DEPARTMENT OF HEALTH & HUMAN SERVICES ee Centers for Medicare & Medicaid Services Atlanta Regional Office

61 Forsyth Street, Suite 4T20 4 < M S Atlanta, Georgia 30303 S

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

July 3, 2013

Dr. Jerry Dubberly, Chief

Medical Assistance Plans

Georgia Department of Community Health 2 Peachtree Street, NW, 40" Floor Atlanta, Georgia 30303

Re: Georgia Title XIX State Plan Amendment, Transmittal #13-008

Dear Mr. Dubberly:

This letter is being sent as a companion to our approval of GA 13-008 which was filed to allow the Department of Community Health to provide both curative and hospice services in accordance with section 1905 of the Affordable Care Act. During our corresponding page review of GA 13-008, we noted that Georgia’s State Plan financial page for hospice services does not meet comprehensiveness requirements. Based on that review, it was determined that attachment 4.19B, Page 6a is not consistent with the following Medicaid statutory and regulatory requirements. Therefore, we would like to offer our continuing assistance with your efforts.

Statutory and Regulatory Requirements

Section 1902(a) of the Act requires that States have a State plan for medical assistance that meets certain federal requirements that set out a framework for the State program. Implementing regulations at 42 CFR 430.10 require that the State plan be a comprehensive written statement containing all information necessary for CMS to determine whether the plan can be approved as a basis for federal financial participation (FFP) in the State program. In addition, section 1902(a)(30)(A) of the Act requires that States have methods and procedures in place to assure that payments to providers are consistent with efficiency, economy, and quality of care. To be comprehensive, payment methodologies should be understandable, clear, and unambiguous.

In addition, because the plan is the basis for FFP, it is important that the plan language provide an auditable basis for determining whether payment is appropriate.

Comprehensiveness of the State Plan

The current approved State plan advises that GA uses an undisclosed rate to pay for hospice services however further advises that additional per diem amounts are provided for routine home care and room and board. This language is not transparent and does not identify how providers and auditors can locate the applicable fee schedule and the period for which the fee schedule is in effect. The language also does not comply with the revised revisions to the hospice wage index published in final in the Federal Register on August 8, 2008.

Jerry Dubberly, Chief Page 2

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Attachment 4.19B, Page 6a - Please refer to section four of the State Medicaid Manual which addresses Hospice (section 4306). Please see section 4603.3 for the discussion on the payment rates (these rates are revised annually and published). The current state plan approved methodology has not been revised since its effective date of October 1, 1990 and therefore does not comply with the final published guidance in the Federal Register on August 8, 2008. GA currently references Medicaid reimbursement with per diem amounts and daily rates. Any rate being used should be listed and published in the State Plan. Also, the American Recovery and Reinvestment Act (ARRA) required revisions to the hospice wage index previously published in final in the Federal Register on August 8, 2008. The hospice wage index has been revised to eliminate a reduction for the budget neutrality adjustment factor (BNAF), which had begun to be phased-out over 3 years, beginning in FY 2009. The revised wage index has been published on the CMS website, at the following link:

http://www.cms.hhs.gov/Hospice/downloads/FY2009HospiceWI ARRA. pdf.

The wage index is applied to both Medicare and Medicaid hospice rates. While the Medicaid rates published by CMS in a September 10, 2008 memorandum have not changed as a result of the revised wage index, the new wage index should be applied to the portion of each Medicaid hospice rate category subject to the wage index. This will require State Medicaid Agencies to recalculate their hospice rates. The revised wage index is retroactive to October 1, 2008. States’ Medicaid hospice rates should be recalculated accordingly.

When updating the reimbursement methodology for hospice services please include the following:

1. — Stipulate specifically the covered services included their per diem rate reimbursement.

2. Differentiate the difference between the over 21 and under 21 participants as related to curative covered services:

Example: The reimbursement rate for hospice services for participants age 21 and over includes all

covered services related to the treatment of the terminal illness, including the administrative and general supervisory activities performed by physicians who are employees of or working under arrangements made with the hospice. The reimbursement for hospice services for participants under age 21 is the same with the exclusion of reimbursement of curative covered services.

Jerry Dubberly, Chief

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Please amend your hospice service methodolo gy to include reimbursement of nursing home room and board for participants.

Example:

Nursing home room and Board for Medicaid- eligible individuals residing in Medicaid- certified nursing facilities who meet the hospice eligibility criteria may elect Medicaid hospice care services. In addition to the routine home care or continuous home care per- diem rates, an amount may be paid to the hospice to cover the nursing home room and board costs which will be determined in accordance with rates established under 1905 of the Social Security Act.

4.19B, Page 6a, Paragraph 1 — This section references a reimbursement methodology for physician services. Please include the physician services reimbursement methodology page reference on this plan page. Also, please confirm on the plan page that the reimbursement methodology for physicians participating in hospice services is in compliance with 42 CFR 440.50

Example: Physician services will be reimbursed in accordance with Medicaid reimbursement policy for physician services based on 42 CFR 440.50 ‘

Also, please confirm on the plan pages that a nursing facility may not bill Medicaid for the individual's care that duplicates hospice services.

Within 90 days of the date of this letter, the State is required to submit a State plan amendment that resolves the issues, or a corrective action plan to resolve the issues, whichever is appropriate. During the 90-day period, we are happy to provide any technical assistance that the State requires necessary. State plans that are not in compliance with requirements referenced above are grounds for initiating a formal compliance process.

If you have any questions or need any further assistance, please contact Yvette Moore at (404) 562-7327.

Sincerely,

a Che Slay ickie Glaze Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Revision: HCFA-PM-86-20 (BERC) ATTACHMENT 3.1-A SEPTEMBER 1986 Page 7 State/Territory Georgia AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 15. a. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined in accordance with section 1902(aK31K*) of the Act, to be in need of such care. (X) Provided || No limitations |X| With limitations* (| Not Provided: b. Including such services in a publk institution (or distinct part thereof) for the mentally retarded or persons with related conditions. I X ] Provided |] No limitations |X 1 With limitations* [ | Not Provided: 16. Inpatient psychiatric facility services for individuals under 21 years of age. | X| Provided (X | No limitations || With limitations* || Not Provided: 17. Nurse-midwife services | XI Provided 11 No limitations | X| With limitations* [ | Not Provided: 18. Hospice care (in accordance with section 1905(o) of the Act). 1 1 Provided [ I No limitations | X| Provided in accordance with section 2302 of the Affordable Care Act |X | With limitations* i | Not Provided: * Description provided on attachment TNNo. 13-008 Supercedes Approval Date 1-3-13 Effective Date 4/1/13 TNNo. 06-015

Revision: HCFA-PM-86-20 (BERQ ATTACHMENT 3.1-B SEPTEMBER 1986 Page 6 State/Territory: Georgia AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY c. Intermediate care facility services. //Provided //Nolimitation //With limitations* 15. a. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined in accordance with section 1902(a)(31)(A) of the Act, to be in need of such care. / X/ Provided / / No limitation / X/ With limitations* b. Including such services in a public institution (or district part thereof) for the mentally retarded or persons with related conditions. //Provided //No limitation // With limitations* 16. Inpatient psychiatric facility services for individuals under 21 years of age. / X/ Provided /X / No limitation / / With limitations * 17. Nurse-midwife services. /X/ Provided //No limitation / X/With limitations* 18. Hospice care (in accordance with section 1905(o) of the Act). //Provided // No limitation /X/Provided in accordance with section 2302 of the Affordable Care Act /X/With limitations* *Description provided on attachment- TNNo. 13-008 Supercedes Approval Date /->/;? Effective Date 4/1/13 TNNo. 06>01S

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED

1 ‘AL NI 2. STATE STATE PLAN MATERIAL 13-008 GEORGIA 3. M IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR . 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE AND MEDICAID SERVICES April 1, 2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One):

(2) NEW STATE PLAN

BLOCKS 6 U 10 IF THIS IS AN 6. FEDERAL STATUTE/REGULATION CITATION:

8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 3.1-A, Page7

AMENDMENT TO BE CONSIDERED AS NEW PLAN

X AMENDMENT NDMENT Transmital for each amendment) 7. FEDERAL BUDGET IMPACT: FFY 2013 $ FFY 2014 $ 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Attachment 3.1-A, Page 7

10, SUBJECT OF AMENDMENT: The Department of Community Health will provide both curative and hospice services in

accordance with the Affordable Care Act.

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

OTHER, AS SPECIFIED: Single State Agency Comments Attached

16. RETURN TO:

Department of Community Health Division of Medicaid

2 Peachtree Street, NW, 36” Floor Atlanta, Georgia 30303-3159

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 05-24-13

18. DATE APPROVED: 07-03-13

PLAN APPROVED — ONE COPY ATTACHED

19, EFFECTIVE DATE OF APPROVED MATERIAL: 04-01-13

20. Chie bo. OFFICIAL:

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20 TYPED NAME: 22. (ATLE: Associate Regional Adininistrator ' Jackie Glaze Division of Medicaid & Children Health Opns

Approved with the following changes to item 6, 7a, 7b, 8 and ‘9 as authorized by State Agency-e-mails dated 07/01/13 Block # 6 Chaneed to read: 42 USCS 1396d (O\(1){C) as amended by Section 2302 of the Affordable Care Act, Block # 7 Changed to read: FFY 13.0 and FFY 14 0. ; Block # 8 Changed to read: Attachment 3.1-A page 7 and Attachment 3.1-B page 6, Block # 9 Changed to read: Attachment 3.1-A page 7 and Attachment 3.1-B page 6

OMB NO. 0938-0193

Table of Contents State/Territory Name: Georgia State Plan Amendment (SPA) #:13-015 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303 CMS CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS February 18,2014 Dr. Jerry Dubberly, Chief Medical Assistance Plans Georgia Department of Community Health 2 Peachtree Street, NW, 401h Floor Atlanta, Georgia 30303 RE: Title XIX State Plan Amendment (SPA), Transmittal# GA 13-015 Dear Dr. Dubberly: We have reviewed the proposed Georgia State Plan Amendment 13-015, which was submitted to the Atlanta Regional Office on November 15, 2013. The SPA implements a medical coordination program for the aged, blind, and disabled population in the state plan. Based on the information provided, the Medicaid State Plan Amendment GA 13-0 15 was approved on February 11, 2014. The effective date of this amendment is October 1, 2014. We are enclosing the approved HCF A-179 and the plan pages. If you have any additional questions or need further assistance, please contact K.ia Carter- Anderson at (404) 562-7431 or Kia.Carter-Anderson@cms.hhs.gov. Sincerely, /Is// Jackie Glaze Associate Regional Administrator Division of Medicaid & Children's Health Operations Enclosures

TRANSMI'IT ALAND NOTICE OF APPROVAL OF STATE PLAN MATERIAL TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMI1T AL NUMBER: T.N. No.: 13-015 2. STATE GEORGIA 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACf (MEDICAID) 4. PROPOSED EFFECTIVE DATE October 1, 2014 0 NEW STATE PLAN X AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT orate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 C.F.R. §§ 438.6(c), 438.50, and 440.168 FFY 2014- S 0 FFY 2015- (S 3,833,889) FFY 2016- ($10,088,154) FFY 1017- $15,205,594 8. PAGE NUMBER OF THE PLAN SECTION OR A 1T ACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-F, Pages 1 - 14 N/A I 0. SUBJECT OF AMENDMENT: This State Plan Amendment will implement medical coordination services for eligible Medicaid members wbo are aged, blind, and disabled. II. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL / 12. SIGNATURE OF STATE AGENCY OFFICIAL: 13. TYPED NAME: Jeny Dubberly 14. TITLE: Chief, Division of Medicaid 15. DATE SUBMITTED: 11-15-13 181 OTHER, AS SPECIFIED: Single State Agency Comments Attached 16. RETURN TO: Department of Community Health Division of Medicaid l Peachtree Street, NW, 36th Floor Atlanta, Georgia 30303-3159 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 11-15-13 18. DATE APPROVED: 02-1 t-14 PLAN APPROVED- ONE COPY AITACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 10-01-14 20. SIGNATURE OF REGIONAL OFFICIAL: /lsi! 21. TYPED NAME: 22. TITLE: Associate Regional Administrator Jackie Glaze Division of Medicaid & Children Health Opns 23. REMARKS:

