Appropriations Committee created the Medical Assistance Study Committee in June, 1997. It was charged with conducting a comprehensive study of the Medicaid system in Georgia. The rationale was for a core group of people on the Appropriations Committee to learn as much as possible about the complexities of the budget item known as Medicaid.

Identifying problems and finding opportunities in Georgia’s Medicaid system were main challenges of the committee. To meet these, a series of hearings were conducted around the state, sixteen (16) in all. They began in the summer and ended in the fall of 1997. Georgia is comprised of one hundred fifty-nine counties, urban and rural. Input was gathered from big metropolitan areas, such as Atlanta and Savannah, and small rural areas, such as Greensboro and Moultrie, to name a few. Providers and their respective associations, professional health care associations, community groups, patient advocates, Medicaid recipients, and interested citizens were invited to share their concerns with the committee.

Through the hearings, the Committee identified significant findings in fifteen different areas ranging from reimbursement to providers to health care for those with disabilities. Along with the findings, recommendations were made to DMA. A copy of the Committee’s report is on file with DMA. Members of the Committee took lead roles in drafting the Georgia CHIP legislation. The Medical Assistance Study Committee has since become a standing committee of the House Appropriations Committee, which is now known as the DCH Subcommittee of the House Appropriations Committee.

The Department of Community Health is governed by a nine-person board appointed by the Governor. The Board has an active role in developing and approving DCH’s proposed budget, setting priorities for the Department and working with DCH to affect policy and process to improve the health care delivered to its membership. During the budget development process, DCH holds public forums throughout the state for public input. The DCH has additional advisory committees. The Physician Advisory Committee provides a forum for health care providers and advocates to improve the health care delivery to Medicaid and PeachCare for Kids members.

Georgia Families

In February 2003, the State issued a request for information seeking

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comprehensive proposals to redesign the Medicaid program to improve quality and provider accountability while achieving budget predictability and cost containment. Over 42 responses were received. For the next several months, meetings were held with providers, consumer groups, insurance representatives and other stakeholders to design a new program.

In October 2003, a diverse team of stakeholders, including senior executives from healthcare provider organizations and advocacy groups, assembled for several days to discuss state strategies to promote quality healthcare, enhanced access, shared member and provider responsibility, improved efficiency, and better cost management.

In August 2004, the State announced that it would implement a mandatory managed care program using Care Management Organizations. From September 2004 through October 2004, the State held stakeholder sessions with physician and hospital providers, senior associations, children and family coalitions, and others to ensure participation and input from all groups affected by the new mandatory managed care program.

Upon implementation of the program, the State will continue to utilize providers from the various medical advisory committees, recipients involved in NET advisory committees, staff liaisons to advocacy groups that include both providers and recipients, and member satisfaction survey.

Express Lane Eligibility effective April 1, 2011-

The Georgia Department of Community Health evaluated the feasibility of the options designed to facilitate enrollment and retention in the Medicaid and PeachCare for Kids® program and to receive bonus payments as outlined in the Children’s Health Insurance Program Reauthorization Act of 2009, section 203. Express Lane Eligibility was chosen as on of Georgia’s 5 of 8 efforts to enroll more eligible children in Medicaid and PeachCare for Kids® programs.

On December 6, 2010 Medicaid and CHIP (PeachCare for Kids ™) representatives met with the Public Health agency to discuss requirements for Express Lane Eligibility and to develop a plan for data file exchanges. A meeting was also scheduled with the TPA (Policy Studies, Inc.) for PeachCare for Kids® on January 12, 2010 & February 4, 2011. Additional meetings were held with these groups to discuss the implementation.

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WIC applicants will be informed that with their permission, their demographic and income information will be forwarded to the PeachCare for Kids®/Medicaid agency for an eligibility determination.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

There are no nationally recognized American Indian tribes or organizations in the state of Georgia. PeachCare for Kids, however, does not charge cost-sharing to enrolled members who are members of federally-recognized American Indian or Alaskan Native tribes.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d).

On February 8, DCH announced that it would quit enrolling new members in PeachCare for Kids effective March 11, 2007. State code allows for these changes to be made administratively, but public notice was provided in compliance with state laws. A public notice with comment period was published in regional newspapers, posted on the Department of Community Health’s website and made available for review at each county Department of Family and Children Services office. A widely attended public hearing was held on February 23, 2007. Current members, including those “locked-out” of coverage, will be notified by direct mail. The Department also issued a press release and is communicating with providers and stakeholders on the change. On March 8, 2007, the Board of Community Health approved the implementation of the closed enrollment period.

Upon receipt of additional federal funds, DCH issued a public notice announcing that enrollment would resume effective July 12, 2007, pending Board approval. The public notice further stated that in order to ensure that the funding adequately supports the cost of health care for members through September 30, 2007, enrollment will be limited to 295,000 children. The enrollment limit will be reassessed upon passage of SCHIP reauthorization legislation. Public comments were accepted for 30 days and a public hearing was held on June 27, 2007.

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The following documents are enclosed in Attachment 2: • Public Notices • Letter to PeachCare Families • Message to Providers • DCH Press Release

To reflect the new verification requirements, the PeachCare for Kids® website, applications and all correspondence were updated to inform members of the required documentation. The information required has always been information that the Department could seek from individuals in order to determine eligibility and was requested as deemed necessary. This is clearly stated in the PeachCare application. A new application was used beginning July 1, 2007 which requested that applicants send in their proof of income with the application. Furthermore, a public notice was issued on August 24, 2007. Per state policies, the public notice was published in newspapers across the state, on the DCH web and in all DFCS offices. The public notice is enclosed in Attachment 3.

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9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

Planned use of funds, including -- • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected sources of non-Federal plan expenditures, including any requirements for cost sharing by enrollees.

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SPA 20 Budget SCHIP

STATE: GEORGIA Current FFY Budget Co-Pay Implementation Current Budget + SPA Budget Change Federal Fiscal Year FFY 2014 FFY 2014 FFY 2014 State's FMAP Rate 76.15

76.15 Benefit Costs Insurance Payments Managed Care $ 393,038,330 $ - $ 393,038,330 Fee for Service $ 21,570,436 $ - $ 21,570,436 Total Benefit Costs $ 414,608,766 $ - $ 414,608,766 (Offsetting beneficiary cost sharing payments) $ (27,790,803) $ (2,406,799) $ (30,197,602) Net Benefit Costs $ 386,817,963 $ (2,406,799) $ 384,411,165 Total Administration Costs $ 42,979,774 $ (267,422) $ 42,712,352 Federal Share $ 327,290,977 $ (2,036,419) $ 325,254,558 State Share $ 102,506,760 $ (637,802) $ 101,868,959 TOTAL COSTS OF APPROVED SCHIP PLAN $ 429,797,737 $ (2,674,221) $ 427,123,516

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Assumptions:

1. Benefit Expenditures This line item reflects the reimbursements to providers for the provision of health care services to the PeachCare members. The State assures that benefit expenditures do not include any cost sharing payments, including premiums.

2. Administrative Expenditures This line item includes costs associated with enrolling children in the PeachCare for Kids program.

Explanation of Revenues

3. Federal Share This line item reflects a portion of funds, which have been allocated to Georgia under Title XXI. It is calculated by reducing total expenditures by the amount estimated for premium collections and multiplied by the federal financial participation rate for Georgia’s Title XXI program.