CMS-PM-10120 ATIACHMENT 3.1-F Page 1 Date: October 10, 2013 State: __ -'G=eo"-'r.og=ia Citation 1932(a)(l )(A) Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement A Section 1932(a)(l)(A) of the Social Security Act The State of Georgia enrolls Medicaid beneficiaries on a mandatory basis into managed care entities (managed care organization (MCOs) and/or primary care case managers (PCCMs)) in the absence of section 1115 or section 1915(b) waiver authority. This authority is granted under section 1932(a)(l)(A) of the Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance with provisions of section 1902 of the Act on statewideness (42 CFR 431.50), freedom of choice (42 CFR 431.51) or comparability ( 42 CFR 440.230). This authority may not be used to mandate enrollment in Prepaid Inpatient Health Plans (PIHPs), Prepaid Ambulatory Health Plans (PAHPs), nor can it be used to mandate the enrollment of Medicaid beneficiaries who are Medicare eligible, who are Indians (unless they would be enrolled in certain plans--see D.2.ii. below), or who meet certain categories of"special needs" beneficiaries (see D.2.iii. -vii. below) B. General Description of the Program and Public Process. The Georgia Department of Community Health (DCH) will procure a single statewide vendor to provide a Medical Coordination Program for Medicaid Members who are aged, blind and disabled (ABD) as identified by Members' Categories of Aid. The vendor is expected to achieve DCH's healthcare goals and Member health outcomes, and serve as an administrative agent of the State. The Medical Coordination Program will provide: • Person-centered Medical Coordination for all eligible Members • Intensive Medical Coordination services for targeted high-risk, impactable populations • A medical home to coordinate and manage care for participants receiving Intensive Medical Coordination services • Care Coordinators to assist eligible Members in obtaining needed medical services With the exception of partial benefit dual eligible Members and those Members enrolled in the Georgia Families program (Medicaid managed care), all other Medicaid Members will be eligible to receive services through the Medical Coordination Program. Thus, the Medical Coordination Program includes individuals who are dually eligible, enrolled in a Home- and Community-Based Approval Date:02-11-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F Page2 State : __ __,G"'"'e"'-'o<.!.rg='i""a Citation TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement Services (HCBS) waiver program or residing in a long-term institutional setting. DCH and its sister agencies will continue to administer State Plan benefits and HCBS waiver programs and to provide non-conflicting case management services. All Members will receive Core Coordination Services to include Member education, call center services and access to a twenty-four (24) hour nurse line. Members with chronic conditions, behavioral health conditions, co-morbidities or other complex diagnoses deemed "high-risk and impactable" will have the option to receive Intensive Medical Coordination services to include a health risk assessment, establishment of a health care plan, assistance with establishing a medical home and interdisciplinary team care management. The Medical Coordination Program vendor must develop and maintain a Primary Care Case Management (PCCM) network to ensure Members will have adequate access to medical home providers. The vendor will use a variety of mechanisms to identify Members potentially eligible for Intensive Medical Coordination services including those who currently have or are likely to experience catastrophic or other high-cost or high-risk conditions. These mechanisms must include, at a minimum, predictive modeling and other data analyses. For potential Intensive Medical Coordination participants, the vendor must complete a comprehensive health risk assessment that evaluates the Member's medical condition(s), including physical, behavioral, social and psychological needs. The goals of the health risk assessment are to confirm the Member's need for Intensive Medical Coordination, identify the Member's existing and/or potential health care needs, determine the types of services needed by the Member, and begin to develop the health care Plan and treatment team. Health risk assessments may require on-site visits to a Member's residence, doctor's office, pharmacy, or other locations. Meeting the Members "where they are" will be an important component of interaction and engagement. Members in the Medical Coordination Program will be advised by DCH and the Medical Coordination Program vendor on the provisions for opting out of Intensive Medical Coordination services. The vendor will inform Members and/or Members' legal guardians, as well as primary care providers, specialists and/or behavioral health providers that the Member has been identified as meeting the criteria for Intensive Medical Coordination services. The notification must provide a description of the Intensive Medical Coordination services, the Intensive Medical Coordinator's contact information and phone number, patient confidentiality and protection information, and the mechanism for opting out should the Member and/or Members' legal guardians prefer not to receive Intensive Medical Coordination services. In addition, the vendor's call center staff will be required to Approval Date:02-11-14 Effective Date: 10-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F Page 3 State: __ -'G"'"e""o~r.og=ia Citation 1932(a)(1)(B)(i) 1932( a)( 1 )(B )(ii) 42 CFR 438.50(b)(1) TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement assist those Members wishing to either opt-out of or opt back into Intensive Medical Coordination services. The vendor's Medical Coordination Program website will also provide information to Members on the provisions for opting out or into Intensive Medical Coordination services. Members eligible to receive Intensive Medical Coordination services will also be assisted by the vendor in selecting a medical home provider which may be a primary care provider, specialist, behavioral health provider or Patient-Centered Medical Home. If a Member is unable to select a medical home provider, the vendor will assign such a provider based on an algorithm approved by DCH and which heavily weighs the practitioner the Intensive Medical Coordination participant is frequenting the most. DCH expects the Program and vendor to achieve substantive improvements in service, access, appropriateness, and health and quality outcomes while reducing expenditures over the course of the contract. A significant component of the Program is a Value-Based Purchasing (VBP) approach that recognizes and rewards positive financial, and health and quality outcomes achieved through this Program. To be successful, DCH believes a VBP approach must align payer, Offeror and Provider goals, objectives and incentives. The VBP model performance targets will include transactional and quality measures and indicators. A percentage of the fees paid by DCH to the vendor will be withheld and returned to the vendor if these performance measures are met. DCH will reimburse the selected Offeror on a Per Member Per Month (PMPM) basis for all Members, regardless of whether the Member is eligible for or is an Intensive Medical Coordination Participant receiving Intensive Medical Coordination services. This PMPM payment to the vendor will include the provision of core services to all Members, Intensive Medical Coordination services for eligible Members and a Case Management fee for medical homes selected or assigned to Members receiving Intensive Medical Coordination services. For B.l and B.2, place a check mark on any or all that apply. 1. The State will contract with an i. MCO X ii. PCCM (including capitated PCCMs that qualify as PAHPs) iii. Both Approval Date:02-11-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F Page4 State: __ _;G=eo.,.,r~g=ia Citation 42 CFR 438.50(b )(2) 42 CFR 438.50(b )(3) 1905(t) 42 CFR 440.168 42 CFR 438.6(c)(5)(iii)(iv) TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement 2. The payment method to the contracting entity will be: i. ii. X iii. X iv. v. fee for service; capitation; a case management fee; a bonus/incentive payment; a supplemental payment, or vi. other. (Please provide a description below). 3. For states that pay a PCCM on a fee-for-service basis, incentive payments are permitted as an enhancement to the PCCM's case management fee, if certain conditions are met. If applicable to this state plan, place a check mark to affirm the state has met all of the following conditions (which are identical to the risk incentive rules for managed care contracts published in 42 CFR 438.6(c)(5)(iv)). X i. Incentive payments to the PCCM will not exceed 5% of the total FFS payments for those services provided or authorized by the PCCM for the period covered. X ii. Incentives will be based upon specific activities and targets. X iii. Incentives will be based upon a fixed period of time. X iv. Incentives will not be renewed automatically. X v. Incentives will be made available to both public and private PCCMs. X vi. Incentives will not be conditioned on intergovernmental transfer agreements. vii. Not applicable to this 1932 state plan amendment. Approval Date:02-11-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F Page 5 State: ___ G=eo=r...,g=ia Citation CFR 438.50(b )( 4) TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement 4. Describe the public process utilized for both the design of the program and its initial implementation. In addition, describe what methods the state will use to ensure ongoing public involvement once the state plan program has been implemented. (Example: public meeting, advisory groups.) The procurement for a Medical Coordination Program for eligible Members is the result of extensive public input and program analyses. In August 2011, DCH began an effort to analyze the Medicaid program to identify opportunities to achieve efficiencies and to provide improved outcomes and quality of care for Members. These efforts include a transparent, collaborative process working with stakeholders through focus groups and ongoing taskforces to obtain insights about challenges and opportunities for improvement. Stakeholders with which DCH has collaborated include Medicaid Members, advocates, Providers, legislators and Offerors. DCH formed three task forces that meet regularly to provide input: Provider; Aged, Blind and Disabled; and Children and Families Task Forces. DCH also convened a Mental Health and Substance Abuse Workgroup. Common themes identified by these groups are as follows: • Due to the often chronic and serious nature of their health issues, the ABD population including individuals in long-term care and disability programs-- would significantly benefit from intensive care management approaches. • Care coordinators should be used to help all ABD Members obtain timely needed services. • A true focus on quality and outcomes is critical to the success of the Medicaid program. • A person-centered model with a holistic view of an individual's needs is essential to quality outcomes. • The ABD population is not homogenous in terms of their medical needs. Some Members are aged or have a disability, but they are otherwise healthy. Other Members of the ABD population have high acuity levels and intense medical needs. Approval Date:02-ll-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F Page6 State: __ _;G=e=o=r~P"gi=a Citation 1932(a)(1)(A) TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement • Due to the often chronic and serious nature of their health issues, the ABD population- including individuals in long-term care and disability programs- would significantly benefit from intensive Care Management approaches or integrated healthcare coordination. • Member linkages to Patient-Centered Medical Homes are strongly encouraged for those who have the highest level of needs. • Improved care coordination for Medicaid/Medicare dually-eligible Members is needed. Examples of additional methods that DCH will employ to continue collecting public input during and after implementation are as follows: • Inclusion of stakeholders such as established Task Forces, providers, members and advocates on an as needed basis • Requirement for the vendor to identify and work with DCH to resolve issues pertaining to access to health care services, to communicate and educate members, providers and caregivers and to regularly report findings to the Medicaid Agency • Inclusion of related topics in the agenda for the Medical Care Advisory Committee on an as needed basis 5. The state plan program will_/will not_ X_ implement mandatory enrollment into managed care on a statewide basis. If not statewide, mandatory __ / voluntary_X_ enrollment will be implemented in the following county/area(s): i. county/counties (mandatory)------------- n. county/counties (voluntary) Statewide ___ X. _____ _ iii. area/areas (mandatory) _____________ _ iv. area/areas (voluntary) Approval Date:OZ-11-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 AITACHMENT 3.1-F Page 7 State:. __ -==G=e=or'-l;?g=ia Citation 1932(a)(1 )(A)(i)(I) 1903(m) 42 CFR 438.50(c)(l) 1932(a)(l )(A)(i)(I) 1905(t) 42 CFR 438.50(c)(2) 1902(a)(23)(A) 1932(a)(l)(A) 42 CFR 438.50(c)(3) 1932(a)(l)(A 42 CFR 431.51 1905(a)( 4)(C) 1932(a)(l)(A) 42CFR 438 42 CFR 438.50(c)(4) 1903(m) 1932(a)(l)(A) 42 CFR 438.6(c) 42 CFR 438.50(c)(6) 1932(a)(l)(A) for 42 CFR 447.362 42 CFR 438.50(c)(6) Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement C. State Assurances and Compliance with the Statute and Regulations. If applicable to the state plan, place a check mark to affirm that compliance with the following statutes and regulations will be met. 1. __ The state assures that all of the applicable requirements of section 1903(m) of the Act, for MCOs and MCO contracts will be met. Not applicable. 2. _X_ The state assures that all the applicable requirements of section 1905(t) of the Act for PCCMs and PCCM contracts will be met. 3. __ The state assures that all the applicable requirements of section 1932 (including subpart (a)(l)(A)) of the Act, for the state's option to limit freedom of choice by requiring recipients to receive their benefits through managed care entities will be met. Not applicable. 4. _X_The state assures that all the applicable requirements of 42 CFR 431.51 regarding freedom of choice for family planning services and supplies as defined in section 1905(a)( 4)(C) will be met. 5. _X_The state assures that all applicable managed care requirements of 42 CFR Part 438 for MCOs and PCCMs will be met. 6. __ The state assures that all applicable requirements of 42 CFR 438.6(c) for payments under any risk contracts will be met. Not applicable. 7. _X_ The state assures that all applicable requirements of 42 CFR 447.362 payments under any nonrisk contracts will be met. Approval Date:02-ll-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F PageS State:. ___ G~eo~r:.,;g~ia Citation 45 CFR 74.40 1932(a)(l)(A)(i) 1932( a )(2)(B) 42 CFR 438( d)(l) 1932(a)(2)(C) 42 CFR 438(d)(2) 1932(a)(2)(A)(i) 42 CFR 438.50(d)(3)(i) TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement 8. _X_ The state assures that all applicable requirements of 45 CFR 92.36 for procurement of contracts will be met. D. Eligible groups 1. List all eligible groups that will be enrolled on a mandatory basis. There will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. 2. Mandatory exempt groups identified in 1932(a)(l)(A)(i) and 42 CFR 438.50. Use a check mark to affirm if there is voluntary enrollment any of the following mandatory exempt groups. i. _X_Recipients who are also eligible for Medicare. There will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. If enrollment is voluntary, describe the circumstances of enrollment. (Example: Recipients who become Medicare eligible during mid- enrollment, remain eligible for managed care and are not disenrolled into fee-for-service.) ii. __ Indians who are members of Federally recognized Tribes except when the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act. iii. _X_Children under the age of 19 years, who are eligible for Supplemental Security Income (SSI) under title XVI. Approval Date:02-11-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F Page 9 State: ___ G=e=o=r_..g=ia Citation 1932(a)(2)(A)(iii) 42 CFR 438.50(d)(3)(ii) 1932(a)(2)(A)(v) 438.50(3)(iii) 1932(a)(2)(A)(iv) 42 CFR 438.50(3)(iv) 1932(a)(2)(A)(ii) 42 CFR 438.50(3)(v) OMB No.:0938-0933 Condition or Requirement iv. v. VI. vii. _X_Children under the age of 19 years who are eligible under 1902( e )(3) of the Act. __ Children under the age of 19 years who are in foster care or 42 CFR other out-of-the-home placement. __ Children under the age of 19 years who are receiving foster care or adoption assistance under title IV -E. _X_ Children under the age of 19 years who are receiving services through a family-centered, community based, coordinated care system that receives grant funds under section 501(a)(1 )(D) of title V, and is defined by the state in terms of either program participation or special health care needs. E. Identification of Mandatory Exempt Groups 1932(a)(2) 42 CFR 438.50(d) TN No. 13-015 Supersedes TNNo.New 1. Describe how the state defines children who receive services that are funded under section 501(a)(l)(D) of title V. (Examples: children receiving services at a specific clinic or enrolled in a particular program.) Children receiving services funded by Title V are enrolled in the Children's Medical Services Program administered by the Georgia Division of Public Health. This program provides comprehensive, coordinated, community- based, Title V services for children birth to age 21 with chronic medical conditions. Medical eligibility includes but is not limited to: a. Burns b. Cardiac conditions Cystic fibrosis Hearing disorders Spina bifida Cerebral palsy Diabetes mellitus c. d. e. f. g. h. Vision disorders 1. Craniofacial anomalies (including cleft lip/palate) j. Gastrointestinal disorders k. Neurological and neurosurgical conditions including epilepsy and Approval Date:02-11-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 AITACHMENT 3.1-F Page 10 State: __ --'G=e=o=r...,gi=· a Citation 1932(a)(2) 42 CFR 438.50(d) 1932(a)(2) 42 CFR 438.50(d) 1932(a)(2) 42 CFR 438.50 (d) Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement hydrocephalus l. Orthopedic and/or neuromuscular disorders (scoliosis) m. Congenital or traumatic amputations of limbs 2. Place a check mark to affirm if the state's definition of title V children is determined by: i. ii. X iii. program participation, special health care needs, or both 3. Place a check mark to affirm if the scope of these title V services is received through a family-centered, community-based, coordinated care system. X i. yes no 4. Describe how the state identifies the following groups of children who are exempt from mandatory enrollment: (Examples: eligibility database, self- identification) Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. i. Children under 19 years of age who are eligible for SSI under title XVI; Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. ii. Children under 19 years of age who are eligible under section 1902 ( e )(3) of the Act; Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive Approval Date:02-ll-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 AITACHMENT 3.1-F Page 11 State: __ _,G"-'e""o,.,_r,.,g=ia Citation 1932(a)(2) 42 CFR 438.50(d) 1932(a)(2) 42 CFR 438.50(d) TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement intensive medical coordination may decline to receive, or opt out, of services. iii. Children under 19 years of age who are in foster care or other out- of-home placement; Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. iv. Children under 19 years of age who are receiving foster care or adoption assistance. Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. 5. Describe the state's process for allowing children to request an exemption from mandatory enrollment based on the special needs criteria as defined in the state plan if they are not initially identified as exempt. (Example: self- identification) Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. 6. Describe how the state identifies the following groups who are exempt from mandatory enrollment into managed care: (Examples: usage of aid codes in the eligibility system, self- identification) Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. i. Recipients who are also eligible for Medicare. Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive Approval Date:02-11-14 Effective Date:l0-01-14

CMS-PM-10120 ATTACHMENT 3.1-F Page 12 Date: October 10, 2013 State : __ --"G""'e"'o'-"-r.:.gt"'. a Citation 42 CFR 438.50 42 CFR 438.50 1932(a)(4) 42 CFR 438.50 TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement intensive medical coordination may decline to receive, or opt out, of services. ii. Indians who are members of Federally recognized Tribes except when the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act. Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. F. List other eligible groups (not previously mentioned) who will be exempt from mandatory enrollment Not applicable as there will not be mandatory enrollment into the program. Additionally, members who are identified to receive intensive medical coordination may decline to receive, or opt out, of services. G. List all other eligible groups who will be permitted to enroll on a voluntary basis • SSI • Public Laws • Institutionalized (Nursing facility, inpatient hospice, long-term hospital, etc.) • Home and Community Based Waiver • Deeming Waiver • Medically Needy H. Enrollment process. 1. Definitions 1. An existing provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous year. This may be established through state Approval Date:02-ll-14 Effective Date:l0-01-14

CMS-PM-10120 Date: October 10, 2013 S ta te: __ -'G"'-""eo,_,r""g""ia Citation Condition or Requirement ATIACHMENT 3.1-F Page 13 OMB No.:0938-0933 records of previous managed care enrollment or fee-for-service experience, or through contact with the recipient. ii. A provider is considered to have "traditionally served" Medicaid recipients if it has experience in serving the Medicaid population. 1932(a)(4) 2. State process for enrollment by default. 42 CFR 438.50 TN No. 13-015 Supersedes TNNo.New Describe how the state's default enrollment process will preserve: 1. the existing provider-recipient relationship (as defined in H.l.i). All members will receive provider services through the fee-for- service delivery system and so existing provider-recipient relationships may continue at the member's option. Members identified to receive intensive medical coordination services will be formally assigned to a medical home. Members may voluntarily select or the vendor may assign members to a medical home. The vendor will determine if the member has a primary source of care that is participating in the Medical Coordination Program, and if so, assign the member to that provider. ii. the relationship with providers that have traditionally served Medicaid recipients (as defined in H.2.ii). The provider networks for Medicaid members are limited to Medicaid-participating providers. iii. the equitable distribution of Medicaid recipients among qualified MCOs and PCCMs available to enroll them, (excluding those that are subject to intermediate sanction described in 42 CFR 438. 702(a)( 4)); and disenrollment for cause in accordance with 42 CFR 438.56 ( d)(2). (Example: No auto-assignments will be made if MCO meets a certain percentage of capacity.) DCH is contracting with one vendor to provide services to eligible populations. All members will have access to a minimum set of general coordination services and be subject to predictive modeling Approval Date:02-ll-14 Effective Date: 10-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F Page 14 S tate: __ --"'G'""e"'o""'rg=-'i""a Citation 1932(a)(4) 42 CFR 438.50 TN No. 13-015 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement and other analyses by the vendor to identify the need for intensive medical coordination services. Members identified by the vendor as high-risk and impactable will be eligible to receive intensive medical coordination services. The vendor must have a process for individuals to decline to receive, or opt out of, Intensive Medical Coordination services. 3. As part of the state's discussion on the default enrollment process, include the following information: 1. The state will __ /will not_X_ use a lock-in for managed care. ii. The time frame for recipients to choose a health plan before being auto-assigned will Medical Coordination program services will be available to Medicaid members in the fee-for-service delivery system at the time that they are determined eligible under an aged, blind and disabled eligibility category. The vendor will conduct regular analyses to identify eligible members who may be in need of intensive medical coordination services, and contact those members to enroll in those services. The vendor must have a process for individuals to decline to receive, or opt out of, Intensive Medical Coordination services. iii. Describe the state's process for notifying Medicaid recipients of their auto-assignment. (Example: state generated correspondence.) DCH has a process in place to mail notification to the member of the availability of services the vendor will provide. iv. Describe the state's process for notifying the Medicaid recipients who are auto-assigned of their right to disenroll without cause during the first 90 days of their enrollment. (Examples: state generated correspondence, HMO enrollment packets etc.) Not applicable. v. Describe the default assignment algorithm used for auto-assignment. (Examples: ratio of plans in a geographic service area to potential enrollees, usage of quality indicators.) Approval Date:02-ll-14 Effective Date: 10-01-14