4. State Share This line item reflects a portion of the funds, which have been allocated specifically to the Georgia Department of Community Health by the Georgia General Assembly.

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Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750) 10.1.1.  The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

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10.2.  The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

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10.3.  The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

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Section 11. Program Integrity (Section 2101(a))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1  The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

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11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1.  42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.  Section 1124 (relating to disclosure of ownership and related information) 11.2.3.  Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.  Section 1128A (relating to civil monetary penalties) 11.2.5.  Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.  Section 1128E (relating to the National health care fraud and abuse data collection program)

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Section 12. Applicant and enrollee protections (Sections 2101(a))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Upon denial of eligibility, a parent will be notified by mail of the reason for the denial and the process to notify PeachCare for Kids if the parent believes the denial is in error. Parents will first be directed to call the toll- free number and report additional information or clarify information on the applicant’s account. The information or clarification will be input into the TPA eligibility system and a review of eligibility will be initiated. If the information provided does not result in the child being eligible, the parent will be notified of the reason the denial was upheld. If the parent would like additional reconsideration of the decision, the request will be directed to a senior supervisor and/or the account manager of the TPA. The management level will review if the determination made by the TPA system and supported by the staff is correct based on state and federal policy. If the supervisory level does not overturn the denial, the parent will once again be informed of the decision. If the parent continues to dispute the denial, the supervisory staff will inform the parent that they may submit a request in writing to the PeachCare for Kids, to be reviewed by state- level PeachCare for Kids staff.

Receipts of requests for review will be acknowledged in writing within 10 days, including notification that that member will receive a decision within 30 days. PeachCare for Kids will review requests for reconsiderations of denials. If PeachCare disagrees with the decision of the TPA, the child will be enrolled in PeachCare for Kids retroactive to the first day of the month in which the complete application, including any additional information affecting the outcome of PeachCare’s decision, is received. If PeachCare for Kids agrees with the decision to deny eligibility, a letter will be sent to the parent detailing the reason for denial. If the parent elects to dispute the decision, the parent will have the option of having the decision reviewed by the Formal Appeals Committee for the State Health Benefit Plan. The member will have 30 days from the issuance of the letter to

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submit a request for a formal appeal. Formal appeals will be held within 45 days of request, allowing both parties adequate time to prepare documentation and schedule of the appeal, either in person or through written communication.

The decision of the Formal Appeals Committee will be the final recourse available to the member. If at any level of dispute, the appropriate party determines the child is eligible for enrollment in PeachCare for Kids, the enrollment will become effective retroactive to the first day of the month in which the complete application, including any additional information affecting the outcome of PeachCare’s decision, is received.

The State assures that in the review process, enrollees have the opportunity to fully participate in the review process; decisions are made in writing; and impartial reviews are conducted in a reasonable amount of time and consideration is given for the need for expedited review when there is an immediate need for health services.

Members whose coverage is cancelled due to closed enrollment will follow all of the same procedures for review as detailed in this section, including having the right to continue services pending completion of a review.

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Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

Upon denial of covered benefits, a parent will notify the Care Management Organization if the parent believes that the service should be covered. The information provided by the parent in the phone call will initiate a review. The contracted CMO will research the situation, including reviewing the medical policy, the claims system and any documentation submitted by the physician, if applicable. The CMO will ensure that all reviews are conducted by a health care professional with appropriate clinical expertise, as determined by DCH, in treating the Member’s Condition. If the initial review does not result in a change in the decision to deny a service, the parent will be notified of the reason the denial was upheld. If the parent would like additional reconsideration of the decision, the parent may submit a request in writing to the PeachCare for Kids, to be reviewed by DCH management staff, including the policy director of the service area and the Chief of the Division of Medicaid Services or his designee. If this decision of this review is maintain the denial of service, a letter will be sent to the parent detailing the reason for denial. If the parent elects to dispute the decision, the parent will have the option of having the decision reviewed by the Formal Appeals Committee for the State Health Benefit Plan. The decision of the Formal Appeals Committee will be the final recourse available to the member. In reference to the Formal Appeals level, the State assures:

• Enrollees receive timely written notice of any determinations that include the reasons for the determination, an explanation of applicable rights to review, the standard and expedited time frames for review, the manner in which a review can be requested, and the circumstances under which enrollment may continue pending review. • Enrollees have the opportunity for an independent, external review of a delay, denial, reduction, suspension, termination of health services, failure to approve, or provide payment for health services in a timely manner. The independent review is available at the Formal Appeals level. • Decisions are written when reviewed by the CMO, DCH and the Formal Appeals Committee. • Enrollees have the opportunity to represent themselves or have representatives in the process at the Formal Appeals level.

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• Enrollees have the opportunity to timely review of their files and other applicable information relevant to the review of the decision. While this is assured at each level of review, members will be notified of the timeframes for the appeals process once an appeal is filed with the Formal Appeals Committee. • Enrollees have the opportunity to fully participate in the review process, whether the review is conducted in person or in writing. • Reviews that are not expedited due to an enrollee's medical condition will be completed within 90 calendar days of the date a request is made consistent with 42 CFR §457.1160(b)(1). • Reviews that are expedited due to an enrollee's medical condition are completed within 72 hours of the receipt of the request consistent with 42 CFR §457.1160(b)(2).

Consistent with 42 CFR §457.1130(c), DCH and its Agents are not required to provide an opportunity for review of medical or eligibility matters if the sole basis for the decision is a provision in the State Plan or in Federal or State law requiring an automatic change in eligibility, enrollment, or a change in coverage under the health benefits package that affects all applicants or enrollees without regard to their individual circumstances.

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Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

N/A

Attachment 1 PeachCare for Kids Application

Links to Application

www.peachcare.org www.compass.ga.gov

Georgia Department of Human Services

Application for Benefits

if you need help filling out this application, ask us or call 1-877-423-4746_ If you have a hearing impairment, call

(GA Relay at 1-800-255-0135. Our services are free.

What Services Do We Offer at the Division of Family and Children Services (DFCS)?

Food Assistance

Food Stamps are benefits that you can use to buy food at any store thathas the EBT/Quest sign. We will subtract the price of your food purchase from your Food Stamp account.

(Cash Assistance/Employment Support Services. Temporary Assistance for Needy Families (TAMF) provides cash assistance to families with dependent children for a limited time. Parents or caretakers who are incuded in the grant are required to:

‘Cash Assistance program also provides financial assistance to refugee households who are not eligible for the TANF program.

Medical Assistance Medicaid, for those who are eligible, may help pay medical bills, doctor's visits, and Medicare premiums.

Community Outreach Services: For more information about Community Outreach Services, please

visit our website at: httodiwww.dfes chr geongia.qow or call 1-277- 423-4746.

How Do | Apply for Benefits?

Step 1. Fill out the application.

and date the application.

Step 2. Tum in the application. You will need to tear off pages 1 -3 and keep it for yourself.

Mail, fax, or bring in pages 4-8 of this application to your local Division of family & Children Services (DFCS) office. If you or the person for whom you are applying is eligible for benefits, Food Stamps or TANF benefits will be provided from the date that we receive the application with your name, address, and signature on it.

Hr you apply for Food Stamps, and/or Medicaid you can file an application for benefits with only your name, address and signature. However, it may help us to process. your application quicker if you complete the entire form.

Step 3. Talk with us.

You may need to complete an interview with a case manager. If so, we will give you an appointment. This interwiew can be completed by phone.

Fom 237 (Rev. D413}

Frequently Asked Questions: How long does it take to get benefits?

Food Stampe: ‘up 1D 30 days:

TANF: up to 45 days:

‘Medicaid: 10 to 60 days

“You may be able to get Food Stamps within 7 days it you quay. S2= page S.

benefit amounts. We will be able to give you specific Information once we determine your eligibility.

How will | get my benefits?

For Food Stampe. and TANF, you will get an Electronic Benefit Transfer (EBT) card to access your benefits. For Medicaid, you will recelve a Medicaid card foreach eligible member.

What information will | need to provide? Itls a good Idea to provide the following:

‘= Proof of Identity for te appileant if apptying for Food Stamps andior TANF. Proof of kientity for everyone requesting Medicald If applying for Medicaid. Exc An identification card /iD) or driver's Ilbense {DL}

«© Proof of US cltizenship/qualfied Immigrant ‘status for everyone requesting benefits

« = Socal Security numbers of everyone: requesting assistance

= Proof of Income for example, pay stubs, child SUppOn payments, and Income award letters

«Proof of expenses like child care receipts, medical bills, medical transportation costs, and child support payments

‘You will be given time to retum any Information to

‘our oMce. Ifyou need help getting this Information,

please tell us.

How do we use the applicant's personal information?

“You only Nave to provide Social Security Numbers. (SSN) and cttizenship of immigration status for persons who want 1D apply Tor beens. This. Information wil De used to check the Income and

and local agencies io verify your Income and ellgibilty. Tf alhousenold member does not want to give us Information about thelr SSN, citizenship, or Immigration ‘status, other household members may sill recelve benefits.

(Can someone else apply for me?

"Yes, for Food Stamps and Medicaid, you may ask ‘someone to apply for you.

‘For TANF, anyone can apoty but the parent or ‘caretaker must be Interviewed.

Georgia Department of Human Services Application for Benefits

“In accordance with Federal law and US. Deparment of Agriculture (USDA) and US. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national ongin, sex, age. or disability. Under the Food and Nutrition Act of 2008 and USDA policy, discrimination is aiso prohibited on the basis of religion or political beliefs.”

To file a complaint of discrimination, you may contact USDA or HHS.

Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, 3.¥V.. Washington, D.C. 20250-0411 or calll (900) 785-2272 {woice) or (202) 720-6382 (TTY).

Write HHS. Director, Office of Civil Rights, Room 509-F_ 200 Independence Avenue, S.W., Washington, DLC, 20201 or call (202) 619- (0403 (voice) or (202) 619-3257 (TTY).

USDA and HHS are equal oppertunity providers and employers

‘You may also fle a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street, N.W_, Suite 18- 248, Atlanta, Georgia 30303 or call (404) 657-3735 or fax (404) 463-3078.

Under the Department of Community Health (DCH) policy, Medicaid cannot deny you eligibility or benefits based on your race, age. sex, disability, national origin, or political or religious beliefs. To report Medicaid eligibility or provider discrimination, call the Georgia Department of Community Health's Office of Program Integrity local 404-463-7500) (toll free) B00-533-D686,

What Do the Words Used in this Application Mean?

This. chart explains the words we have used in this application.

(Caretaker A parent, relative or legal guardian who applies for and receives TANF with chikiren in his or her care.

(Grantee Relative A parent, relative or legal guardian who applies for and receives TANF in his or her name on behalf of the children

Disqualified The action taken to remove an individual from a Food Stamp or TANF case because they did not tell the

Electronic Benefit The system used in Georgia to pay benefits to individuals who are eligible for Food Starnps. Individuals

Transfer (EBT) receiving assistance are issued an EBT debi card, which is used to access their food stamp accounts.

EPPICard debit New debit card issued by Merox for individuals receiving cash assistance in Georgia. The

MasterCard EPPIiCard debit MasterCard will be accepted for purchases and cash withdrawals anywhere the MasterCard is accepted.

Household Members Individuals who live in your home. For Food Stamps, individuats who live together and purchase and prepare their meals together.

Income Payments such as wages. salaries, commissions, bonuses, worker's compensation, disability, pension,

retirement benefits, interest, child support or any other form of money received.

Migrant Farm Workers Individuals who are seasonal fam workers and move from one home base to another to work or book fior farm work,

Resources ‘Cash, property, or assets such as bank accounts, wehicles, stocks, bonds, and lif insurance.

‘Seasonal Fam Workers | Individuals who work at certain times of the year planting, picking or packing produce. They are hired on a temporary basis when a job requires. more workers than the fanm employs on a regular basis.

Fom 297 (Rev. D413) 2

Leas eet

‘Georgia Department of Human Services Application for Benefits 6

OG

What Do the Words Used in this Application Mean? (cont'd)

This chart explains the words we have used in this application.

Trafficking in the SNAPiFood Stamp Program

Trafficking SMAP benefits means:

(1) Buying, selling, stealing, or othenvise exchanging SMAP benefits issued and accessed via EBT cards, card numbers and PIN numbers or by manual voucher and signature. for CASH or consideration other than eligible food, either directly, indirectly. in complicity or collusion with others, or acting alone: (2) The exchange of firearms, ammunition, explosives, or controlled substances; (3) Purchasing a product with SNAP benefits that has a container requiring a retum deposit with the intent of abtaining cash by discarding the product and retuming the container for the deposit amount, intentionally discarding the product, and intentionally retuming the container for the deposit amount; (4) Purchasing a product with SMAP benefits wath the intent of obtaining cash or consideration other than eligible food by reselling the product, and subsequently intentionally reselling the product purchased with SNAP benefits in exchange for cash or consideration other than eigible food. (5) Intentionally purchasing products originally purchased with SNAP benefits in exchange for cash or consideration other than eligible food.

‘Qualified Alien/immigrant

A qualifed alien‘immigrant is a person who is legally residing in the U.S. who falls wathin one of the following categories: a person lawfully admitted for permanent residence (LPR) under the Immigration and Nationality Act (INA): Amerasian immigrant under section £24 of the Foreign Operations, Export Financing and Related Program Appropriations Act of 1988; a person who is granted asylum under section 208 of the INA; Refugees, admitted under section 207 of the INA; A person parofed into the US under section 212(d)(5) of the INA for at beast one year, A person whose deportation is being withheld under section 243(h) of the INA as in effect priorto Apel 1, 1227 , or section 241 (b\(3) of the INA, as amended; a person who is granted conditional entry under section 202{a){7) of the INA as in effect prior to Apel 1, 1980; Cuban or Haitian immigrants as defined in section 5D1(e) of the Refugee Education Assistance Act of 1980: victims of human trafficking under section 107(b)(1) of the Trafficking Victims Protection Act of 2000; batfered immigrants who meet the conditions set forth in section 431 (c) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, a5 amended; Afghan or Iraqi immigrants. granted special immigrant status under section 101/a (27) of the INA (subject to spectied conditions); American Indians bom in Canada living im the U.S. under section 280 of the INA or non- ‘citizens of federallyrecognized Indian tbe under Section 4(e) of the Indian Self-Determination and Education Assistance Act and Hmang or Highland Laotian inbal members that rendered assistance to U_S. personne! by taking part in military or rescue operation during Vietnam Era (8/06/1864 — S'07/1875).

An individual who chooses to apply for or to receive public assistancebenefts

An Individual who chooses NOT to apply for or to receive public assistance/benefits; non-applicants are ot required to provide an SSN, citizenship or immigration status.