CMS-PM-10120 Date: October 10, 2013 AITACHMENT 3.1-F Page 15 State: __ _;G=e=o<!-rl;>'gi.,.a Citation 1932(a)(4) 42 CFR 438.50 Supersedes TNNo.New OMB No.:0938-0933 Condition or Requirement Not applicable. vi. Describe how the state will monitor any changes in the rate of default assignment. (Example: usage of the Medical Management Information System (MMIS), monthly reports generated by the enrollment broker) Not applicable. I. State assurances on the enrollment process Place a check mark to affirm the state has met all of the applicable requirements of choice, enrollment, and re-enrollment. 1. K._ The state assures it has an enrollment system that allows recipients who are already enrolled to be given priority to continue that enrollment if the MCO or PCCM does not have capacity to accept all who are seeking enrollment under the program. 2. __ The state assures that, per the choice requirements in 42 CFR 438.52, Medicaid recipients enrolled in either an MCO or PCCM model will have a choice of at least two entities unless the area is considered rural as defined in 42 CFR 438.52(b )(3). Not applicable. 3. The state plan program applies the rural exception to choice requirements of 42 CFR 438.52(a) for MCOs and PCCMs. _X_ This provision is not applicable to this 1932 State Plan Amendment. 4. __ The state limits enrollment into a single Health Insuring Organization (HIO), if and only if the HIO is one of the entities described in section 1932(a)(3)(C) of the Act; and the recipient has a choice of at least two primary care providers within the entity. (California only.) _X_ This provision is not applicable to this 1932 State Plan Amendment. 5. _X_ The state applies the automatic reenrollment provision in accordance Approval Date:02-ll-14 Effective Date:l0-01-14

CMS-PM-10120 ATTACHMENT 3.1-F Page 16 Date: October 10, 2013 State: __ _,G=e,_,o'-'-rg...,i,.a Citation 1932(a)(4) 42 CFR 438.50 1932(a)(5) 42 CFR 438.50 42 CFR 438.10 1932fa)(5)(D) 1905(1) 1932 (a)(1)(A)(ii) TN No. 13-015 Supersedes TNNo.New J. OMB No.:0938-0933 Condition or Requirement with 42 CFR 438.56(g) if the recipient is disenrolled solely because he or she loses Medicaid eligibility for a period of 2 months or less. _This provision is not applicable to this 1932 State Plan Amendment. Disenrollment 1. The state will_/will not_ X_ use lock-in for managed care. 2. The lock-in will apply for __ months (up to 12 months). Not applicable. 3. Place a check mark to affirm state compliance. _X_ The state assures that beneficiary requests for disenrollment (with and without cause) will be permitted in accordance with 42 CFR 438.56(c). 4. Describe any additional circumstances of"cause" for disenrollment (if any). Members may opt out of receiving intensive care management services at any time for any reason. K. Information requirements for beneficiaries Place a check mark to affirm state compliance. _ X_The state assures that its state plan program is in compliance with 42 CFR 438.10(i) for information requirements specific to MCOs and PCCM programs operated under section 1932(a)(l)(A)(i) state plan amendments. (Place a check mark to affirm state compliance.) L. List all services that are excluded for each model (MCO & PCCM) Services will continue to be provided through the fee-for-service delivery system. M. Selective contracting under a 1932 state plan option To respond to items #1 and #2, place a check mark. The third item requires a brief narrative. Approval Date:02-11-14 Effective Date:10-01-14

CMS-PM-10120 Date: October 10, 2013 ATTACHMENT 3.1-F Page 17 State: __ ....:G""e"-"o'-!.rgl:>'i""-a Citation OMB No.:0938-0933 Condition or Requirement 1. The state will_X_/will not ___ intentionally limit the number of entities it contracts under a 1932 state plan option. 2. The state assures that if it limits the number of contracting entities, this limitation will not substantially impair beneficiary access to services. 3. Describe the criteria the state uses to limit the number of entities it contracts under a 1932 state plan option. (Example: a limited number of providers and/or enrollees.) DCH has elected to contract with a single vendor that has targeted expertise to effectively provide intensive medical coordination for members who are aged, blind and disabled and have unique and complex health care needs. This program is meant to provide additional coordination to meet the needs of eligible members who remain in the fee-for-service delivery system, and DCH believes that one vendor is sufficient to meet the requirements of the contract and the population being served. 4. __ The selective contracting provision in not applicable to this state plan. 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 0938-0933. The time required to complete this information collection is estimated to average 10 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 CMS-10120 (exp. 3/31/2014) No. 13-015 Supersedes TNNo.New Approval Date:02-ll-14 Effective Date:10-0l-14

Table of Contents State/Territory Name: Georgia State Plan Amendment (SPA) #: 13-0020-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

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

Atlanta Regional Office

61 Forsyth Street, Suite 4T20

Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 10, 2014

Dr. Jerry Dubberly, Chief

Medical Assistance Plans

Georgia Department of Community Health 2 Peachtree Street, NW, 40" Floor Atlanta, Georgia 30303

RE: Georgia (GA) Title XIX State Plan Amendment (SPA), Transmittal # GA 13-0020-MMI1 Dear Dr. Dubberly:

Enclosed is an approved copy of Georgia’s State Plan Amendment (SPA) 13-0020-MM1, which was received on November 15, 2013. SPA 13-0020-MM1I incorporates the MAGI-Based Eligibility Group SPA into Georgia’s State Plan in accordance with the Affordable Care Act. The SPA was approved on February 7, 2014 and the effective date is January 1, 2014.

Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of Georgia’s approved State Plan:

S14, Pages $14-1 through $14-8 825, Pages S25-1 through S25-4 828, Pages $28-1 through S28-4 $30, Pages S30-1 through S30-5 $32, Page $32-1

$33, Page S33-1

S50, Page S50-1

S51, Page S5S1-1

S52, Page S52-1 through S52-5 S53, Page S53-1

$54, Page 54-1

S55, Page S55-1

S57, Page S57-1 through $57-2 S59, Page S59-1

Dr. Jerry Dubberly Page 2

In addition, enclosed is a summary of State Plan pages which are superseded by SPA 13-0020-MM1, which should also be incorporated into a separate section in the front of the State Plan:

e Superseding Pages of State Plan Material, 13-0020-MM1

Notwithstanding any other provisions of the Georgia Medicaid State Plan, the financial eligibility methodologies described in SPA GA 13-0020-MM1 will apply to all MAGI-based eligibility groups covered under Georgia’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Tandra Hodges at 404-562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

/Is/I

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Georgia

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.

13-020

Proposed Effective Date

01/01/2014

i

({mm/dd/yyyy) Federal Statute/ Regulation Citation

—

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $l 0.00 Second Year | 2015 $l 0.00

Subject of Amendment

Character count out of 2000

MAGHbased Eligibility Groups +

ca Ll J aa

Governor's Office Review

bd Governor's office reported no comment

bd Comments of Governor's office received

+ on ae

bd No reply received within 45 days of submittal

Describe:

bd Other, as specified

Describe:

Character count: out of 2000

Governor's Review is not os

LL ae

Signature of State Agency Official

Submitted By: Therese Brisco Last Revision Date: Nov 15, 2013

Submit Date:

Nov 15, 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE:

GA-13-0020 Georgia

Pages or sections of pages being superseded by $25, $28, $30, S51, $52, $53, $54, S57, and $14 and related pages or sections of pages being deleted as obsolete

State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A.2.b Page 3 Page 2, A.2.c Page 3a Page 2a, A.3 Page 4 Page 5, A.10 Page 4a Page 9c, B.1 for Page 12 caretaker relatives Page 13 & pregnant women Page 13a Page 20, B.14 Attachment 2.2-A Page 14 Page 25, C.2 Page l4a Page 23 Page 23c Supprement 1 to Attachment Page 1 Page 3b Page l, Page lla A.2.a.(i)&(iii) Page 19 Page 6 related to Page 19a AFDC recipients, Page 19b pregnant women, Attachment 2.6-A Page 21 infants, and children Page 7, 1l.a.(1)&(2) Page 12,C.1.e(2) Page 18, C.5.e Page 25,11.a.(3) Supplement 1 to Attachment Page 1 Page 2, #3 and #4 2.6-A Pages 3 - 4 Supplement 2 to Attachment 2.6-A Pages 1 - 5

Supplement 8a to Attachment 2.6-A

Page 1, 1°, 3°, and 5° disregards for AFDC-related groups Page 2, 1°* cont. and 2°¢ disregards and 4‘ disregard for

AFDC related groups.

Supplement 8b to Attachment 2.6-A

Page 3, #3

Supplement 12 to Attachment 2.6-A

Pages 1 - 2

Enter the AFDC Standards below. All states must enter:

AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

The standard is as follows: @ Statewide standard C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

Household size | Standard ($)

162

243

292

345

395

432

469

501

529 Ye

10 568

111 608

MAGI-equivalent AFDC Payment Standard in Effect As of May |, 1988 and

@ Yes (No

Increment amount $

Medicaid Eligibility

Additional incremental amount

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

23

TN No: 13-0020-MM1 Georgia

Approval Date: 02/07/14

$14-1

Effective Date: 01/01/14

The dollar amounts increase automatically each year

C Yes @ No

The standard is as follows:

@ Statewide standard C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount

Household size | Standard ($) @ Yes CNo

155

Increment amount $ |17

235

280

330

378

410

444

470

496

10 530

I 568

The dollar amounts increase automatically each year

C Yes @ No

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $14-2

The standard is as follows:

@ Statewide standard

C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

Household size | Standard ($)

173

259

310

366

420

458

498

530

562

603

647

Additional incremental amount

@ Yes C No

Increment amount $

C Yes @No

The dollar amounts increase automatically each year

The standard is as follows: @ Statewide standard

C Standard varies by region

TN No: 13-0020-MM1 Georgia

$14-3

Approval Date: 02/07/14

Effective Date: 01/01/14

Medicaid Eligibility

C Standard varies by living arrangement

C Standard varies in some other way

Household size | Standard ($)

235

356

424

500

573

621

672

713

75\

804

860

Additional incremental amount

@ Yes (No

Increment amount $

C Yes @No

The dollar amounts increase automatically each year

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

TN No: 13-0020-MM1 Approval Date: 02/07/14

Georgia

CIAA

Effective Date: 01/01/14

MSs

CPT TO METACR A MAECHECANT BET

Medicaid Eligibility

Household size

Standard ($)

@ Yes C No

155

Increment amount $

235

280

330

378

410

444

470

496

530

568

Additional incremental amount

C Yes @No

The dollar amounts increase automatically each year

The standard is as follows:

@ Statewide standard

C Standard varies by region

C Standard varies in some other way

C Standard varies by living arrangement

TN No: 13-0020-MM1 Georgia

Approval Date: 02/07/14 $14-5

Effective Date: 01/01/14

Medicaid Eligibility

Household size

Standard ($)

@ Yes CNo

173

Increment amount $

259

310

366

420

458

498

530

562

603

647

Additional incremental amount

23

C Yes @ No

The dollar amounts increase automatically each year

The standard is as follows:

@ Statewide standard

C Standard varies by region

C Standard varies in some other way

C Standard varies by living arrangement

TN No: 13-0020-MM1 Georgia

Approval Date: 02/07/14 $14-6

Effective Date: 01/01/14

Medicaid Eligibility

Household size

Standard ($)

@ Yes CNo

155

Increment amount $

280

330

378

410

444

470

496

530

568

Additional incremental amount

C Yes (@ No

The dollar amounts increase automatically each year

The standard is as follows:

@ Statewide standard

© Standard varies by region

C Standard varies in some other way

C Standard varies by living arrangement

TN No: 13-0020-MM1 Georgia

Approval Date: 02/07/14 614-7

Effective Date: 01/01/14

Medicaid Eligibility

Additional incremental amount

Household size | Standard ($) @ Yes CNo

173 Increment amount $ |23

259

310

366

420

458

498

530

562

603

647

The dollar amounts increase automatically each year

C Yes @ No

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

TN No: 13-0020-MM1 Approval Date: 02/07/14

Georgia 514-8 Effective Date: 01/01/14

Medicaid Eligibility

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

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

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

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

[M) Individuals qualifying under this eligibility group must meet the following criteria:

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

The state elects the following options:

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

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

(21 Options relating to the definition of caretaker relative (select any that apply): EX] Options relating to the definition of dependent child (select the one that applies):

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

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

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

@ The principal earner may work 100 or more hours per month and still qualify as unemployed.

Indicate the number of hours used: ]100 | hours

C The principal earner may earn up to a specific dollar amount and still qualify as unemployed.

Indicate the specific dollar limit of earnings: $

C Other less restrictive standard

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

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

[m) Income standard used for this group

{—] Minimum income standard

TN No: 13-0020-MM1

Approval Date: 02/07/14 Georgia

Effective Date: 01/01/14 $25-1

Medicaid Eligibility

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

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

Maximum income standard

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

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

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

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

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

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

Enter the amount of the maximum income standard:

C A percentage of the federal poverty level: %

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

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

C increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards.

Cc The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in $14 AFDC Income Standards.

@ Other dollar amount

The standard is as follows:

TN No: 13-0020-MM1 Approval Date: 02/07/14

Effective Date: 01/01/14 §25-2

Medicaid Eligibility

@ Statewide standard C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

Household size | Standard ($) @ Yes CNo

310 Increment amount $

457

551

653

752

826

903

970

1,034 bs

1,113

1,194

Additional incremental amount

The dollar amounts increase automatically each year C Yes @No

{M]_ Income standard chosen:

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

C The minimum income standard @ The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage C. increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. C Another income standard in-between the minimum and maximum standards allowed TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14

Georgia

$25-3

Medicaid Eligibility

[@) There is no resource test for this eligibility group. [m] Presumptive Eligibility

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

C Yes @No

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $25-4

Medicaid Eligibility

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

42 CFR 435.116

1902(a)(10)(A)(i)(IH) and (IV) 1902(a)(10)(A)(ii)(1), (TV) and (IX) 1931(b) and (d)

1920

[@] Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: (M) Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other

Caretaker Relatives at 42 CFR 435.110.

@ Yes © No

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

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

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

C Yes @No The minimum income standard for this eligibility group is 133% FPL. [SH] Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant

women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

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

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income

families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), !902(a)(10)(A)(i)(IV) (mandatory poverty level-

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

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

TN No: 13-0020-MM1 Approval Date: 02/07/14

Effective Date: 01/01/14 Georgia S$28-1

Medicaid Eligibility

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

C

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

Cc The state's effective income level for any population of pregnant women under a Medicaid | 115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 185% FPL

The amount of the maximum income standard is:/220 % FPL

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

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

[@] Presumptive Eligibility

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

@ Yes (| No [Mj The presumptive period begins on the date the determination is made.

[M] The end date of the presumptive period is the earlier of:

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

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

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

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia S28-2

Medicaid Eligibility

@ Yes C No

C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

{] The presumptive eligibility determination is based on the following factors: {®] The woman must be pregnant {W] Household income must not exceed the applicable income standard at 42 CFR 435.116. | State residency Citizenship, status as a national, or satisfactory immigration status

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

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

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

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

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

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

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

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

(71 Is an elementary or secondary school operated or supported by the Bureau of Indian A ffairs (1 Is a state or Tribal child support enforcement agency under title IV-D of the Act

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

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

TN No: 13-0020-MM1

Approval Date: 02/07/14

Effective Date: 01 $28-3 /01/14

Medicaid Eligibility

Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any

O other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

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

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

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act,

and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

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

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

TN No: 13-0020-MM1

Approval Date: 02/07/14 Georsia

Effective Date: 01/01 /1A

Medicaid Eligibility

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

42 CFR 435.118

1902(a)(10)(A)(i)(1I1), (TV), (VI) and (VII) 1902(a)(10)(A)(ii)(TV) and (IX)

1931(b) and (d)

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

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

aw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to $10 MAGI- Based Income Methodologies, completed by the state.

[m) Income standard used for infants under age one {@] Minimum income standard

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

C Yes (@-No

The minimum income standard for infants under age one is 133% FPL.

(®] Maximum income standard

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

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

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

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

TN No: 13-0020-MM1 Approval Date: 02/07/14

Effective Date: 01/01/14 Georgia $30-1

Medicaid Eligibility

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

C. infants), 1902(a)(10)(A)(ii)(IEX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

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

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

C 185% FPL

Enter the amount of the maximum income standard: }|205 % FPL

{Income standard chosen The state's income standard used for infants under age one is: @ The maximum income standard

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

C (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(1V) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

1f higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified children), 1902(a)(10)

c (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(LX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants

c under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants

c under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

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

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

[| Minimum income standard

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $30-2

Medicaid Eligibility

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

Maximum income standard

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

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

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

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

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

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

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

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

Enter the amount of the maximum income standard: |149 % FPL

Income standard chosen

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

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II1) (qualified children),

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

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IID) (qualified children),

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

TN No: 13-0020-MM1 Approval Date: 02/07/14

Effective Date: 01/01/14 $30-3

Medicaid Eligibility

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children

c age one through five under a Medicaid |115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children

c age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. [®] Income standard for children age six through age eighteen, inclusive [&) Minimum income standard The minimum income standard used for this age group is 133% FPL.