An assistance unit includes eligible individuals who live together and recsive public assistancelbenefits together.

Form 237 (Rev. 04/13}

gs ane

Georgia Department of Human Services 4 Application for Benefits ie ee O

What Am | Applying For? Check all that apply:

a

a

Food Stamps The Food Stamp program helps meet the food and nutritional needs of eligible households.

Temporary Assistance for Needy Families (TANF)

Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash payments, or other support services, to sirengthen eligible families with children. If you are the child's parent, or the caretaker who would like to be included in the grant, we will require you to Participate in a work program.

Refugee Cash Assistance

The Refugee Cash Assistance program provides financial assistance to refugee households whe are not eligible for the TANF program. The term refugee includes refugees, Cuban/ Haitian Entrants, victims of human trafficking, Amerasians, and unaccompanied refugee minors.

Medicaid

Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families. When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.

Tell Us About The Applicant

Does the applicant or person applying on behalf of the applicant need assistance when communicating with us? Ifso check all that apply.

() Foreign Language Interpreter (specify language) () Other Please fill out the chart below about the applicant.

First Name Middle Initial Last Name Suit | Sireet Address Where You Live Apt Ty Tae Tip Cade

| Mailing Address [if daterent)

City State Zip Gade Main Telephone Number Other Contact Number E-Mail address (optonal) Signature Date

‘Winess Signature i signed by X Date

| For Office Use Only iste Received By The County

Form 297 (Rev. D4't3)

Georgia Department of Human Services pHs Application for Benefits B ’ oO

Do | Qualify to Get Food Stamps Faster?

Answer these questions about the applicant and all household members to see if you can get Food Stamps within 7 days.

4. Are you or any household member a migrant or seasonal farm worker? O Yes O No 2. Total Gross eared income that will be received for this month: $ Employer Name Employment Begin Date Employment End Date. Rate of Pay Hours Worked Weekly wh/bi-wk/semi-moa/mo (circle one) 3. Total Gross unearned income that will be received for this month: 3 Type of Uneamed Income Amount wh/bi-wk/semi-mo/mo (circle one) Type of Uneamed Income Amount wh/bi-wk/semi-mo/mo (circle one) 4. Total eamed and uneamed income for this nvonth: 3

5. How much money do you and all household members have in cash or in the bank? $

6. How much do you and all household members pay for rent or mortgage? 3

7. How much do you and all household members pay for electric, water, gas,ete.? §

Can I Choose Someone to Apply for Food Stamps or Medicaid for me?

‘Complete this section only if you want someone to fill out your application, complete your interview, and/or use your EBT card to buy food when you cannot go to the store. If you are applying for Medicaid, you can choose more than one person to apply for medical assistance on your behalf.

Name: Phone:

Address: Apt:

City: State: Zip: Name: Phone:

Address: Apt:

City: State: Zip:

For Medicaid, do you want this individual to have a copy of your Medicaid card? O Yes O No

Form 297 (Rev. 0413) 5

Georgia Department of Human Services

> Application for Benefits

Tell Us about the Applicant and All Household Members

Please fill out the chart below about the

icant and all household members.

. The following federal

laws and regulations: The Food and Nutrition Act of 2008, 7 U.S.C. § 20141-2036, 7. C.F.R. § 273.2, 45 CLFR. § 205.52, 42 C.F.R. § 435.910, and 42 C.F.R. § 435.920, authorize DFCS to request your and your household members social security number(s).lf anyone in your household does not want to give us information about his or her citizenship, immigration status, or social security numbers, then that person can be designated as a non-applicant. This means that the person will not be considered an applicant and will not be eligible for benefits. However, other household menbers may still be able to receive benefits, if they are otherwise eligible. If you want us to decide whether any household members are eligible for benefits, you will still need to tell us about their citizenship or immigration status and give us their SSN. ‘You will still need to tell us about your income and resources to determine the eligibility and benefit level of the household. Individuals will not be reported to the United States Citizenship and Immigration Services (USCIS) Systematic Alien Verification for Entitlements (SAVE) system if they do not give us their citizenship or immigration status. However if immigration status information has been submitted on your application, this information may be subject to verification through the SAVE system and may affect the household's eligibility and benefit level.

NAME etation: is this Erin Socal Securty | Sex Hispanicy Race Are you a US ship person Date ‘Number Latino? Code clizen, qualited First Middle Initial «= Last toYou | applying allanvinmnigrant ‘tor or benefits? [Optionay | (Optional | HmongHighiand Lactan Imenigrant? (Applicants only} (ven Format (Applicants (See codes: and) only) (MIF) Ten) Belov) LYN SELF

Race Codes (Choose all that apply):

Al—Amencan Indian/Alaska Native AS — Asian HP — Native Hawaiian/Pacific Islander WH —White

BL — Black/African American

By providing Race/Ethnicity information, you will assist us in administering our programs in a non-discriminatory manner. ‘Your household is not required to give us this information and it will mot affect your eligibility or benefit level.

Tell Us More about the Applicant and All Household Members

We need more information about the applicant and all household members in order to decide who is eligible for

benefits. Please answer only the questions about the benefits you want to receive on the page below.

Form 297 (Rev. 0413)

Georgia Department of Human Services Application for Benefits Db

1. Has anyone received any benefits in another county or state? If yes: Who: Where: When:

2. Has anyone been convicted of giving false information about where they live and who: they are to get multiple FS benefits in more than one area after 8/22/96? If yes: ‘Who: Where: When:

3. Did anyone in your household voluntarily quit a job or voluntarily reduce his/her work hours below 30 hours per week within 30 days of the date of application? If yes, who quit? Why did he/she quit?

4. ls anyone pregnant? *Please provide proof of pregnancy if available. (This question does not apply to Food Stamp only applicants) Wha: Due Date:

5. For Medicaid, does anyone have any unpaid medical bills for the last 3 months?

(This question does not apply to Food Stamp or TANF only applicants)

6. ls anyone disqualified from the Food Stamp or TANF Program? If yes: a. Who: b. Where:

7. Is anyone trying to avoid prosecution or jail fora felony? (Food Stamps and TANF Only)

If yes, who:

Fom 237 (Rev. 0413)

O Yes O No

Oves ONo

Oves ONo

O Yes ONo

O Yes ONo

0 Yes ONo

Oves ONo

Georgia Department of Human Services

pHs Application for Benefits

8. Is anyone violating conditions of probation or parole? (For Food Stamps and TANF only) If yes, who:

‘9. Does anyone have a felony conviction because of behavior related to the possession, use or distribution of a controlled drug substance after 8/22/96 (FS and TANF only) or a violent felony (TANF only)?

If yes: Who: When:

10. Have you or any household member been convicted of trading Food Stamp benefits for drugs after 8/22/9687 If yes: Who: When:

11. Have you or any household member been convicted of buying or selling Food Stamp benefits over $500 after 6/22/967

If yes: Who: When:

12. Have you or any household member been convicted of trading Food Stamp benefits: for guns, ammunition or explosives after Q/22/967

If yes: Who: When:

13. Has anyone used TANF funds or the EPPIC Card at the following establishments, liquor stores, casinos, poker rooms, adult entertainment business, bail bonds, night clubs,

OvYes ONo

Oves ONo

Oves ONo

OvYes ONo

salons/tavems, bingo halls, race tracks, gun/ammunition stores, cruise ships, psychic readers, smoking

shops, tattoo/piercing shops, and spa/massage salons.? If yes:

Who: O Yes O No

When:

Fonm 237 (Rev. 04/13)

Georgia Department of Human Services Application for Benefits B

oO

a

Food Stamp Program Penalties

Any household member who breaks any of the food stamp rules on purpose can be barred from the Food Stamp Program for one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. She/he may also be subject to prosecution under other applicable Federal and State laws. She/he may also be barred from the Food Stamp Program for an additional 18 months if court ordered.