[Maximum income standard

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

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

The state's highest effective income level for coverage of children age six through eighteen under sections 1931

Cc (low-income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)(VIL) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(1V) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 Cc (low-income families), 1902(a)(10)(A)(i)(IID) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty

level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect

under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

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

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

@ 133% FPL

[m) Income standard chosen

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

TN No: 13-0020-MM1 Approval Date: 02/07/14

Effective Date: Georgia 530-4 e: 01/01/14

Medicaid Eligibility

@ The maximum income standard

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

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

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 193! (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)Ci)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

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

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

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

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

C Yes @ No

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georcvia S20 -s

Medicaid Eligibility

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

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

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

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $32-1

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

42 CFR 435.150 1902(a)(10)(A)(i)(1X)

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

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

[M] Individuals qualifying under this eligibility group must meet the following criteria:

[@ Are under age 26. mw Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group.

Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state {m) plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program.

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

@Yes (No

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

CYes @No

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

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

TN No: 13-0020-MM1 Approval Date: i Coors pp va! Date: 02/07/14 Effective Date: 01/01/14

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

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

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

C Yes @No

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 i ane var Effective Date: 01/01/14

Medicaid Eligibility

OMB Control Number 0938-1148

OMB Expiration date: 10/3 1/2014 ral

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

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

C Yes @ No

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $51-1

Medicaid Eligibility

OMB Control Number 0938-1148

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

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

@ Yes C No

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

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

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

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

[™] Not be eligible and enrolled for mandatory coverage under the state plan.

im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to $10 MAGI- Based Income Methodologies, completed by the state.

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

@ Yes C No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010

with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@ Yes C No Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010

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

Current Coverage of All Children under a Specified Age

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $52-1

Medicaid Eligibility

The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income.

C Yes @No

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

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

@ Yes C No

Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

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

Individuals for whom public agencies are assuming full or partial financial responsibility.

Individuals placed in foster care homes by public agencies Indicate the age which applies: @ Under age 21 (Underage 20 (Underage 19 (7 Under age 18

(J Individuals placed in foster care homes by private, non-profit agencies

Individuals placed in private institutions by public agencies Indicate the age which applies: @ Under age 21 (Underage 20 (Underage 19 (C Under age 18

(1 Individuals placed in private institutions by private, non-profit agencies

KK] Individuals in adoptions subsidized in full or part by a public agency Indicate the age which applies: @ Under age 21 (7 Underage 20 (Underage 19 ( Under age 18

(J Individuals in nursing facilities, if nursing facility services are provided under this plan

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14

Georgia 659.9

Medicaid Eligibility

oO Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan

(D Other reasonable classifications

Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23,

2010 and no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

) Ss SR er an {M@] Income standard used

[m) Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

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

C Yes @No

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

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

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

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

TN No: 13-0020-MM1 Approval Date: 02/07/14

Ranraias era 4

Effective Date: 01/01/14

Medicaid Eligibility

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

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

Enter the amount of the maximum income standard:

C A percentage of the federal poverty level: %

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

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

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is C described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

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

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

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

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

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

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

TN No: 13-0020-MM1 Approval Date: ‘ TN No: PP val ate: 02/07/14 Effective Date: 01/01/14

Medicaid Eligibility

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

[mM] Income standard used

[®) Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect

as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

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

December 31, 2013.

C Yes @No

The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the

ra maximum income standard to be used for this classification of children under this eligibility group.

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

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

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

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

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

Enter the amount of the maximum income standard:

N No: 13-0020-MM1 Ap : ; proval Date: 02/07, 14 Eff : Georgia cook / ective Date: 01/01/14

Medicaid Eligibility

© A percentage of the federal poverty level: %

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

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

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is C. described in $14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

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

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

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

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

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

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

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

[m Income standard used

[&] Minimum income standard

TN No: 13-0020-MM1 Approval Date: 02/07/14

Georgia 352-6 Effective Date: 01/01/14

Medicaid Eligibility

TN No: 13-0020-MM1

Georgia

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

[lB] Maximum income standard

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

C Yes

@ No

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

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

e

Cc

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

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

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

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

Enter the amount of the maximum income standard:

CO

A percentage of the federal poverty level: %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

Other dollar amount

Approval Date: 02/07/14

Effecti : val Ctive Date: 01/01/14

Medicaid Eligibility

[ml Income standard chosen Individuals qualify under this classification under the following income standard: C The minimum standard.

@ The maximum income standard.

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

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this

c classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this

c classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size.

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

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

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

Other Reasonable Classifications Previous! ver

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

group. C Yes @No Additional new age groups or reas le classifications covere

If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional

option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage.

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

TN No: 13-0020-MM1

Approval : Georgia PP Date: 02/07/14

E i . ce 9 ffective Date: 01/01/14

Medicaid Eligibility

C Yes @No

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

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

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

TN No: 13-0020-MM1 Approval Date: Georgia Pprowa vate: 02/07/14 Effective Date: 01/01/14

Medicaid Eligibility

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

42 CFR 435.227 1902(a)(10)(A)(ii)( VII)

Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227.

@ Yes C No The state attests that it operates this eligibility group in accordance with the following provisions: [M] Individuals qualifying under this eligibility group must meet the following criteria:

wi The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; [M) Are under the following age (see the Guidance for restrictions on the selection of an age): @ Under age 21 C Under age 20 C Under age 19 C Under age 18 im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes ©No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes CNo

mm Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement.

The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

C Yes @ No

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

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $53-1

Medicaid Eligibility

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

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

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

C Yes @-No

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

TN No: 13-0020-MM1 Appr ‘oval Date: i Georgia Pp val Date 02/07/14 Effective Date: 01/01/14

Medicaid Eligibility

OMB Control Number 0938-1148

1902(a)(10)(A)(ii)(X11) 1902(z)

Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services.

C Yes @ No

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

TN No: 13-0020-MM1 Georgia Approval Date: 02/07/14 Effective Date: 01/01/14 -1 *

Medicaid Eligibility

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

42 CFR 435.226 1902(a)(10)(A (ii) XV)

Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226.

@ Yes (No The state attests that it operates this eligibility group in accordance with the following provisions: {] Individuals qualifying under this eligibility group must meet the following criteria:

{@] Are under the following age @ Under age 21 C Under age 20 C Under age 19

{§] Were in foster care under the responsibility of a state on their 18th birthday.

[Wf Are not eligible and enrolled for mandatory coverage under the Medicaid state plan.

{™] Have household income at or below a standard established by the state.

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

The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes CNo

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

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

@ All children under the age selected C A reasonable classification of children under the age selected:

[mM] Income standard used for this eligibility group

[®] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $57-1

Medicaid Eligibility

[m] Maximum income standard

No income test was used (all income was disregarded) for this eligibility group either in the

Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (No

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

{] The Medicaid state plan as of March 23, 2010. XX] The Medicaid state plan as of December 31, 2013. (A Medicaid 1115 demonstration as of March 23, 2010. [] A Medicaid 1115 demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded).

[lM] Income standard chosen Individuals qualify under this eligibility group under the following income standard: This eligibility group does not use an income test (all income is disregarded).

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

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

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia $57-2

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(X XT) 42 CFR 435.214

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

C Yes @No

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

TN No: 13-0020-MM1 Approval Date: 02/07/14 Effective Date: 01/01/14 Georgia S59-1

(ptoz/

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Table of Contents

State/Territory Name: Georgia State Plan Amendment (SPA) #: 13-0021-MM2

This file contains the following documents in the order listed:

1) Approval Letter

2) Additional Companion letter

3) Summary Form (with 179-like data)

4) Superseding Pages Notice

5) Approved SPA Pages

6) Additional Attachments that are part of the state plan

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

Atlanta Regional Office

61 Forsyth Street, Suite 4T20

Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 10, 2014

Dr. Jerry Dubberly, Chief

Medical Assistance Plans

Georgia Department of Community Health 2 Peachtree Street, NW, 40" Floor

Atlanta, Georgia 30303

RE: S94 - Eligibility Process State Plan Amendment (SPA), GA 13-0021-MM2

Dear Dr. Dubberly:

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-13-0021-MM2, which was submitted to CMS on November 18, 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 | July 1, 2014 questions will be removed in the next revision.

Questions regarding access to employer- December 31, 2014 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.

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.

Dr. Jerry Dubberly Page 2

If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 786-8684. If you have any additional questions or require any further assistance, please contact Tandra Hodges at (404) 562-7409 or at Tandra.Hodges@cms.hhs.gov.

Sincerely, /Is// Jackie Glaze

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

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

Atlanta Regional Office

61 Forsyth Street, Suite 4720

Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 10, 2014

Dr. Jerry Dubberly, Chief

Medical Assistance Plans

Georgia Department of Community Health 2 Peachtree Street, NW, 40" Floor

Atlanta, Georgia 30303

RE: $94 -— Eligibility Process State Plan Amendment (SPA), GA-13-0021-MM2 Dear Dr. Dubberly:

Enclosed is an approved copy of Georgia’s state plan amendment (SPA) GA-13-0021-MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 18, 2013. SPA GA-13-0021-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Georgia’s Medicaid state plan in accordance with the Affordable Care Act. This SPA was approved on February 7, 2014. The effective date of this SPA is October 1, 2013.

The approval of SPA GA-13-0021-MM2 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 CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following $94 state plan pages and attachments to be incorporated within a separate section at the end of Georgia’s approved state plan:

e $94, pages $94-1 and $94-2 e Attachment 2 — Statement of use with respect to the alternative single streamlined online application

In addition, enclosed is a summary of state plan pages which are superseded by SPA GA-13- 0021-MM2, which should also be incorporated into a separate section in the front of the state plan.

e Superseding Pages of State Plan Material, GA-13-0021-MM2

Dr. Jerry Dubberly Page 2

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Tandra Hodges at (404) 562-7409 and Tandra.Hodges@cms.hhs.gov.

Sincerely,

/Is//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179) e« State/Territory name: Georgia

¢ Transmittal Number:

Please enter the Transmittal Number (TN) in the format ST-YY-O0000 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 13-021

Proposed Effective Date

[

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

Federal Statute/ Regulation Citation

| 42C.F.R§

Federal Budget Impact

Federal Fiscal Year Amount

First Year | 2014 gl 0.00 Second Year | 2015 $l 0.00

Subject of Amendment

Character count out of 2000

Eigibility Process- Streamined < +

aL —

Governor's Office Review

Governor's office reported no comment

© Comments of Governor's office received

Describe:

Le | ma

No reply received within 45 days of submittal

& Other, as specified

Describe:

Character count dl out of 2000

Governor's Review not require +

a xi a4 Signature of State Agency Official Submitted By:

Therese Brisco Last Revision Date: Nov 18, 2013

Submit Date:

Nov 18, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0021-MM2 Georgia

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 — Eligibility Process

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

Section 2.1 (d) TN 91-30, Effective Date 07/01/91, Approved 10/22/92

Section 2.1 (a) TN 91-31, Effective Date 10/1/91, Approved 12/18/91

Medicaid Eligibility

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

42 CFR 435, Subpart J and Subpart M

Eligibility Process

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

Application Processing

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

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

An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the

(OD Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary.

i‘

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.

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

The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and

C approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary.

i a

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

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

The agency also accepts applications by other electronic means:

@ Yes C No

TN No: 13-0021-MM2

Approval Date: 02/07/14 Georgia

Effective Date: 10/01/13 $94-1

Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description

COMPASS

COMPASS is a quick and easy way for people in Georgia to }'~ apply for Medicaid, TANF, SNAP and get answers to questions about health and human services

Individuals may submit applications by fax.

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

Parents and Other Caretaker Relatives

Pregnant Women

Infants and Children under Age 19 Redetermination Processing

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

[M) Once every 12 months

am 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

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

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

—] Once every 12 months (1 Once every 6 months (1) Other, more often than once every 12 months

Coordination of Eligibility and Enrollment

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

PRA Disclosure Statement

TN No: 13-0021-MM2 Approval Date: 02/07/14 Effective Date: 10/01/13 Georgia $94-2

Medicaid Eligibility

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

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

TN No: 13-0021-MM2 Approval Date: 02/07/14 Effective Date: 10/01/13 Georgia $94-3

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application &] Online Application

TRANSMITTAL NUMBER: STATE: GA-13-0021-MM2 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.

Georgia Department of Human Services

Application for Benefits

Geongia Deparment ‘of Haman Servirs

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,

Georata Department ‘ama Sere

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 that we

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)

Frequently Asked Questions How long does it take to get benefits?

Food Stamps: up to 30 days TANF: up to 45 days Medicaid: 10 to 60 days

You may be able to get Food Stamps within 7 days if you qualify. See page 4.

How much will | get?

Your income, resources, and family size determine benefit amounts. We will be able to give you specific information once we determine your eligibility.

How will | get my benefits?

For Food Stamps and TANF, you will get an Electronic Benefit Transfer (EBT) card to access your benefits. For Medicaid, you will receive a Medicaid card for each eligible member.

What information will | need to provide? It is a good idea to provide the following:

© — Proof of identity for the applicant if applying for Food Stamps and/or TANF. Proof of identity for everyone requesting Medicaid if applying for Medicaid. Ex: An identification card (ID) or driver's license (DL)

* Proof of US citizenship/qualified immigrant Status for everyone requesting benefits

«Social Security numbers of everyone requesting assistance

e¢ Proof of income for example, pay stubs, child support 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 return any information to our office. If you need help getting this information, please tell us.

How do we use the applicant’s personal information?

You only have to provide Social Security Numbers (SSN) and citizenship or immigration status for persons who want to apply for benefits. This information will be used to check the income and eligibility verification system (IEVS). We will also match your information against other Federal, state and local agencies to verify your income and eligibility. lf a household member does not want to give us information about their SSN, citizenship, or immigration status, other household members may still receive 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 apply but the parent or caretaker must be interviewed.

“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

A parent, 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 alien/immigrant 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)

‘of Raman Severs

Georgia Department of Human Services

Application for Benefits

What Am | 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.

7.

Are you or any household member a migrant or seasonal farm worker? Q Yes Q No 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)

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)

Total earned and unearned income for this month: $

. How much money do you and all household members have in cash or in the bank? $

. How much do you and all household members pay for rent or mortgage? $

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 ONo

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 (--/--/--) Only) (M/F) (Y/N) Below) (Y/N) 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? QO Yes ONo 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 ONo

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 Q 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 Q No a. Who: b. Where:

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

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

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

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)

‘eceya permet paersians

1. If you are an adult applying for Health Coverage for your dependent child(ren), do you want to receive Health Coverage for yourself? O Yes Q No

2. Is anyone in the household pregnant? OQ Yes Q No If yes, how many babies are expected during this pregnancy?

3. Is anyone applying for health coverage blind or disabled? Q Yes Q No If yes, please list

Does anyone have other health insurance that covers anyone in your household? QO Yes QO No If you answered yes to question 5 above, please complete the following information:

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. Q Yes If yes, you'll need to complete Attachment A. Is this a state employee benefit plan? Q Yes Q No

7. Have you or anyone listed on this application lost any health coverage in the last 2 months? Q Yes If yes, why was it lost? Q) No

8. Was anyone in your household in Foster Care atage 18? 0 Yes QO No

9. Does anyone in the household have any unpaid medical bills from the last 3 months? OG YesQ No

10. Is anyone in your household American or Alaska Native? Q Yes QO 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? Q Yes Q 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 (SSI) application? Q Yes Q No Ifyes, 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? Q Yes Q No

14. Are you applying for Medicaid to help pay for the care of a person who is in a nursing home? Q Yes Q No 297M (01/14) -1-

15. Are you applying for Medicaid for a person over the age of 18 whose SSI check has stopped? Yes Q 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)?

Q Yes Q 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 QO Yes QO No Funeral Plans/Prepaid Burial item QO Yes OQ No Savings Accounts QO Yes QO No Burial Plots or Contracts Q Yes O No Government Bonds QO Yes Q No Stocks and Bonds Q Yes O No Trust Funds QO Yes O No Other (IRA, CD, etc.) Q Yes O No Real Property/Homeplace Property Q Yes QO No Have you or your spouse given away any assets for less than its value? Q Yes O No

If you answered | yes toa any. of these questions, please describe below._

r [Val me of Ba ce Company, etc. Does anyone in the household own a vehicle? If so, please describe below. Q Yes Q No Wehicle Make |: : Do you or your spouse have a life insurance policy? Q Yes QO No

information.

Tax Filer Information

1. Does anyone in the household plan to file a federal income tax return NEXT YEAR? O Yes Q No If yes, who? (list each person who plans to file)

2. Will any of the tax filers listed file jointly with a spouse? Q Yes Q No if yes, please list spouse’s name:

3. Will any of the tax filers claim any dependents on their tax return? O Yes Q No If yes, please list name(s) of dependents:

4. Will anyone be claimed as a dependent on someone else’s tax return? OQ Yes QO 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 filer?

297M (01/14) -2-

Income and Earnings: List all types of earnings and income that your household receives. List the income amount before deductions such as taxes, insurance or Medicare premiums , health insurance, dental, and vision premiums or Spending accounts are taken out.

Does anyone expect any change in monthly income? Q 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. OQ Alimony $ How often? Q Other Deductions $ How often?