Any household member who intentionally breaks the rules may not get Food Stamps for one year for the first offense, two years for the second offense, and penmanently for the third offense.

If a court of law finds you or any household member guilty of using or receiving food stamp benefits in a transaction involving the sale of a controlled substance, you or that household member will not be eligible for benefits for two years for the first offense, and permanently for the second offense.

Ifa court of law finds you or any household member guilty of having used or received benefits ina transaction involving the sale of firearms, ammunition or explosives, you or that household member will be permanently ineligible to participate in the Food Stamp Program upon the first offense of this: violation.

If a court of law finds you or any household member guilty of having trafficked benefits for an aggregate amount of $500 or more, you or that household member will be permanently ineligible to Participate in the Food Stamp Program upon the first offense of this violation.

If you or any household member is found to have given a fraudulent statement or representation with respect to identity (who they are) or place of residence (where they live) in order to receive multiple Food Stamp benefits, you or that household member will be ineligible to participate in the Food Stamp Program for a period of 10 years.

For All Medicaid, Food Stamps and TANF Applicants: | have read and completed everything on this form that applies to the applicant and the applicant's

household. | certify, under penalty of perjury, all the information that | provided is true and complete as far as | know. | understand | can be punished by law if | do not tell the complete truth.

Applicant's Signature Date Authorized Representative’s Signature Date (Case Manager's Name and Signature Date

Fom 297 (Rev. D413) 3

Georgia Department of Human Services Health Coverage Addendum

Please answer the following questions if you are applying for Health Coverage (Please complete all three pages of this form)

1. Ifyou are an adult applying for Health Coverage for your dependent child(ren), do you want to receive Health Coverage for yourself? O ‘Yes O No

2. Is anyone in the household pregnant? O ‘ves O No If yes, how many babies are expected during this pregnancy? 3. Is anyone applying for health coverage blind or disabled? O Yes O No If yes, please list 4. Does anyone have other health insurance that covers anyone in your household? O Yes O No 5. Ifyou answered yes to question 5 above, please complete the following information:

Name | Health Insurance Company | Type of Coverage Name of Persons Effective Policy

of Name, Address and (Hospital, Medicare Covered Date Number Policy Telephone Number Supplement, Drugs, holder Major Medical)

6. Is 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. O Yes If yes, you'll need to complete Attachment A. Is this a state employee benefit plan? O Yes O No

7. Have you or anyone listed on this application lost any health coverage in the last 2 months? O Yes If yes, why was it lost? ONo

8. Was anyone in your household in Foster Care atage 1670 Yes OF No

9. Does. anyone in the household have any unpaid medical bills from the last 3 months? OO YesO No

10. Is anyone in your household American or Alaska Native? DO Yes O No If Yes, complete Attachment B.

If you are applying for Aged, Blind or Disabled Medicaid please answer questions 11-16 and complete the Resources section. Otherwise, skip to the tax filer questions on page 3.

11. Are you or your spouse currently covered by Medicare? OQ Yes QO No If Yes please list,

12. Are you applying for Medicaid to cover unpaid medical bills from the three months prior to a ‘Supplemental Security Income (SS!) application?

QO Yes O No If yes, date of SSI application: 13. Are you applying for someone who is now deceased and has unpaid medical bills within the last three (3) months? QO Yes 2 No

14. Are you applying for Medicaid to help pay for the care of a person who is in a nursing home? oO Yes O No ‘297M (01/14) -1-

15. Are you applying for Medicaid for a person over the age of 18 whose SSI check has stopped? ao ‘Yes O No

16. Are you applying for Medicaid to help pay for community based waiver services such as Community Care Services, NOW/COMP, Hospice Care, Independent Care Waiver or the Deeming Waiver (Katie Beckett)?

a Yes QO No

Resources: Check all resources (assets) owned by you, your spouse, your dependents or jointly owned with someone else. Attach additional pages if necessary.

‘Checking Accounts O Yes O No Funeral Plans/Prepaid Burial tem O Yes O No Savings Accounts O Yes O No Burial Plots or Contracts O Yes O No Government Bonds O Yes O No Stocks and Bonds O Yes O No Trust Funds O Yes O No Other (IRA, CD, etc.) O Yes O No Real Property/Homeplace Property QO Yes O No Have you or your spouse given away any assets for less than its value? 2 Yes 2 No

If you answered yes to any of these questions, please describe below.

Type of Resource Account/Policy Number | Value Name of Bank, Insurance Company, etc.

Does anyone in the household own a vehicle? If so, please describe below. O Yes O No Vehicle Make Model Year Amount Owed

Do you or your spouse have a life insurance policy? O Yes O No If yes, please complete the following information.

Policy Owner Insurance Company | Policy Number Face Value (Cash Value

Tax Filer Information

1. Does anyone in the household plan to file a federal income tax retum NEXT YEAR? O Yes O No If yes, who? (list each person who plans to file},

2. Will any of the tax filers listed file jointly with a spouse? O Yes O No If yes, please list spouse's name:

3. Will any of the tax filers claim any dependents on their tax retum? O Yes O No If yes, please list name(s) of dependents:

4. Will anyone be claimed as a dependent on someone else's tax retum? O) Yes O No If yes, please list the name of the tax filer and the dependent:_(Filer), (Dependent). How is the tax dependent related to the tax fiber?

297M (ULI) -2-

Income and Earmings: List all types of eamings and income that your household receives. List the income anvount before deductions such as taxes, insurance or Medicare premiums , health insurance, dental, and vision premiums or Spending accounts are taken out.

Income Type ‘Gross amount How often? (weekly, every 2 Name of Person

‘Child Support ‘Contributions ‘Other Income (please specify)

Does anyone expect any change im monthly mcome? O Yes Q No

If yes, please list who expects the change, the type of income that is changing. and the date it is expected to change below.

Deductions: Check all that apply, and give the amount and how often you pay it.

O Alimony § How often? O Other Deductions § How often?

© Student loan interest §. How often?,

Assignment of Rights of Payment for Medical Support and Other Medical Care:

(If you are applying on behalf of another individual and do not have the power to execute an assignment for that individual, the individual will need to execute an assignment of the rights described below, as a condition of his/her eligibility for Medicaid.) As a condition of my eligibility, | agree to assign to the State all rights to medical support and to payment for medical care from any third party (hospital amd medical benefits). | agree to cooperate with the state im identifying and providing information to assist the state in pursuing any third party who may be liable to pay for care and services. | understand that | must report any payments received for medical care within ten days. | agree to give the State the right to require an absent parent to provide medical insurance, if available. | understand | must get Medical support from the absent parent if it is available and must cooperate with the Division of Child Support Services. in obtaining this support. If | do not cooperate, | understand | may lose my Medicaid benefits, and only my child(ren) will receive benefits unless good cause is established.

| certify, under penalty of perjury, that all the information listed is truthful to the best of my knowledge.

Signature Date 297A (ULL) -3-

DECLARATION OF CITIZENSHIP/IMMIGRATION STATUS |

Georgia of Human Services

Tunderstand that the Georgia Division of Family and Children Services (DFCS) may require verification from the United States Department of Homeland Secunty (DHS) of my and/or my child(ren)’s citz Ip or mumigration status when seeking benefits. Information received from DHS may affect my or my childiren)’s

eligibility. Please fill out and sign ONE or BOTH of the following statements as it pertains to the status of each person seeking benefits. CHILDREN SEEKING BENEFITS | Date Naturalized or Tumigration Admitted intoU.S. Document ID# (Check applicable) ‘Lawfully Place of Birth Us. Admitted Name (City, State Country) Citizen Immigrant (If applicable) (if applicable) A. A- A A L declare the child/children is/are a U.S. Citizens or a Qualified Immigrant. PET RaE

I attest to the identity of the child/children listed above, and certify under penalty of perjury, that the

information wiitten and checked above is true.

SIGNATURE (PARENT/GUARDIAN) Date)

ADULT(S) SEEKING BENEFITS

Date Naturalized or Admitted into TS.

Immierati Document ID #

(Check applicable)

Lawfully

Place of Birth Us. Admitted

Name (City. State, Country) Citizen _Immisrant __(If applicable)

Gfapplicable) _

a

A-

L , declare Tam a U.S. Citizen or a Qualified Immigrant. I certify under

penalty of perjury, that the information written and checked above is true.

SIGNATURE Tale)

n6 11g 4.

Attachment 2:

PeachCare for Kids Closed Enrollment Public Information

PUBLIC NOTICE

Pursuant to 42 CFR § 457.65, the Georgia Department of Community Health is required to give public notice of any state plan amendment that limits or restricts eligibility in the State Children’s Health Insurance Program, known as the Georgia’s PeachCare for Kids® Program. PEACHCARE FOR KIDS

Pursuant to Title XXI of the Social Security Act, the PeachCare Program is a jointly funded state and federal insurance program for low-income children. Effective March 11, 2007, the Department will discontinue enrollment in the PeachCare for Kids® Program.

• Any new applications received or postmarked after March 11, 2007 will not be processed for PeachCare eligibility.

• Members whose participation in the program is suspended for failure to timely pay premiums or for failure to provide required income verification will also be affected by this change and will be precluded from re- enrollment. These members will receive additional notice by direct mail as required by governing regulations.

• Members enrolled and/or determined eligible prior to March 11, 2007 will not be impacted by this particular proposed change.

This change serves as an effort to sustain the PeachCare for Kids® Program so that low- income children currently enrolled in the program may continue to receive low-cost health insurance.

This public notice is available for review at each county Department of Family and Children Services office and will also be published in regional newspapers and on the Georgia Department of Community Health’s website. An opportunity for public comment will be held on February 23, 2007, 10:00 a.m.-12:00 p.m., at the Floyd Room of the Twin Towers Building, 20th Floor, West Tower, 200 Piedmont Avenue, Atlanta Georgia. Individuals who are disabled and need assistance to participate during the meeting should call (404) 656-4479. Citizens wishing to comment in writing on the proposed changes should do so before March 2, 2007 to the Board of Community Health, P.O. Box 38406, Atlanta, Georgia 30334.

Submitted comments will be available for review by the public at the Department of Community Health, Monday through Friday, 9:00 a.m. to 4:30 p.m., in Room 4074, 2 Peachtree Street, NW, Atlanta, Georgia 30303.

Comments from written and public testimony will be summarized and provided to the Board of Community Health prior to the March 8, 2007 Board meeting. The Board will vote on the proposed change at the March meeting which will be held 10:30 a.m. at the Floyd Room of the Twin Towers Building, 20th Floor, West Tower, 200 Piedmont Avenue, Atlanta, Georgia.

NOTICE IS HEREBY GIVEN THIS 8TH DAY OF FEBRUARY, 2007 Rhonda M. Medows, M.D., Commissioner

To:

Parents/Guardians of PeachCare for Kids Members From: Commissioner Dr. Rhonda Medows, M.D. Date: February 20, 2007 Re:

PeachCare for Kids® Enrollment Freeze

It was with a heavy heart that I announced we will stop accepting new applications to enroll in the PeachCare for Kids® (PKC) program effective March 11, 2007. This freeze will then be in effect until further notice.

While we are no longer accepting new enrollees, I am writing to you as parents and guardians of children already enrolled in PKC to inform you that you should not be alarmed by this notification. This is NOT a notice announcing that the program is ending. As long as PKC has money to operate, your children will receive care under the terms of their current enrollment.

As a parent, I understand the importance of providing quality health care to your children, and I have notified providers that the enrollment freeze does not impact the health care services of current PKC members. Providers will continue to render health care services to current PKC members.

However, if you are required to pay a PCK premium, it is crucial that you make your monthly payment on time or your child(ren)’s coverage will be at risk. After March 11, 2007, any family whose participation in the program is cancelled for failure to pay premiums will no longer be re-enrolled during this period.

PCK, Georgia’s State Children's Health Insurance Program, is a partnership between the state and federal government to provide comprehensive health care program for uninsured children living in Georgia. The state has committed its share of the funds; however, the program has a $131 million federal funding shortfall for Federal Fiscal Year 2007.

We continue to work with members of Congress, the members of our State Legislature and the Governor' office to resolve the funding needs of this very important program.

For additional information on the PeachCare for Kids® program, please access http://www.dch.ga.gov.

If you have any questions or concerns, please feel free to call 1-877-GAPEACH (1-877-427- 3224)

Equal Opportunity Employer

Rhonda M. Medows, MD, Commissioner

2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov Sonny Perdue, Governor

To: Providers of PeachCare for Kids® Health Care Services

From: Commissioner Dr. Rhonda Medows, M.D.

Date: February 16, 2006

Re: PeachCare for Kids® Enrollment Freeze

It was with a heavy heart that I announced we will stop accepting new applications to enroll in the PeachCare for Kids® (PKC) program effective March 11, 2007. This freeze will then be in effect until further notice.

While we are no longer accepting new enrollees, I am writing to inform you that the enrollment freeze does not affect the rendering of services to current PKC members. This is NOT a notice announcing that the program is ending. As long as PCK has money to operate, members of PCK will receive care under the terms of their current enrollment.

PCK, Georgia’s State Children's Health Insurance Program, is a partnership between the state and federal government to provide comprehensive health care program for uninsured children living in Georgia. The state has committed its share of the funds; however, the program has a $131 million federal funding shortfall for Federal Fiscal Year 2007.

We continue to work with members of Congress, the members of our State Legislature and the Governor' office to resolve the funding needs of this very important program.

For additional information on the PeachCare for Kids® program, please access http://www.dch.ga.gov.

If you have any questions or concerns, please feel free to call 1-800-766-4456.

Equal Opportunity Employer

Rhonda M. Medows, MD, Commissioner 2 Peachtree Street, NW Atlanta, GA 30303-3159 Sonny Perdue, Governor www.dch.georgia.gov FOR IMMEDIATE RELEASE CONTACT: February 8, 2007 Dena’ Brummer 404-463-5391

PeachCare for Kids® Enrollment Closes to New Members

Children currently enrolled continue to receive care

ATLANTA – Today, Georgia Department of Community Health Commissioner Dr. Rhonda Medows informed the Board of Community Health that PeachCare for Kids® (PCK) will no longer accept new enrollees to the program as of March 11, 2007.