Q 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 and medical benefits). | agree to cooperate with the state in 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

297M (01/14) -3-

DECLARATION OF CITIZENSHIP/IMMIGRATION STATUS

Georgia Department of Human Services Division of Family and Children Services

I understand that the Georgia Division of Family and Children Services (DFCS) may require verification from the United States Department of Homeland Security (DHS) of my and/or my child(ren)’s citizenship or immigration status when seeking benefits. Information received from DHS may affect my or my child(ren)’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 Immigration Admitted into U.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- A- I, , declare the child/children is/are a U.S. Citizens or a Qualified Immigrant.

(PRINT NAME) I attest to the identity of the child/children listed above, and certify under penalty of perjury, that the information written and checked above is true.

SIGNATURE (PARENT/GUARDIAN) (DATE) ADULT(S) SEEKING BENEFITS | Date Naturalized or Immigration Admitted into U.S. Document ID # (Check applicable) Lawfully Place of Birth US. Admitted Name (City, State, Country) Citizen Immigrant (if applicable) {If applicable) A- A- I, , declare Iam a U.S. Citizen or a Qualified Immigrant. I certify under (PRINT NAME)

penalty of perjury, that the information written and checked above is true.

SIGNATURE (DATE)

216 (01/14) -4-

CMCS/OSG: 12/2/13 _____________________________________________________________________________

Table of Contents State/Territory Name: Georgia State Plan Amendment (SPA) #: 13-0022-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

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

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 9, 2013

Dr. Jerry Dubberly, Chief Medical Assistance Plans Georgia Department of Community Health 2 Peachtree Street, NW, 40th Floor Atlanta, Georgia 30303

RE: Title XIX State Plan Amendment (SPA), GA 13-0022-MM3

Dear Dr. Dubberly:

Enclosed is an approved copy of Georgia’s state plan amendment (SPA) 13-0022-MM3, which was submitted to CMS on November 15, 2013. SPA 13-0022-MM3 incorporates the MAGI- Based Income Methodologies into Georgia’s state plan in accordance with the Affordable Care Act. This SPA was approved on December 6, 2013. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages to be incorporated within a separate section at the back of Georgia’s approved state plan:

S10, Pages S10-1 and S10-2

In addition, enclosed is a summary of state plan pages which are superseded by SPA 13-0022- MM3, which should also be incorporated into a separate section in the front of the state plan:

Superseding Pages of State Plan Material, 13-0022-MM3

Notwithstanding any other provisions of the Georgia Medicaid state plan, the financial eligibility methodologies described in SPA GA-13-0022-MM3 will apply to all MAGI-based eligibility groups covered under Georgia’s Medicaid state plan. The MAGI financial methodologies set forth in 42 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid state plan only with respect to the MAGI-based eligibility groups.

Page 2 Dr. Jerry Dubberly

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562- 7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

e State/Territory name: Georgia

e 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.

13 - 022

« Proposed Effective Date

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

« Federal Statute/Regulation Citation

—

« Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $ 0.00 Second Year 2015 $l 0.00

e Subject of Amendment

Character Count: out of 2000

MAGI Income Methodology 4

ia Lt ra

Governor's Office Review

c Governor's office reported no comment

Cc Comments of Governor's office received

5

J

Describe:

Lt J c No reply received within 45 days of submittal

cE Other, as specified

Describe:

Character count <I out of 2000

Governor's review is not requir ~ | Ll | al Signature of State Agency Official Submitted By:

Therese Brisco Last Revision Date: Nov 26, 2013

Submit Date:

Nov 15, 2013

Medicaid Eligibility

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

1902(e)(14) 42 CFR 435.603

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

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

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

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

C The pregnant woman is counted just as herself.

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

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

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

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

@ Current monthly household income and family size

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

In determining current monthly or projected annual household income, the state will use reasonable methods to: (1 Include a prorated portion of a reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size.

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

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

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

CYes @No

TN No: 13-0022-MM3 Approval Date: 12/06/13 Effective Date: 01/01/14 Georgia $10-1

Medicaid Eligibility

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

@ Age 19

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

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

TN No: 13-0022-MM3 Approval Date: 12/06/13 Effective Date: 01/01/14 Georgia $10-2

State/Territory Name: Georgia

State Plan Amendment (SPA) #:13-0023-MM5

This file contains the following documents in the order listed:

1) Approval Letter

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

4) Approved SPA Pages

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

Atlanta Regional Office

61 Forsyth Street, Suite 4T20

Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 18, 2014

Dr. Jerry Dubberly, Chief

Medical Assistance Plans

Georgia Department of Community Health 2 Peachtree Street, NW, 40" Floor Atlanta, Georgia 30303

RE: Title XIX State Plan Amendment (SPA), GA 13-0023-MMS5 Dear Dr. Dubberly:

Enclosed is an approved copy of Georgia’s state plan amendment (SPA) 13-0023-MM5S, which was submitted to CMS on November 15, 2013. SPA 13-0023-MM5S affirms state residency regulations and addresses interstate agreements and temporary absence in accordance with the Affordable Care Act. This SPA was approved on February 12, 2014. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of Georgia’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 13-0023-MMS, which should be incorporated into a separate section in the front of the state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Georgia

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.

| 13-023

Proposed Effective Date

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

Federal Statute/Regulation Citation

——

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 gl 0.00 Second Year 2015 $l 0.00

Subject of Amendment

Character Count: out of 2000

Residency +

L<l_ | m3

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

4

No reply received within 45 days of submittal

Describe:

Other, as specified

Describe:

Character Count: out of 2000

Governor's review not requried |

bo ne

Signature of State Agency Official

Submitted By: Therese Brisco Last Revision Date: Feb 12, 2014

Submit Date:

Nov 15, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0023 MMS Georgia PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable):

S88 Non-Financial Eligibility- State Residency Attachment 2.6-A:; Page 3, item (4), TN 13-0024 MM6

Medicaid Eligibility

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

42 CFR 435.403

State Residency

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

Individuals are considered to be residents of the state under the following conditions:

iw Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and:

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

im Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live.

{®) Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: [m] Residing in the state, with or without a fixed address, or

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

im Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married:

im Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or

im Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or

If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the

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

im Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement.

[®] Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state.

im Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state.

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

TN No. 13-0023-MM5 Approval Date: 02-12-14 Effective Date: 01-01-14 Georgia S88-1 i

Ccms. Medicaid Eligibility

[m] Otherwise meet the requirements of 42 CFR 435.403.

TN No. 13-0023-MM5 Approval Date: 02-12-14 Georgia $88-2

Effective Date: 01-01-14

rer ra werent Beara EC

Medicaid Eligibility

Meet the criteria specified in an interstate agreement.

@ Yes (CC No

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

a

Alabama [X] Illinois Montana Rhode Island Xx] Alaska [X] Indiana Nebraska KK] South Carolina Arizona KK] lowa X] Nevada South Dakota Arkansas {K] Kansas New Hampshire [KX] Tennessee California {X] Kentucky KK] New Jersey Texas Colorado [X] Louisiana New Mexico Utah

Connecticut [Xx] Maine New York Vermont Delaware [x] Maryland North Carolina Virginia

District of Columbia

KK] Massachusetts

North Dakota

[IX] Washington

KK] Florida [X] Michigan KK] Ohio West Virginia (CD Georgia Minnesota Oklahoma KK] Wisconsin Hawaii [X] Mississippi Oregon (1 Wyoming {K] Idaho DX] Missouri {X] Pennsylvania

The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency

status and criteria for resolving disputed residency of individuals who (select all that apply):

Are IV-E eligible

(1 Are in the state only for the purpose of attending school

[J Are out of the state only for the purpose of attending school

( Retain addresses in both states

Other type of individual

TN No. 13-0023-MM5 Approval Date: 02-12-14

Effective Date: 01-01-14 Georgia $88-3

Medicaid Eligibility

Tuseen ene werac aaa Aur aip a

Name of Type Description

Long Term Care residents Waive the Georgia residency requirement if the individual

who is determined to be a resident of another state meets the

following conditions:

the applicant is placed in a medical treatment facility (LA-D)

in Georgia

AND

the applicant is under age 18

OR

the applicant is age 18 or older but became mentally incapable prior to age 18

+ AND x

Georgia has an interstate residency agreement with the

individual's state of residence.

GA currently has interstate residency agreements with the following 17 states:

Alabama, California, Florida, Iowa, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, New Jersey, New Mexico, New York, Ohio, Pennsylvania, Tennessee, West Virginia, Wisconsin

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

[B] Otherwise meet the criteria of resident, but who may be temporarily absent from the state. The state has a definition of temporary absence, including treatment of individuals who attend school in another state.

@ Yes (C No

Provide a description of the definition:

An applicant/recipient may still be considered a resident of Georgia if s/he is temporarily out of state and intends to return to Georgia once the purpose of the absence has been accomplished. However, if the applicant/recipient is receiving Medicaid benefits from another state, s/he is no longer considered a resident of Georgia, and Georgia Medicaid benefits should be terminated until/unless applicant/recipient returns.

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

TN No. 13-0023-MM5 Approval Date: 02-12-14 Effective Date: 01-01-14 Georgia S88-4

Table of Contents State/Territory Name: Georgia State Plan Amendment (SPA) #:13-0024-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 18, 2014

Dr. Jerry Dubberly, Chief

Medical Assistance Plans

Georgia Department of Community Health 2 Peachtree Street, NW, 40" Floor Atlanta, Georgia 30303

RE: Title XIX State Plan Amendment (SPA), GA 13-0024-MM6 Dear Dr. Dubberly:

Enclosed is an approved copy of Georgia’s state plan amendment (SPA) 13-0024-MM6, which was submitted to CMS on November 18, 2013. SPA 13-0024-MM6 affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance with the Affordable Care Act. This SPA was approved on February 12, 2014. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of Georgia’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 13-0024-MM6, which should be incorporated into a separate section in the front of the state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562-7409 or Tandra. Hodges@cms.hhs.gov.

Sincerely, /s// Jackie Glaze

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

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Georgia

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.

| GA13-024

Proposed Effective Date

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

Federal Statute/Regulation Citation

| 42C.F.R. §

Federal Budget Impact

Federal Fiscal Year Amount

First Year | 2014 g! 0.00 Second Year 2015 $ 0.00

Subject of Amendment

Character count out of 2000

Citizenship and Immigration Stat “|

La ie

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

4 em an

No reply received within 45 days of submittal

Describe:

© Other, as specified

Describe:

Character count out of 2000

Gavernor's Review is not mms

Signature of State Agency Official

Submitted By: Therese Brisco Last Revision Date: Feb 6, 2014

Submit Date:Nov 18, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-024 Georgia PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable):

S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility Attachment 2.6-A: Page 2, item (3), paragraphs (a) , (b), and (c), TN 91-31

Attachment 2.6-A: Page 3, item (3), paragraphs (d) and (e), TN 91-31

CcCmMs. Medicaid Eligibility

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

S89

i

1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4)

42 CFR 435.4

42 CFR 435.406

42 CFR 435.956

Citizenship and Non-Citizen Eligibility

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

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

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

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

and 956.

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

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

@ Yes (No

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

@ Yes CNo The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status.

C The date the reasonable opportunity notice is sent.

C Other date, as described:

TN No. 13-0024-MM6 Approval Date: 02-12-14 Effective Date: 01-01-14 Georgia ‘ S89-1

Medicaid Eligibility

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

@ Yes (CNo

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

C Yes (@No

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

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

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

3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

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

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

@

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

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

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

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

[S] Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

[@ Has been granted employment authorization; or

[@) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

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

TN No. 13-0024-MM6 Approval Date: 02-12-14 Effective Date: 01-01-14 Georgia __ $89-2

| |

Medicaid Eligibility

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

(1) Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an

organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration

status and/or present an SSN: |

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

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

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

TN No. 13-0024-MM6 Approval Date: 02-12-14 Effective Date: 01-01-14 Georgia $89-3

Table of Contents

State/Territory Name: Georgia State Plan Amendment (SPA) #:13-0028-MM7

This file contains the following documents in the order listed:

1) Approval Letter

2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

4) Additional Attachments that are part of the state plan

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

DIVISION OF M EDICAID & CHILDREN’S HEALTH OPERATIONS

February 9, 2015

Mr. Clyde L. Reese III, Esq. Medical Assistance Plans Georgia Department of Community Health 2 Peachtree Street, NW, 40th Floor Atlanta, Georgia 30303

Re: Title XIX State Plan Amendment, GA 13-0028-MM7

Dear Mr. Reese:

Enclosed is an approved copy of Georgia’s State Plan Amendment (SPA) 13-0028-MM7, which was originally submitted to the Centers for Medicare & Medicaid Services (CMS) on January 9, 2014. SPA 13-0028-MM7 establishes that one or more qualified hospitals are determining presumptive eligibility, and that the state is providing coverage for individuals determined presumptively eligible, in accordance with the Affordable Care Act. The SPA was approved on February 6, 2015. The effective date of this SPA is January 1, 2014.

We understand that the state is still in the process of finalizing its system to support hospital presumptive eligibility and is estimating an implementation date of February 26, 2015. If any systems or other issues threaten this date, the state should inform CMS as soon as possible.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of Georgia’s approved state plan.

If you have any questions, please contact Ms. Tandra Hodges of my staff at 404-562-7409.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosure

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Georgia

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-13-002

Proposed Effective Date

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

Federal Statute/Regulation Citation

| 42 C.F.R.§

Federal Budget Impact

Federal Fiscal Year Amount

First Year

2014

0.00

$

Second Year

2015

ii

$ 0.00

Subject of Amendment

Character Count: out of 2000

Hospital Presumptive Eligibility “|

i Lal | J

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

Describe:

No reply received within 45 days of submittal

&

Other, as specified

Describe:

Character Count: out of 2000

Pursuant to 42 C.F.R. § 430.12, +

=i il ma

Signature of State Agency Official

Submitted By: Therese Brisco Last Revision Date: Jan 9, 2014

Submit Date: Jan 9, 2014

ccmMs Medicaid Eligibility

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

42 CFR 435.1110

One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision.

@ Yes (CNo

The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: [MJ A qualified hospital is a hospital that:

Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of

[i] its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance

[@) with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency.

Assists individuals in completing and submitting the full application and understanding any documentation requirements.

@yYes CNo

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

{@] Pregnant Women

[my] Infants and Children under Age 19

{m] Parents and Other Caretaker Relatives

[i] Adult Group, if covered by the state

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

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

[&) Former Foster Care Children

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

(F Other Family/Adult groups:

C Eligibility groups for individuals age 65 and over

LD Eligibility groups for individuals who are blind

(7 Eligibility groups for individuals with disabilities

(J Other Medicaid state plan eligibility groups

(1) Demonstration populations covered under section 1115

The state establishes standards for qualified hospitals making presumptive eligibility determinations. TN No: 13-0028-MM7

Approval Date: 02/06/15 Effective Date: 01/01/14 Georgia

$21-1

CccCmMS Medicaid Eligibility

@Yes CNo

Select one or both:

The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular

7 application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period.

Qualified Hospital PE Performance Standards will be established at the end of the first (6) months.

The Department of Community Health (DCH) will review all Qualified Hospital (QH) Presumptive Eligibility (PE) determinations for the first six months before establishing specific performance standards.

This time period will allow DCH to eliminate any potential barriers to providing QH's with the proper tools to determine PE applications correctly and timely.

Base targets on data gathered during the initial implementation:

Georgia will look at the share of PE applicants who file a full application and are found eligible for regular Medicaid at the end of the six month review period, identify the average or median outcome on this measure, and use it to set the target for hospitals in 2015. There is an indicator on our hospital presumptive application so that we can monitor that a full Medicaid application lwas offered and completed.

Increasing benchmarks over time:

Georgia will start with a modest target accuracy but then increase it by five percentage points (or more) in future years.

Description of standards: Percent of PE determinations conducted accurately:

Georgia will require that 90 percent of a hospital's PE determinations be done correctly based on the information that an applicant has provided. If an applicant provides misinformation, his or her circumstances change, or his or her information cannot be verified, it would not affect a hospital's performance on the accuracy measure.

Percent of applicants checked for existing Medicaid enrollment:

Hospitals would be required to ensure that 100 percent of potential applicants are checked for existing enrollment in Medicaid before a PE determination is conducted. A screening function is built into the web portal.

Percent of applicants checked for prior PE enrollment:

Hospitals would be required to ensure that 95 to 100 percent of potential applicants are checked for recent PE determinations (e.g., with the exception of pregnant women, not enrolled in PE within prior 2 calendar years) before a new PE determination is conducted on their behalf. Hospitals would be trained to identity PE eligibility.

Qualified Hospitals may be disqualified from conducting PE determinations for failure to adhere to the above standards or the state's policies and procedures.

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

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

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

TN No: 13-0028-MM7 Approval Date: 02/06/15 Effective Date: 01/01/14

Georgia $21-2

ccmMs Medicaid Eligibility

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

[lB] Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year.

C No more than one period within two calendar years. Pi y'

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

@ Other reasonable limitation:

Name of limitation Description

Pregnant Women/because a woman can potentially have a + miscarriage and conceive again before the end of 12 months.

Pregnant women may receive presumptive x eligibility, once per pregnancy.

Infants and Children under age Infants and Children under age 19, Parents and 19, Parents and Other Caretaker | Other Caretaker Relatives, Former Foster Care Ff | Relatives, Former Foster Care Children, and Women's Health (BCC) may receive | XX Children, and Women's Health presumptive eligibility no more than one period (BCC) within two calendar years.

The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes C No C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

3 The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

An attachment is submitted.

[| The presumptive eligibility determination is based on the following factors:

The individual's categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is [m] being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group)

im Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group.

State residency X] Citizenship, status as a national, or satisfactory immigration status

The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals, A copy of the training materials has been included.

TN No: 13-0028-MM7 Approval Date: 02/06/15 Effective Date: 01/01/14 Georgia $21-3 kepe eee

ccms Medicaid Eligibility

An attachment is submitted.

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

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

TN No: 13-0028-MM7 Georgia Approval Date: 02/06/15

Effective Date: $21-4 o1/o1/14

EFFECTIVE FOR SERVICES

BEGINNING P.O. BOX 105200

HP PROVIDER CONTACT CENTER

PHONE: 1-800-766-4456 FAX: 1-866-483-1044

MEDICAID IDENTIFICATION NUMBER

MONTH DAY YEAR TUCKER, GA 30085-5200 QUALIFIED HOSPITAL PRESUMPTIVE ELIGIBILITY DETERMINATION HEALTH INSURANCE: OO yes 1] No APPLICANT'S NAME. MAIDEN NAME: FORMER FOSTER CARE: APPLICANT'S ADDRESS TELEPHONE NUMBER: FORMER FOSTER CARE? [] YES (J N/A APARTMENT/LOT NUMBER: SOCIAL SECURITY NUMBER: WHAT AGE DID YOU LEAVE FOSTER CARE? (OPTIONAL) IN WHAT STATE DID YOU RECEIVE FOSTER CARE? CITY: STATE: ZIP CODE: COUNTY OF RESIDENCE: TAX FILER HOUSEHOLD MB Yes HNo . MONTHLY NON TAX FILER HOUSEHOLD Ml YES ILNO DATE or « RELATION | MONTHLY GROSS TAXABLE INCOME MONTHLY DEDUCTIONS NET , . RACE | GENDER TO ; MONTHLY PRE-TAX 1040 TAXABLE FIRSTNAME MI LASTNAME SUFFIX | MM/DD/YYYY APPLICANT | TYPE | AMOUNT | FREQ | Avount | DEDUCTION as INCOME 01 SELF 02 | UNBORNCHILD OWA (10120304 Os 06 APPLICANT’S STATEMENT/NAME OF PREGNANT WOMAN: 03 : 04 05 : SWORN STATEMENT OF APPLICANT: TOTAL GROSS TAXABLE INCOME = SUBTOTAL NET INCOME =

I UNDERSTAND THAT THIS IS A TEMPORARY DETERMINATION OF MY ELIGIBILIY FOR MEDICAID AND THAT THE RIGHT FROM THE START MEDICAID (RSM) PROJECT OR COUNTY DIVISION OF FAMILY AND CHILDREN SERVICES (DFCS) WILL DETERMINE MY CONTINUING ELIGIBILITY WHEN | SUBMIT A HEALTCARE COVERAGE APPLICATION.

I DECLARE UNDER PENALTY OF PERJURY THAT I AM A U.S. CITIZEN OR LAWFULLY PRESENT IMMIGRANT IN THE UNITED STATES. 1 CERTIFY UNDER PENALTY OF PERJURY 1 HAVE PROVIDED TRUE AND ACCURATE INFORMATION ABOUT MYSELF, MY FAMILY, PREGNANCY, RESIDENCY, TAX STATUS, PRET-TAX DEDUCTIONS, 1040 DEDUCTIONS, FOSTER CARE STATUS AND INCOME.

I AGREE TO ASSIGN TO THE STATE ALL RIGHTS TO MEDICAL SUPPORT AND THIRD PARTY SUPPORT PAYMENTS (HOSPITAL AND MEDICAL BENEFITS).

1 UNDERSTAND THAT MY ELIGIBILITY FOR THIS TEMPORARY ELIGIBILITY ENDS THE MONTH IN WHICH THE RSM OR DFCS OFFICE MAKES THE DECISION ABOUT MY CONTINUING ELIGIBILITY, OR NO LATER THAN THE LAST DAY OF THE FOLLOWING MONTH.

I WILL REPORT ALL CHANGES IN MY HOUSEHOLD WITHIN 10 DAYS THROUGH WWW.COMPASS.GA.GOV OR CALL 1-877-423-4746 (TDD/TTY 1-800-255-0135); FAX 1-888-740-9355.

DATE OF APPLICATION APPLICANT'S SIGNATURE

*By providing Race information, you will assist us in admi non-discriminat manner. You are not required to give u: affect your el ity or benefit level.

ig OUF programs in a information and it will not

DMA 632H (03/01/2014) TN No: 13-0028-MM7 Approval Date: 02/06/15 Georgia S21

Effective Date 0)

5 % FPL DEDUCTION = TOTAL NET INCOME =

NUMBER IN BUDGET GROUP = POVERTY INCOME LEVEL =

APPLICANT IS (] ELIGIBLE OR [] INELIGIBLE FOR RESUMPTIVE ELIGIBLITY MEDICAID

THE WOMAN FOR WHOM THIS PRESUMPTIVE DETERMINATION OF ELIGIBILITY HAS BEEN MADE IS APPROXIMATELY WEEKS PREGNANT WITH FETUS(ES). HER EXPECTED DELIVERY DATE IS

I HAVE OBTAINED A HEALTHCARE COVERAGE APPLICATION FROM THE APPLICANT AND HAVE FAXED

IT TO DCH AT 770-302-8169: (2 YES (Included in PE Packet) 0 No APPLICANT'S INITIALS.

DATE OF COMPLETION COMPLETED BY (PLEASE PRINT) TITLE

QH DIRECT PHONE NUMBER - = SIGNATURE OF QUALIFIED HOSPITAL PERSONNEL

QUALIFIED HOSPITAL NAME AND ADDRESS QH PROVIDER ID

REIMBURSEMENT FOR MEDICAID SERVICES THROUGH THE PREGNANGY PRESUMPTIVE ELIGIBILITY PERIOD DOES NOT INCLUDE INPATIENT HOSPITAL SERVICES OR DELIVERY

Date

| Date Updated

Qualified Hospital Provider Name

QH Provider ID Number:

Address

City, State, Zip Code

County

Phone

FAX

PE Coordinator

Direct Phone Number

Email Address

PE Certification:

Date Requested

Date Completed

Parent/Caretaker with Child(ren)

Children Under 19 Years of Age

Pregnant Women

Former FosterCare

Women's Health ***

Page 1 of 3

*** Requires Certification from Department of Public Health for BCCP

Authorized User List Page 2

Corrective Action Plan Page 3

TN No: 13-0028-MM7 Approval Date: 02/06/15

Georgia

$21

Effective Date: 01/01/14

'

EFFECTIVE FOR SERVICES HP PROVIDER CONTACT CENTER PHONE: 1-800-766-4456 4 BEGINNING P.O. BOX 105200 FAX: 1-866-483-1044 ae MEDICAID IDENTIFICATION NUMBER MONTH DAY YEAR TUCKER, GA 30085-5200 PRESUMPTIVE ELIGIBILITY DETERMINATION FOR WOMEN’S HEALTH MEDICAID VALID FOR LISTED MONTH ONLY APPLICANT’S NAME MAIDEN NAME: HEALTH INSURANCE: [J YES [J] NO APPLICANT'S ADDRESS TELEPHONE NUMBER: SOCIAL SECURITY NUMBER: APPLICANT'S RECORD: APARTMENT/LOT NUMBER: (Optional) DATE OF INTERVIEW: CITY: STATE: ZIP CODE: COUNTY OF RESIDENCE: FAMILY MEMBERS DATE OF ‘ RELATION MONTHLY GROSS INCOME MONTHLY DISREGARDS MONTHLY BIRTH : STANDARD DEPENDENT NET RACE. GENDER TO MONTHLY FIRSTNAME MI LASTNAME SUFFIX | MM/DD/YYYY .- | TYPE | AMOUNT | FREQ WORK CARE INCOME APPLICANT AMOUNT | _pisrEGARD DISREGARD

01 SELF

02

03

04

05

06

SWORN STATEMENT OF APPLICANT:

I UNDERSTAND THAT THIS IS A TEMPORARY DETERMINATION OF MY ELIGIBILIY FOR MEDICAID AND THAT THE ARROWHEAD RIGHT FROM THE START MEDICAID (ARSM) PROJECT WILL DETERMINE MY CONTINUING ELIGIBILITY.

1 DECLARE UNDER PENALTY OF PERJURY THAT I AM A U.S. CITIZEN OR LAWFULLY PRESENT IN THE UNITED STATES AND I HAVE PROVIDED TRUE AND ACCURATE INFORMATION ABOUT MY FAMILY AND INCOME.

I AGREE TO ASSIGN TO THE STATE ALL RIGHTS TO MEDICAL SUPPORT AND THIRD PARTY SUPPORT PAYMENTS (HOSPITAL AND MEDICAL BENEFITS).

I UNDERSTAND THAT MY ELIGIBILITY FOR THIS TEMPORARY ELIGIBILITY ENDS THE MONTH IN WHICH ARSM MAKES THE DECISION ABOUT MY CONTINUING ELIGIBILITY.

I WILL REPORT ALL CHANGES IN MY HOUSEHOLD WITHIN 10 DAYS.

DATE OF APPLICATION APPLICANT’S SIGNATURE

“By providing Race information, you will assist us in ad tering our progra You are not required to give us this information and it will not affect your eligi

a non-discriminatory manner. y or benefit level.

DATE OF COMPLETION COMPLETED BY (PLEASE PRINT) TITLE

DIRECT PHONE NUMBER SIGNATURE OF INDIVIDUAL COMPLETING FORM.

632W (03/01/2014)

TN No: 13-00028-MM7 Approval Date: 02/06/15 Georgia $21

Effective Date: 01/01/14

TOTAL GROSS INCOME =

CHILD SUPPORT DISREGARD=

NUMBER IN FAMILY =. POVERTY INCOME LEVEL =

TOTAL FAMILY NET INCOME =

Applicant is [] ELIGIBLE — or

PROVIDER CERTIFICATION:

CIINELIGIBLE for PE WHM.

1 CERTIFY THAT THE WOMAN FOR WHOM THIS PRESUMPTIVE DETERMINATION

OF ELIGIBILITY HAS BEEN DETERMINED WAS SCREENED IN ACCORDANCE WITH THE REQUIREMENTS OF PULIC LAW 106-354 ON

HER DIAGNOSIS MET THE BCC PROGRAM IN GEORGIA. I HAVE OBTAINED A SIGNED HEALTHCARE COVERAGE APPLICATION FROM THE APPLICANT AND HAVE FAXED IT TO THE ARROWHEAD (ARSM) PROJECT AT 770-359-1813.

QUALIFIED PROVIDER SIGNATURE

TITLE

QUALIFIED PROVIDER NAME

QUALIFIED PROVIDER ADDRESS: _

QUALIFIED PROVIDER ID NUMBER

Va >) GEORGIA DEPARTMENT

Ye g)}/ 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

GEORGIA QUALIFIED HOSPITAL PROVIDER AGREEMENT FOR PRESUMPTIVE ELIGIBILITY MEDICAID DETERMINATIONS

Qualified Hospital (QH) Name:

Qualified Hospital Provider agrees:

1. To participate as a qualified hospital provider in the Georgia Medicaid program with the Department of Community Health (DCH);

2. To complete full Presumptive Eligibility (PE) Medicaid training; 3. To maintain PE Medicaid knowledge with PE Manual usage, and PE Medicaid meetings;

4. To complete monthly internal reviews of PE Medicaid cases for both approved and denied PE Medicaid applications, act upon findings when required;

5. To conduct periodic PE Medicaid refresher training for veteran staff and full PE Medicaid training for new workers. Submit completed training list to DCH monthly (DCH/QH worksheet provided);

6. To correctly determine Presumptive Eligibility (PE) in accordance with Medicaid regulations and guidelines as promulgated by the Department of Community Health; all procedures and regulations are outlined in each PE Medicaid manual;

7. To participate in quality assurance reviews which will be conducted by the Department of Community Health;

8. To timely act upon corrective action required by the Department of Community Health.

Failure to continue to meet any of the above conditions shall be cause for termination of this qualified hospital provider agreement.

The qualified hospital provider also agrees that either the qualified hospital provider, or the

Department of Community Health, may terminate this agreement by giving the other party thirty (30) days written notice.

Date Signature of Authorized QH Provider

QH Provider ID Number Title

Health Information Technology | Healthcare Facility Regulation | Medical Assistance Plans | State Health Benefit Plan

QHA (01/01/14) Page 1 of 2 Equal Opportunity Employer

TN N.: 13-0028-MM7 Approval Date: 02/06/15 Effective Date: 01/01/14 Georgia S$21-1

Va y GEORGIA DEPARTMENT

a, OF COMMUNITY HEALTH SZ

Nathan Deal, Governor Clyde L. Reese Ill, Esq., Commissioner

2 Peachtree Street, NW | Atlanta, GA 30303-3159 | 404-656-4507 | www.dch.georgia.gov

ACA Presumptive Eligibility (PE) for Medicaid Training Statement of Completion of Required PE Training

Employee’s Name (Please Print) Qualified Hospital Provider ID Number

All Qualified Hospital Providers must complete PE policies & procedures training prior to rendering PE services. After review of all of the PE training documents and requirements listed below, please initial and enter date next to each policy, sign at the bottom of the page, and return the originals to your PE Coordinator, fax a copy to DCH at 1-770-302-8169 or email to pecorrections@dch.ga.gov within five (5) business days of completion of training.

Initials | Date Document/Form Title ACA PE Manual ACA Presumptive Eligibility for Medicaid DMA-632H Presumptive Eligibility Application (* required

exercise-must compute a PE budget using Form 632H and Federal Poverty Levels) DMA-Form 216 Citizenship Affidavit/Qualified Immigrant Status

DMA-634H Notice of Action Medicaid Single Streamed Lined Application form and how to Application order PE Forms Order Forms PE Document Quick Guide on Medicaid PE Document Procedures for processing On-line, Manual & Denied Applications 1 P4HB Planning for Healthy Babies

By my initials and signing, | acknowledge that I am aware of and accountable for compliance of ACA Presumptive Eligibility for Medicaid program policies and procedures.

Employee’s Signature: Date:

By my signature below, I acknowledge my responsibility to ensure that this employee is aware of PE Medicaid policies and procedures and DCH compliance requirements.

PE Coordinator’s Name (Please Print):

PE Coordinator’s Signature: Date:

Health Information Technology | Healthcare Facility Regulation | Medical Assistance Plans | State Health Benefit Plan

TN N.: 13-0028-MM7 Approval Date: 02/06/15 Effective Date: 01/01/14 Georgia $21-2

Table of Contents

State/Territory Name: Georgia State Plan Amendment (SPA) #: 14-003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

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

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 20, 2014

Dr. Jerry Dubberly, Chief Medical Assistance Plans Georgia Department of Community Health 2 Peachtree Street, NW, 40th Floor Atlanta, Georgia 30303

RE: Title XIX State Plan Amendment (SPA), Transmittal # GA 14-003

Dear Dr. Dubberly:

We have reviewed the proposed Georgia State Plan Amendment 14-003, which was submitted to the Atlanta Regional Office on March 31, 2014. The SPA supports the early assessment of pregnant women by local public health agencies at the time of the presumptive eligibility determination.

Based on the information provided, the Medicaid State Plan Amendment 14-003 was approved on June 20, 2014. The effective date of this amendment is January 1, 2014. We are enclosing the approved HCFA-179 and the plan pages.

If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

2. STATE GEORGIA

1. TRANSMITTAL NUMBER: 14-003

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

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

4. PROPOSED EFFECTIVE DATE January 1, 2014

5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN

AMENDMENT TO BE CONSIDERED AS NEW PLAN

X AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: FFY 2013 $ 0.°° FFY 2014 $ 0.”

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 3.1-A pg. 1-5 (Part B) Attachment 4.19-B pg 5.002 Attachment 4,19-B pg Sa-5b

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

Attachment 3.1-A pg. 1-5 (Part B) Attachment 4.19-B pg 5.002 Attachment 4.19-B pg 5a-5b

10. SUBJECT OF AMENDMENT: Perinatal Case Management

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

] OTHER, AS SPECIFIED: Single State Agency Comments Attached

12. SIGNATURE OF STATE AGENCY OFFICIAL: Is/1

16. RETURN TO: Department of Community Health

13. TYPED NAME: Jerry Dubberly

Division of Medicaid 2 Peachtree Street, NW, 36" Floor

14. TITLE: Chief, Division of Medicaid

Atlanta, Georgia 30303-3159

15. DATE SUBMITTED:

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 03-31-14

18. DATE APPROVED: 06-20-14

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: 01-01-14

20. SIGNATURE OF REGIONAL OFFICIAL: Msil

21, TYPED NAME: Jackie Glaze

22. TITLE: Associate Regional Administrator Division of Medicaid & Children Health Opns

Block#6 changed to read: 42 CFR 440.169.