“We have seen this important program grow to cover over 270,000 children. It is a way for hard working parents to try to provide health care for their children,” Dr. Medows said. “We continue to wait for an act of Congress to occur so that we can provide care for the children currently enrolled in the program through October 2007.”

PCK, Georgia’s State Children's Health Insurance Program (SCHIP), is a partnership between the state and federal government to provide comprehensive health care program for uninsured children living in Georgia. The state has reserved its share of the funds needed; however, the program has a $131 million federal funding shortfall for Federal Fiscal Year 2007.

The announcement comes as the state is actively urging Congress to allot funds for the SCHIP shortfall that Georgia and 14 other states face. State projections show that PCK will run out of operating funds sometime in March 2007.

A public notice has been filed to cease the allowance of new members to the PCK program. Effective March 11, 2007, only those currently enrolled in the PCK program may continue to receive services via the state.

“Parents and guardians of children already enrolled in PCK should not be alarmed by this notification,” Dr. Medows said. “As long as the PCK has money to operate, your children will receive care under the terms of their current enrollment. We remain hopeful that Congress will fulfill its commitment to the SCHIP program.” For more information about the PeachCare for Kids® program, please access http://www.dch.ga.gov

PUBLIC NOTICE

Pursuant to 42 CFR § 457.45, the Georgia Department of Community Health is required fo give public notice of any state plan amendment that limits or restricts eligibility in the State Children's Health Insurance Program, Known as the Georgia's PeachCare for Kids™ Program.

PEACHCARE FOR KIDS

Pursuant to Title XXI of the Social Security Act, PeachCare for Kids™ is a jointly funded state and federal insurance program for low-income children. Effective July 1, 2007, the Department has modified its procedures for validating eligibility for the Program.

Income and citizenship information are a condition of eligibility for PeachCare for Kids™. This information has been accepted through selfdeciaration or upon request of documentation. To ensure appropriate enrollmentin the program, effective July 1, 2007, the Department is requiring proof ofincome and citizenship status to determine eligibility.

Verification documents will be required for new applications received after July 1, 2007 and for all renewing accounts annually. Additionally, documentation may be sought at any time when changes in income are reported.

This public notice is available for review at each county Department of Family and Children Services office and will also be published in regional newspapers and on the Georgia Department of Community Health's website. Citizens wishing to comment in writing on the proposed changes should do so before September 26, 2007, to the Board of Community Health, P.O. Box 33406, Atlanta, Georgia 30334.

Attachment 3: Public Notice- Co-pay Implementation

PUBLIC NOTICE

Pursuant to 42 C.F.R. § 457.525, the Georgia Department of Community Health is required to give public notice of any significant proposed change in its methods and standards for setting payment rates for services.

Copayments for Medicaid and New Copayments for PeachCare for Kids® Members

Effective for services provided on and after November 1, 2011 and subject to payment at fee-for- service rates, the Department will increase existing Medicaid co-payments to the current definition of nominal as defined in the Code of Federal Regulations 42 C.F.R. § 447.54. Additionally, the same co-payments will be applicable to PeachCare for Kids® members six (6) years of age and older. All other existing copayment exemptions will continue to apply. A copy of the proposed copayment rates is included in this public notice for illustrative purposes.

This action is anticipated to result in savings of approximately $3,397,100 in State funds in SFY 2012.

This public notice is available for review at each county Department of Family and Children Services office. An opportunity for public comment will be held on September 27, 2011, at the Department of Community Health (2 Peachtree Street, N.W., Atlanta, Georgia 30303) in the 5th Floor Board Room at 2:00 pm. Individuals who are disabled and need assistance to participate during this meeting should call (404) 656-4479. Citizens wishing to comment in writing on any of the proposed changes should do so on or before September 30, 2011, to the Board of Community Health, Post Office Box 1966, Atlanta, Georgia 30303.

Comments submitted will be available for review by the public at the Department of Community Health, Monday – Friday, 9:00 a.m. to 4:30 p.m., in Room 4074, 2 Peachtree Street, N.W., Atlanta, Georgia 30303.

Comments from written and public testimony will be provided to the Board of Community Health prior to the October 13, 2011, Board meeting. The Board will vote on the proposed changes at the Board meeting to be held at 10:30 a.m. at the Department of Community Health (2 Peachtree Street, N.W., Atlanta, Georgia 30303) in the 5th Floor Board Room.

NOTICE IS HEREBY GIVEN THIS 8th DAY OF September, 2011 David A. Cook, Commissioner

Medicaid and PeachCare for Kids® Proposed CoPayment Schedule

Category of Service Co-Payment Current Proposed Copayments Advanced Nurse Practitioners Cost-Based Ambulatory Surgical Centers / Birthing $3.00 $3.65 Durable Medical Equipment $2.00 and $3.00 $2.45 and $3.65 Federally Qualified Health Centers $2.00 $2.45 Free Standing Rural Health Clinic $2.00 $2.45 Home Health Services $3.00 $3.65 Hospital-based Rural Health Center $2.00 $2.45 Inpatient Hospital Services $12.50 $25.00 Oral Maxillofacial Surgery Cost-Based Orthotics and Prosthetics $3.00 $3.65 Outpatient Hospital Services $3.00 $3.65 Pharmacy - Preferred Drugs $0.50 $0.65 Pharmacy - Non-Preferred Drugs Cost-Based Physician Assistant Services Cost-Based Physician Services Cost-Based Podiatry Cost-Based Vision Care Cost-Based

Cost-Based Co-Payment Schedule Cost of Service Current Proposed $10.00 or less $0.50 $0.65 $10.01 to $25.00 $1.00 $1.25 $25.01 to $50.00 $2.00 $2.45 $50.01 or more $3.00 $3.65

Attachment 4: Public Notice- Co-pay Decrease/Rounding

PUBLIC NOTICE

Pursuant to 42 C.F.R. § 447.205, the Georgia Department of Community Health is required to give public notice of any significant proposed change in its methods and standards for setting payment rates for services.

NEW CO-PAYMENTS FOR PEACHCARE FOR KIDS® MEMBERS

Effective for services provided on and after April 1, 2012, and subject to payment at fee-for-service rates, the Department will implement co-payments for covered services to PeachCare for Kids® members six (6) years of age and older. These copayments will be consistent with CMS-approved Medicaid co-payments and co-payment exemptions for adults. This action is anticipated to result in state fund savings of $318,462 in the Amended SFY 2012 budget and $1,273,849 for SFY 2013.

ILLUSTRATIVE CO-PAYMENTS

Ambulatory Surgical Centers / Birthing $3.00 Durable Medical Equipment $1.00 or $3.00 (service based) Federally Qualified Health Centers $2.00 Free Standing Rural Health Clinic $2.00 Home Health Services $3.00 Hospital-based Rural Health Center $2.00 Inpatient Hospital Services $12.50 Oral Maxillofacial Surgery Cost Based Orthotics and Prosthetics $3.00 Outpatient Hospital Services $3.00 Pharmacy - Preferred Drugs $0.50 Pharmacy - Non-Preferred Drugs Cost Based Physician Program Services Cost Based Podiatry Cost Based Vision Care Cost Based

COST BASED CO-PAYMENTS

Cost of Service Proposed Co-Payment $10.00 or less $0.50 $10.01 to $25.00 $1.00 $25.01 to $50.00 $2.00 $50.01 or more $3.00

This public notice is available for review at each county Department of Family and Children Services office. An opportunity for public comment will be held on December 28, 2011, at 1 p.m. at the Department of Community Health (2 Peachtree Street, N.W., Atlanta, Georgia 30303) in the 5th Floor Board Room at 2:00 pm. Individuals who are disabled and need assistance to participate during this meeting should call (404) 656-4479. Citizens wishing to comment in writing on any of the proposed changes should do so on or before 5:00 p.m. on December 28, 2011, to the Board of

Community Health, Post Office Box 1966, Atlanta, Georgia 30303. Comments submitted will be available for review by the public at the Department of Community Health, Monday – Friday, 9:00 a.m. to 4:30 p.m., in Room 4074, 2 Peachtree Street, N.W., Atlanta, Georgia 30303.