Block #7 changed to read: FFY 2014 $0 and FFY 2015 $0.

Block #15 changed to read: March 31, 2014.

23. REMARKS: Approved with the following changes as authorized by state agency email s dated 06/04/14, 6/13/14 and 06/16/14.

Block # 8 changed to read: Atch 3.1-A pages 1-5(Part B), Atch 3.1-A pages 1-3 (Part M) and Atch 4.19-B pages 5.002 and 5a-5b. Block # 8 changed to read: Atch 3.1-A pages 1-5(Part B), Atch 3.1-A pages 1-3 (Part M) and Atch 4.19-B pages 5.002 and Sa-5b.

FORM HCFA-179 (07-92)

TN No.: 14-003

Effective Date: January 1, 2014 Supersedes:

Approval Date: 06-20-14 TN No.: 91-04

Supplement 1 to Attachment 3.1-A Page 1 (Part B) State: Georgia

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

PERINATAL CASE MANAGEMENT SERVICES

A. Target Group (42CFR 441.18(a) (8) (i) and 441.18(a) (9): All Medicaid eligible pregnant women within the state of Georgia at risk for an adverse birth outcome.

B. Areas of the State in which services will be provided: _x_ Entire State ___ Only in the following geographic areas:

C. Comparability of Services (§1902(a)(10)(B) and 1915(g)(1)): ___ Services are provided in accordance with §1902 (a) (10) (B) of the Act. _x_ Services are not comparable in amount, duration, and scope (§1915 (g) (1))

D. Definition of services (42 CFR 440.169):

Perinatal Case Management services are defined as services furnished to assist women, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Perinatal Case Management includes the following assistance:

• One initial comprehensive face-to-face assessment per pregnancy of the woman’s needs to determine her need for any medical, educational, social or other services. The assessment activities include: o Taking a client history; o Identifying the individual’s needs and completing related documentation; o Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual. • Women identified as at risk for an adverse birth outcome will have periodic reassessment of their needs monthly as a component of their case management follow up. Additional or different needs identified will be added to their plan of care. Reassessments may be face-to-face (for women with complex needs or at the woman’s request) or telephonic.

TN No.: 14-003

Effective Date: January 1, 2014 Supersedes:

Approval Date: 06-20-14 TN No.: 91-04

Supplement 1 to Attachment 3.1-A Page 2 (Part B) State: Georgia STATE/TERRITORY: GEORGIA

• Development (and periodic revision) of a plan of care that is based on the information collected through the assessment that: o Specifies the goals and actions to address the medical, social, educational, and other services needed by the woman; o Includes activities such as ensuring the active participation of the eligible woman, and working with the woman (or the woman’s authorized health care decision maker) and others to develop those goals; and o Identifies a course of action to respond to the assessed needs of the eligible woman. • Monitoring and follow up activities: o Activities and contacts with the woman (either face-to-face or telephonic) occur at least monthly during the pregnancy. They are necessary to ensure the plan of care is implemented and adequately addresses the eligible woman’s needs. These activities and contacts may also be with family members, service providers, or other entities or individuals and conducted as frequently as necessary. The purpose of this monitoring is to determine whether the following conditions are met:  The services are being furnished in accordance with the woman’s plan of care;  The services in the plan of care are adequate; and o Any changes in the needs or status of the woman are reflected in the plan of care.

Perinatal Case Management includes: contacts with non-eligible individuals that are directly related to identifying the eligible woman’s needs and care for the purposes of helping the eligible woman access services; identifying needs and supports to assist the eligible woman in obtaining services; providing case managers with useful feedback; and alerting case managers to changes in the eligible woman’s needs. (42 CFR 440.169 (e)).

E. Qualifications of the Provider (42 CFR 441.18 (a) (8) (v) and 42 CFR 441.18 (b)):

A Medicaid enrolled perinatal case management provider may be an individual or group entity qualified to provide perinatal case management services and eligible to enroll as a Medicaid provider under this program. Every perinatal case management provider must be or utilize a Perinatal Case Manager to deliver the perinatal case management services.

TN No.: 14-003

Effective Date: January 1, 2014 Supersedes:

Approval Date: 06-20-14 TN No.: 91-04

Supplement 1 to Attachment 3.1-A Page 3 (Part B) State: Georgia STATE/TERRITORY: GEORGIA

A signed copy of the applicable license(s) must be submitted with the provider’s application for enrollment.

The Perinatal Case Management provider must be a Medicaid enrolled: • GA licensed physician • Physician’s Assistant working under the direction of a licensed physician • Nurse Practitioner • Certified Nurse-Midwife • Entity that employs or arranges for registered nurses to furnish the perinatal case management services, such as a local public health agency.

The Perinatal Case Manager must: • Have the capacity to provide the full range of perinatal case management services; • Have demonstrated, direct experience in the delivery of healthcare services to women such as providing primary care, prenatal care, family planning, or case management services; and • Have demonstrated the ability to provide or coordinate pregnancy-related health and human services.

Independent licensed registered nurses are not eligible to enroll as Perinatal Case Management providers under this program. Only Perinatal Case Management providers are allowed to bill for case management services under this program.

The Perinatal Case Manager may be a: • GA licensed physician • Physician’s assistant working under the direction of a licensed physician • Nurse practitioner • Certified nurse midwife • Licensed registered nurse

F. Freedom of Choice (42 CFR 441.18 (a) (1):

The State assures that the provision of perinatal case management services will not restrict an individual’s free choice of providers in violation of section 1902 (a) (23) of the Act. 1. Eligible women will have free choice of any qualified Medicaid providers within the State.

TN No.: 14-003

Effective Date: January 1, 2014 Supersedes:

Approval Date: 06-20-14 TN No.: 91-04

Supplement 1 to Attachment3.1-A Page 4 (Part B) State: Georgia STATE/TERRITORY: GEORGIA

2. Eligible women will have free choice of any qualified Medicaid providers of other medical care under the State Plan.

G. Access to Services (42 CFR 441.18 (a) (2), 42 CFR 441.18 (a) (3), and 42 CFR 441.18 (a) (6):

The State assures the following: • Perinatal Case Management services will not be used to restrict an individual’s access to other services under the State Plan. • Women will not be compelled to receive perinatal case management services, condition receipt of perinatal case management services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on the receipt of perinatal case management services; and • Providers of perinatal case management services do not exercise the state’s authority to authorize or deny the provision of other services under the State Plan.

H. Case Records (42 CFR 441.18 (a) (7)):

Perinatal Case Management providers maintain case records that document, for all women receiving perinatal case management services, the following: 1. The name of the woman 2. The dates of the perinatal case management services 3. The name of the perinatal case management provider and the perinatal case manager 4. The nature, content, units of perinatal case management service received and whether goals specified in the plan of care have been achieved 5. Whether the woman has declined services in the plan of care 6. The need for, and occurrence of, coordination with other case managers 7. A timeline for obtaining needed services 8. A timeline for re-evaluation of the plan.

TN No.: 14-003

Effective Date: January 1, 2014 Supersedes:

Approval Date: 06-20-14 TN No.: 91-04

Supplement 1 to Attachment 3.1-A Page 5 (Part B) State: Georgia STATE/TERRITORY: GEORGIA

I. Limitations:

Perinatal Case Management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities are an integral and inseparable component of another covered Medicaid service. (State Medicaid Manual (SMM) 4302.F)

Perinatal Case Management does not include, and FFP is not available in expenditures for services defined in §440.169 when the perinatal case management activities constitute the direct delivery of underlying medical, educational, social or other services to which an eligible woman has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements, recruiting and interviewing potential foster care parents; serving legal papers, making home investigations, providing transportation, administering foster care subsidies, making placement arrangements (42 CFR 441.18 (c))

FFP is only available for perinatal case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with §1903 (c) of the Act. (§§1902 (a) (25) and 1905 (c)).

TN No.: 14-003

Effective Date: January 1, 2014 Supersedes

Approval Date: 06-20-14 TN No.: 01-027

Attachment 4.19-B Page 5.002 State: Georgia STATE/TERRITORY: GEORGIA

POLICY AND METHOD FOR ESTABLISHING RATES FOR OTHER TYPES OR CARE OR SERVICES

N. PERINATAL CASE MANAGEMENT SERVICES

(a) Except as otherwise noted in the plan, the state-developed fee schedule rates are the same for both governmental and private providers of perinatal case management services. The payment rates for these services can be found in the Perinatal Case Management Provider Manual which can be found at the state’s website: https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Infor mation/Provider%20Manuals/tabId/54/Default.aspx .

These rates were last updated on January 1, 2005, and are effective for services provided on or after that date.

(b) Reimbursement for perinatal case management services is available for the initial comprehensive contact, follow up contacts, and a postpartum contact.

TN No.: 14-003

Effective Date: January 1, 2014 Supersedes

Approval Date: 06-20-14 TN No.: 89-14

Attachment 4.19-B Page 5a

State: Georgia

STATE/TERRITORY: GEORGIA

POLICY AND METHODS FOR ESTABLISHING RATES FOR OTHER TYPES OR CARE OR SERVICE

Reserved for later use.

TN No.: 14-003

Effective Date: January 1, 2014 Supersedes

Approval Date: 06-20-14 TN No.: 89-14

Attachment 4.19-B Page 5b

State: Georgia

STATE/TERRITORY: GEORGIA

POLICY AND METHODS FOR ESTABLISHING RATES FOR OTHER TYPES OR CARE OR SERVICE

Reserved for later use.

TN No: 14-003

Effective Date: January 1, 2014 Supersedes

Approval Date: 06-20-14

TN No: 93-020

Supplement 1 to Attachment 3.1-A

Page 1 (Part M)

STATE/TERRITORY: GEORGIA

Reserved for later use.

TN No: 14-003

Effective Date: January 1, 2014 Supersedes

Approval Date: 06-20-14

TN No: 93-020

Supplement 1 to Attachment 3.1-A

Page 2 (Part M)

STATE/TERRITORY: GEORGIA

Reserved for later use.

TN No: 14-003

Effective Date: January 1, 2014 Supersedes

Approval Date: 06-20-14

TN No: 93-020

Supplement 1 to Attachment 3.1-A

Page 3 (Part M)

STATE/TERRITORY: GEORGIA

Reserved for later use.

Table of Contents

State/Territory Name: Georgia State Plan Amendment (SPA) #: 17-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

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

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

January 12, 2018

Mr. Blake Fulenwider Deputy Commissioner, Medicaid Chief Georgia Department of Community Health 2 Peachtree Street, N.W., Suite 36-450 Atlanta, GA 30303

Re: Georgia State Plan Amendment 17-0015

Dear Mr. Fulenwider:

We have reviewed the proposed Georgia state plan amendment, GA 17-0015, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 17, 2017. This amendment adds coverage of Autism Spectrum Disorder (ASD) services, and enrollment and reimbursement of Board Certified Behavior Analysts for providing ASD services.

Based on the information provided, the Medicaid State Plan Amendment GA 17-0015 was approved on January 11, 2018. The effective date of this amendment is January 1, 2018. We are enclosing the approved HCFA-179 and a copy of the new state plan pages.

If you have any additional questions or need further assistance, please contact Etta Hawkins at (404) 562-7429 or Etta.Hawkins@cms.hhs.gov; or Amr Ali at Amr.Ali@cms.hhs.gov; 404-562- 7338.

Sincerely,

//s//

Charles A. Friedrich, MPA Acting Associate Regional Administrator Division of Medicaid & Children’s Health Operations Enclosures

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

1. TRANSMITTAL NUMBER: 17-015 2. STATE GEORGIA 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE: January 1, 2018

5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION:

42 C.F.R. § 433.51 7. FEDERAL BUDGET IMPACT: FFY 2018: $10,288,880 FFY 2019: $18,220,768

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Coverage: 3.1A, Pages 2 – 7. Reimbursement: 4.19 G, Page 1. 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

New pages. Not applicable.

10. SUBJECT OF AMENDMENT: Medical Assistance Plans, State Plan Amendment: Enroll Board Certified Behavior Analysts as Providers, and Reimburse for Adaptive Behavior Services

11. GOVERNOR’S REVIEW (Check One):

GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED:

COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Single State Agency Comments Attached.

NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: //s// 16. RETURN TO:

Department of Community Health Division of Medicaid 2 Peachtree Street, NW, 36th Floor Atlanta, Georgia 30303-3159 13. TYPED NAME: Blake Fulenwider 14. TITLE: Deputy Commissioner, Chief Division Of Medical Assistance Plans 15. DATE SUBMITTED: November 17, 2017 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 11/17/17

18. DATE APPROVED: 01/11/18 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 01/01/18 20. SIGNATURE OF REGIONAL OFFICIAL: //s// 21. TYPED NAME: Charles A. Friedrich, MPA

22. TITLE: Acting Associate Regional Administrator Division· of Medicaid & Children’s Health Operations 23. REMARKS: Approved with the following changes to. block 7 and 8 as authorize by state agency on emails dated 12/21/1'7, 01/04/18 and 01/05/18.

Block #7 changed to read: FFY 20.18 $22,374,233 and Fi::Y 2019 $39,622,941. Block#8 changed to read: Attachment 3.1-A Pages 6{a),2, 6(a)3, 6(a)4 and 6(a)5; Attachment 4.19-B Page 15.

Attachment 3.1 A

Page 6(a)(4)

State: Georgia

TN. No. 17-015 Approved Date: 01/11/18 Effective Date: 01/01/2018 New

Treatment Descriptions and Authorized Providers.

Code Description Authorized Provider Type Adaptive Behavior Treatment

Adaptive behavior treatment addresses the patient’s specific target problems and treatment goals as defined in assessments. Adaptive behavior treatment is based on principles including analysis and alternation of contextual events and motivating factors, stimulus-consequence strategies and replacement behavior, and monitoring of outcome metrics. Goals of adaptive behavior treatment may include reduction of repetitive and aberrant behavior, and improved communication and social functioning. Adaptive behavior skills tasks are often broken down into small, measurable units, and each skill is practiced repeatedly until the member masters it. Adaptive Behavior Treatment by protocol, administered by Authorized Provider Type, face-to-face with one patient; first thirty (30) minutes of the Authorized Provider Type’s time. Additional (30) minute increments are authorized in accordance with medical necessity. Adaptive Behavior Treatment can be provided on in an individual, group, family or multi-family setting.

Physicians Psychologists BCBA-D BCBA BCaBA RBT who meets the minimum one year of required experience

Adaptive Behavior Treatment with Protocol Modification

Adaptive Behavior Treatment with Protocol Modification includes skills training delivered to a patient who has poor emotional responses and/or deviation in rigid routines. The practitioner introduces small, incremental changes to the patients expected routine along one or more stimulus areas. More intrusive changes in routines are faded into preferred daily activities until the member appropriately tolerates typical variation in daily activities without poor emotional responses. The service may include demonstration of new or modified protocol for a technician, guardian, and/or caregiver. The practitioner modifies the past protocol targeted for desired results to incorporate changes in the context and environment. Adaptive Behavior Treatment with protocol modification administered by Physician or other Authorized Provider Type with one patient; first thirty (30) minutes of patient face-to-face time. Additional (30) minute increments are authorized in accordance with medical necessity.

Physicians Psychologists BCBA-D BCBA BCaBA RBT who meets the minimum one year of required experience

Attachment 3.1 A

Page 6(a)(3)

State: Georgia

TN. No. 17-015 Approved Date: 01/11/18 Effective Date: 01/01/2018 New

Observational Behavioral Follow-up Assessment Observational Behavioral Follow-up Assessment is designed by the practitioner to identify and evaluate factors that many impede the expression of adaptive behaviors.

The assessment utilizes structured observation and/or standardized and non-standardized tests to determine the levels of adaptive behavior. It enables the practitioner to evaluate a member’s social behavior to determine if the patient has a particular set of social skills, as well as the contexts in which social responses are either likely or unlikely to occur. Practitioners may assess cooperation, motivation, visual understanding, receptive and expressive language, imitation, request, labeling, play and leisure, and social interactions. Observational Behavioral Follow-up assessment, includes, Physician or other Authorized Provider Type direction with interpretation and report, administered by one of the Authorized Provider Type; first thirty (30) minutes of the Authorized Provider Type’s time, face-to-face with the patient. Additional (30) minute increments are authorized in accordance with medical necessity.

Physicians Psychologists BCBA-D BCBA BCaBA RBT who meets the minimum one year of required experience

Exposure Behavioral Follow-up Assessment Exposure behavioral follow-up assessments is designed by the practitioner to manipulate or stage environmental or social contexts to examine triggers, events, cues, responses, and consequences associated with maladaptive destructive behavior(s). This service requires the practitioner to provide on-site direction to technicians providing direct service. Exposure behavioral follow-up assessment often requires the use of protective gear and/or padded room to avoid injuries to patient and others. Exposure Behavioral Follow-up assessment, includes Physicians or other Authorized Provider Type, direction with interpretation and report, administered by Physician or Authorized Provider Type with the assistance of one or more Authorized Provider Type; first thirty (30) minutes of the Authorized Provider Type’s, face-to-face with the patient. Additional (30) minute increments are authorized in accordance with medical necessity.