Comments from written and public testimony will be provided to the Board of Community Health prior to the January 12, 2012, Board meeting. The Board will vote on the proposed changes at the Board meeting to be held at 10:30 a.m. at the Department of Community Health (2 Peachtree Street, N.W., Atlanta, Georgia 30303) in the 5th Floor Board Room.

NOTICE IS HEREBY GIVEN THIS 8th DAY OF DECEMBER, 2011 David A. Cook, Commissioner

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

Nathan Deal, Governor Clyde L. Reese Ill, Esq., Commissioner

2 Peachtree Street, NW | Atlanta, GA 30303-3159 | 404-656-4507 | www.dch.georgia.gov PUBLIC NOTICE

Pursuant to 47 CFR 457.65, the Georgia Department of Community Health, Medicaid Division. is Tequired to give public notice of any proposed changes that implement cost-sharing charges. increases existing cost-sharing charges. or increases the cumulative cost-sharing maximum for PeachCare for Kids® members.

PeachCare for Kids® Premium Changes Pursuant to Title XXI of the Social Security Act. PeachCare for Kids® is a jointly funded state and

federal insurance program for low-income children. Effective April 1. 2015. the Department will implement an increase in premiums paid for participation in the program. The current premium

FPL One Child | Family Cap 100-150% $10.00 $15.00 1151-160% $20.00 $40.00 161-170% $22.00 $44.00 '171-180% $24.00 $48.00 181-190% $26.00 $52.00 1191-200% $28.00 $56.00 201-210% $29.00 $58.00 1211-220% $31.00 $62.00 1221-230% $33.00 $66.00 [231-235% $35.00 $70.00

Effective April 1, 2015, the premiums for PeachCare for Kids will change to the following

amounts. FPL One Child | Family Cap 139%-158% 11.00 $16.00 159%-170% 22.00 $44.00 171%-190% 24.00 $49.00 191%-210% 29.00 $58.00 211%-231% 32.00 $64.00 232%-247% 36.00 $72.00

Health Information Technology | Healthcare Facility Regulation | Medical Assistance Plans | State Health Benefit Plan Equal Opportunity Employer

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

The estimated State Fiscal Year 2015 fiscal impact is a decrease of $108,474 total funds of which $25,101 is state funds. In State Fiscal Year 2016 the fiscal impact is a decrease of $433.896 of which $25,101 is state funds.

This public notice is available for review at each county Division of Family and Children Services office. An opportunity for public comment will be held on February 17, 2015 at 10:30 am at the Department of Community Health (2 Peachtree Street. N.W.. Atlanta, Georgia 30303) in the Sth meeting should call (404) 656-4479. Citizens wishing to comment in writing on any of the proposed changes should do so on or before February 24, 2015. to the Board of Community Health. Post Office Box 1966, Atlanta, Georgia 30301-1966.

Attachment 5: ACA SPA Updates

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

Nathan Deal, Governor Clyde L. Reese Ill, Esq., Commissioner

2 Peachires Street, NW | Atlanta, GA 30303-3159 | 404-656-4507 | www.dch.georgia.gov

December 2, 2013

Ms. Jennifer Ryan

Centers for Medicare & Medicaid Services RE: Renewal Waiver Request 7500 Security Boulevard, Mail Stop $2-26-12

Baltimore, Maryland 21244-1850

Dear Ms, Ryan:

In response to CMS' guidance regarding targeted enrollment strategies that are available to states to help facilitate a streamlined enrollment process for 2014, Georgia requests to amend the CHIP and Medicaid renewal period in erder to adopt the MAGI-based eligibility determination methods beginning on January 1, 2014. Georgia would like to extend the CHIP and Medicaid renewal periods.

Georgia requests a waiver under section 1902/e)(14){A) in order to extend the dates for the state's CHIP eligibility renewals scheduled for January 1, 2014 through March 31, 2014 (three (3) months).

Georgia requests a waiver under section 1902(2)(14)(A) in order to extend the dates far the state's Medicaid eligibility renewals scheduled for January 1, 2014 through June 30, 2014 (six (6) months),

We believe this extension is needed in order establ sh income and eligibility determination systems that protect our beneficiaries. In addition, Georgia intends ta delay action on income and household changes that may cause a negative adverse action beginning January 1, 2014 until the beneficiary's first regular renewal in 2014.

We are not requesting any modifications to the demonstration's budget neutrality agreement, as budget neutrality will not be affected by this amendment request.

If you have questions about this request, please contact Shella Niexander for CHIP questions at 404-657-9506 or salexanden@dch ga gov. Medicaid questions should be directed to Yvonne Greene at 404-463-2135 of yoreeneiidch qaqov.

Sinceraly,

Jerfy Dubberly Medicaid Chief

Healln Inlormation Techology | Healthcare Facility Regulation | Medical Assistance Plans | State Health Benefit Plan Equal Opportunity Employer

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

Children and Adults Health Programs Group

FEB 0 6 2014

Ms. Sheila Alexander Program Director, Peach Care for Kids Georgia Department Community Health 2 Peachtree, N.W., 3ih Floor Atlanta, GA 30303

Dear Ms. Alexander:

I am pleased to inform you that your Title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) number GA-13-0017 submitted on November 14,2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

Establish 210l(f) Group: SPA number GA-13-0017 describes the state's plan to provide coverage in its separate CHIP, as specified in the state's submission ofCS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Georgia's approved CHIP state plan.

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

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-5480 Facsimile: (410) 786-5882 E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Division of Medicaid and Children's Health Operations. Ms. Glaze's address IS:

Page 2- Ms. Sheila Alexander

Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Atlanta Federal Center, 4th Floor 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909

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

Sincerely,

Eliot Fishman Director

Enclosures cc: Jackie Glaze, ARA, CMS Region IV, Atlanta Lynette Rhodes, Medicaid Operations, Department of Community Health

CHIP Eligibility

OME Control Number: (938-1148 Expiration date: lW'3 1/2014

Section 201} ofthe ACA and 42 CFR 457,31Nd)

ff Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards

The CHIP agency provides coverage for this group of children as follows:

c The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(8) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CPR 437.3 10(d). Coverage for this population will cease when the last child protected

« from loss of Medicaid coverage as a resultof the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no liter than April 1, 2016 },

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f}of the Affordable Care Act:

@ ‘The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility becouse of an increase in family income at their first renewal applying MAGL methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or

c below the following percentage of FPL. The state bas demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

The state will enroll children in a separate CHIP who arte found to be ineligible for Medicaid based on MAGI but whose family income has nod inereased since the child's last determination of Medicaid eligibility or who would have remained eligible for