Physicians Psychologists BCBA-D BCBA BCaBA RBT who meets the minimum one year of required experience

Attachment 3.1 A

Page 6(a)(2)

State: Georgia

TN. No. 17-015 Approved Date: 01/11/18 Effective Date: 01/01/2018 New

Autism Spectrum Disorder Services. Services to treat Autism Spectrum Disorders (ASD), as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, include assessment and treatment services provided to Medicaid beneficiaries in accordance with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) standards and according to medical necessity. Pursuant to 42 CFR 440.130(c), services must be recommended by a licensed physician or other licensed practitioner of the healing arts acting within their scope of practice under state law to prevent the progression of ASD, prolong life, and promote the physical and mental health and efficiency of the individual. Prior Authorization is required for all services. Services are authorized in two parts, 1) Assessment, and 2) Treatment Plan and Services. An Assessment is the administration of an industry standard assessment tool, and is required to substantiate services. A Treatment Plan is a plan of care required to coordinate treatment.

Georgia Medicaid will enroll Board Certified Behavioral Analysts (BCBA) to provide ASD treatment services. The BCBA must have a graduate-level certification in behavior analysis. Providers who are certified at the BCBA level are independent practitioners who provide behavior-analytic services. In addition, BCBAs supervise the work of Board Certified Assistant Behavior Analysts (BCaBA), Registered Behavior Technicians (RBT), and others who implement behavior-analytic interventions.

The following providers are authorized to provide ASD services: • BCBA-D: Board Certified Behavior Analyst: Doctoral Level. A doctoral level practitioner qualified to diagnose and provide direct services and supervise BCBAs. • BCBA: Board Certified Behavior Analyst. Masters/graduate level independent practitioners who provide behavior-analytic services. May supervise the work of Board Certified Assistant Behavior Analysts, Registered Behavior Technicians, and others who implement behavior-analytic interventions. • BCaBA: Board Certified Assistant Behavior Analyst. Bachelor’s level practitioner, must be supervised by BCBA/BCBA-D; can supervise Registered Behavior Technicians. • RBT: Registered Behavior Technicians. Paraprofessional who implements the service plan under supervision of a Certified Behavior Analyst or Certified Assistant Behavior Analyst.

Assessment Descriptions.

Service Description Authorized Provider Type Behavior Identification Assessment Behavior identification assessment, by the Physician or other Authorized Provider Type, face-to-face with patient and caregiver(s), includes administration of standardized and non- standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report for plan of care.

Physicians Psychologists BCBA-D BCBA

Attachment 3.1 A

Page 6(a)(5)

State: Georgia

TN. No. 17-015 Approved Date: 01/11/18 Effective Date: 01/01/2018 New

Adaptive Behavior Treatment Social Skills Group

Adaptive Behavior Treatment Social Skills Group is administered by a practitioner in a social skills group. The practitioner monitors the needs of the individual and adjusts therapeutic techniques in real-time to address targeted social deficits and problem behaviors using modeling, rehearsing, and corrective feedback. The practitioner develops group activities in which each patient has an opportunity to practice encounters. Adaptive Behavior Treatment Social Skills Group, administered by Physician or other Authorized Provider Type, face-to-face with multiple patients.

Physicians Psychologists BCBA-D BCBA BCaBA RBT who meets the minimum one year of required experience

Exposure Adaptive Behavior Treatment with Protocol Modification Exposure adaptive behavior treatment with protocol modification requires staged environmental conditions to train appropriate alternative responses under the environmental contexts that typically evoke problem behavior. Exposure adaptive behavior treatment addresses one or more specific destructive behaviors. Practitioners directs the sequence of events utilizing real time observation. Exposure Adaptive Behavior Treatment with protocol modification requiring two (2) or more Authorized Provider Type for severe maladaptive behavior(s); first sixty (60) minutes of the Authorized Provider Type’s time, face to face with patient. Additional (30) minute increments are authorized in accordance with medical necessity.

Physicians Psychologists BCBA-D BCBA BCaBA RBT who meets the minimum one year of required experience

Attachment 4.19 B

Page 15

State: Georgia

TN. No. 17-015 Approved Date: 01/11/18 Effective Date: 01/01/2018 New

Autism Spectrum Disorder Services Reimbursement. Services to treat Autism Spectrum Disorders (ASD), as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, include assessment and treatment services provide to Medicaid beneficiaries in accordance with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) standards and according to medical necessity. Pursuant to 42 CFR 440.130(c), services must be recommended by a licensed physician or other licensed practitioner of the healing arts acting within their scope of practice under state law to prevent the progression of ASD, prolong life, and promote the physical and mental health and efficiency of the individual. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Autism Spectrum Disorder Services. The agency’s fee schedule rate was set as of January 1, 2018 and is effective for services provided on or after that date, and is located at: https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Fee%20Schedules/tabId/ 56/Default.aspx.

Table of Contents

State/Territory Name: Georgia State Plan Amendment (SPA) #: GA-18-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Approved SPA Pages

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

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 19, 2018

Frank Berry, Commissioner Georgia Department of Community Health 2 Peachtree Street, NW, 40th Floor Atlanta, Georgia 30303

RE: Title XIX State Plan Amendment (SPA), Transmittal Number 18-0001-MM1

Dear Mr. Berry:

We are pleased to inform you of the approval of Georgia State Plan Amendment (SPA) 18-0001-MM1.

This SPA was submitted to the Centers for Medicare & Medicaid Services (CMS) on January 4, 2018. This amendment removes from the state plan the eligibility of former foster care youth under age 26 who were in foster care under the responsibility of another state, and enrolled in Medicaid at the time they turned 18 or aged out of the foster care system in the other state. This amendment is in compliance with §1902(a)(10)(A)(i)(IX) of the Social Security Act and federal regulations at 42 CFR §435.150

Based on the information provided, Medicaid state plan amendment GA-18-0001-MM1 was approved on March 16, 2018. The effective date of this amendment is January 1, 2018. We are enclosing a copy of the approved SPA pages and the form like CMS-179.

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

Sincerely,

//s//

Charles Friedrich, MPA

Acting Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

1/25/2018 GA - Submission Package - GA2017MS0001O - (GA-18-0001-FFC) - Eligibility CMS-10434 OMB 0938-1188 Approval Notice DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850 Date: Head of Agency: Frank Berry Title/Dept : Commissioner Address 1: 2 Peachtree Street NW Address 2: City : Atlanta State: GA Zip: 30303 MACPro Package ID: GA2017MS0001O SPA ID: GA-18-0001-FFC Subject Georgia Former Foster Care Children Out of State Dear Frank Berry This is an informal communication that will be followed with an oÕcial communication to the State's Medicaid Director. The Centers for Medicare and Medicaid Services (CMS) is pleased to inform you that we are recommending approval for your request for Approval of Georgia SPA 18-0001 Reviewable Unit E×ective Date Financial Eligibility Requirements for Non-MAGI Groups 1/1/2018 Mandatory Eligibility Groups 1/1/2018 Former Foster Care Children 1/1/2018 We are pleased to inform you of the approval of Georgia State Plan Amendment (SPA) 18-0001. This amendment modiÒes the ModiÒed Adjusted Gross Income (MAGI)-Based Eligibility Groups to individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and were in foster care when they turned age 18 or aged out of foster care. Georgia will no longer cover Former Foster Care Youth that have aged out of Foster Care in another state. Georgia will use only state funds going forward. Sincerely, Approval Documentation Name Date Created Ty pe No items available Package Information Package ID GA2017MS0001O Program Name N/A SPA ID GA-18-0001-FFC Submission Type OÕcial State GA Region Atlanta, GA TN NO.: 18-0001-MM1 Approval Date: 03/16/18 Effective Date: 01/01/18 Supersedes: 13-0020-MM1 1 of 7 Georgia

1/25/2018 GA - Submission Package - GA2017MS0001O - (GA-18-0001-FFC) - Eligibility Version Number 3 Submitted By Heather Bond Priority Code P2 Package Status Review Submission Date 1/4/2018 Regulatory Clock 69 days remain Review Status Review 1 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | GA2017MS0001O | GA-18-0001-FFC Package Header Package ID GA2017MS0001O Submission Type OÕcial Approval Date N/A Superseded SPA ID N/A SPA ID GA-18-0001-FFC Initial Submission Date 1/4/2018 E×ective Date N/A State Information State/Territory Name: Georgia Medicaid Agency Name: Georgia Department of Community Health Submission Component Submission Type Allow this oÕcial package to be viewable by other states? Key Contacts Name Title Phone Number Email Address Bond, Heather Associate Chief (404)657-1502 Hbond@dch.ga.gov SPA ID and E×ective Date SPA ID GA-18-0001-FFC Reviewable Unit Proposed E×ective Date Financial Eligibility Requirements for Non-MAGI Groups 1/1/2018 Mandatory Eligibility Groups 1/1/2018 Former Foster Care Children 1/1/2018 Executive Summary Summary Description Including Goals and Objectives Georgia will only cover Former Foster Care Youth as described in 42 CFR 435.150. Georgia will not cover Former Foster Care Youth that aged out of Foster Care in another state. Georgia intends to use only state funds going forward. Dependency Description Description of any dependencies between this submission package and any other submission package undergoing review Disaster-Related Submission Not Started In Progress Complete State Plan Amendment Medicaid CHIP OÕcial Submission Package Draft Submission Package Yes No TN NO.: 18-0001-MM1 Approval Date: 03/16/18 Effective Date: 01/01/18 Supersedes: 13-0020-MM1 2 of 7 Georgia

1/25/2018 GA - Submission Package - GA2017MS0001O - (GA-18-0001-FFC) - Eligibility This submission is related to a disaster Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2018 $-100000 Second 2019 $125000 Federal Statute / Regulation Citation Former Foster Care Youth 42 CFR 435.150 Governor's OÕce Review Authorized Submitter The following information will be provided by the system once the package is submitted to CMS. Name of Authorized Submitter Heather Bond Phone number 4046571502 Email address Hbond@dch.ga.gov Authorized Submitter's Signature Heather Bond Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | GA2017MS0001O | GA-18-0001-FFC Package Header Package ID GA2017MS0001O Submission Type OÕcial Approval Date N/A Superseded SPA ID N/A SPA ID GA-18-0001-FFC Initial Submission Date 1/4/2018 E×ective Date N/A Indicate whether public comment was solicited with respect to this submission. Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | GA2017MS0001O | GA-18-0001-FFC Package Header Package ID GA2017MS0001O SPA ID GA-18-0001-FFC Yes No No comment Comments received No response within 45 days Other I hereby certify that I am authorized to submit this package on behalf of the Medicaid Agency. Not Started In Progress Complete Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Not Started In Progress Complete TN NO.: 18-0001-MM1 Approval Date: 03/16/18 Effective Date: 01/01/18 Supersedes: 13-0020-MM1 3 of 7 Georgia

1/25/2018 GA - Submission Package - GA2017MS0001O - (GA-18-0001-FFC) - Eligibility Submission Type OÕcial Approval Date N/A Superseded SPA ID N/A Initial Submission Date 1/4/2018 E×ective Date N/A One or more Indian health programs or Urban Indian Organizations furnish health care services in this state Medicaid State Plan Eligibility Financial Eligibility Requirements for Non-MAGI Groups MEDICAID | Medicaid State Plan | Eligibility | GA2017MS0001O | GA-18-0001-FFC Package Header Package ID GA2017MS0001O Submission Type OÕcial Approval Date N/A Superseded SPA ID N/A SPA ID GA-18-0001-FFC Initial Submission Date 1/4/2018 E×ective Date 1/1/2018 The state applies the following Ònancial methodologies for all eligibility groups whose eligibility is not based on modiÒed adjusted gross income (MAGI) rules (described in 42 C.F.R. §435.603): A. Financial Eligibility Methodologies B. Eligibility Determinations of Aged, Blind and Disabled Individuals Eligibility is determined for aged, blind and disabled individuals based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneÒciaries. For all other individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, the state requires a separate Medicaid application and determines Ònancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, including SSI beneÒciaries, to Òle a separate Medicaid application, and determines Ònancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, including SSI beneÒciaries, to Òle a separate Medicaid application, and determines Ònancial eligibility using income and resource methodologies more restrictive than SSI. C. Financial Responsibility of Relatives D. Additional Information (optional) Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | GA2017MS0001O | GA-18-0001-FFC Package Header Package ID GA2017MS0001O SPA ID GA-18-0001-FFC Submission Type OÕcial Initial Submission Date 1/4/2018 Yes No Not Started In Progress Complete The state determines Ònancial eligibility consistent with the methodologies described in 42 C.F.R. §435.601. SSA Eligibility Determination State (1634 State) State Eligibility Determination (SSI Criteria State) State Eligibility Determination (209(b) State) The state determines the Ònancial responsibility of relatives consistent with the requirements and methodologies described in 42 C.F.R. §435.602. Not Started In Progress Complete TN NO.: 18-0001-MM1 Approval Date: 03/16/18 Effective Date: 01/01/18 Supersedes: 13-0020-MM1 4 of 7 Georgia

1/25/2018 GA - Submission Package - GA2017MS0001O - (GA-18-0001-FFC) - Eligibility Approval Date N/A Superseded SPA ID 13-020 System-Derived E×ective Date 1/1/2018 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children CONVERTED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI BeneÒciaries NEW Individuals Receiving Mandatory State Supplements NEW Individuals Who Are Essential Spouses NEW Institutionalized Individuals Continuously Eligible Since 1973 NEW Blind or Disabled Individuals Eligible in 1973 NEW Individuals Who Lost Eligibility for SSI/SSP Due to an Increase in OASDI BeneÒts in 1972 NEW Individuals Who Would be Eligible for SSI/SSP but for OASDI COLA increases since April, 1977 NEW TN NO.: 18-0001-MM1 Approval Date: 03/16/18 Effective Date: 01/01/18 Supersedes: 13-0020-MM1 5 of 7 Georgia

1/25/2018 GA - Submission Package - GA2017MS0001O - (GA-18-0001-FFC) - Eligibility Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Disabled Widows and Widowers Ineligible for SSI due to Increase in OASDI NEW Disabled Widows and Widowers Ineligible for SSI due to Early Receipt of Social Security NEW Working Disabled under 1619(b) NEW Disabled Adult Children NEW QualiÒed Medicare BeneÒciaries NEW QualiÒed Disabled and Working Individuals NEW SpeciÒed Low Income Medicare BeneÒciaries NEW Qualifying Individuals NEW B. The state elects the Adult Group, described at 42 C.F.R. §435.219. C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | GA2017MS0001O | GA-18-0001-FFC Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and were in foster care when they turned age 18 or aged out of foster care. Package Header Package ID GA2017MS0001O Submission Type OÕcial Approval Date N/A Superseded SPA ID 13-020 System-Derived SPA ID GA-18-0001-FFC Initial Submission Date 1/4/2018 E×ective Date 1/1/2018 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group B. Individuals Covered Yes No Not Started In Progress Complete TN NO.: 18-0001-MM1 Approval Date: 03/16/18 Effective Date: 01/01/18 Supersedes: 13-0020-MM1 6 of 7 Georgia

1/25/2018 GA - Submission Package - GA2017MS0001O - (GA-18-0001-FFC) - Eligibility 1. The state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) and were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act. 2. Additionally, the state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Additional Information (optional) PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OÕcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 1/25/2018 1:31 PM EST a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. TN NO.: 18-0001-MM1 Approval Date: 03/16/18 Effective Date: 01/01/18 Supersedes: 13-0020-MM1 7 of 7 Georgia

Table of Contents

State/Territory Name: Georgia State Plan Amendment (SPA) #: 19-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Financial Management Group

December 5, 2019

Lynnette R. Rhodes, Esq. Executive Director, Medical Assistance Plans Department of Community Health 2 Peachtree St., 36th Floor Atlanta, Georgia 30303-3159

RE: Georgia State Plan Amendment 19-0005

Dear Ms. Rhodes:

We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number 19-0005. This amendment proposes to revise the DSH language in the plan. The current language states that GA will use the federal definition of UCC in determining the allocation of the DSH allotment to hospitals. The state is proposing to add language that specifically defines uncompensated care, rather than referencing federal definitions. The proposed definition to be added will not result in any change for hospitals.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We have found that the proposed reimbursement methodology complies with applicable requirements and therefore have approved them with an effective date of July 1, 2019. We are enclosing the CMS-179 and the amended approved plan pages.

If you have any questions, please call Anna Dubois at (850) 878-0916.

Sincerely,

/s/

Kristin Fan Director

cc: Anna Dubois Dan Yablochnikov

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

1. TRANSMITTAL NUMBER: 19-0005 2. STATE GEORGIA 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE: July 1, 2019

5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 42 USC§ 1396d(a)(1) (Section 1905(a)(1) of the Social Security Act) 7. FEDERAL BUDGET IMPACT: FFY 2019: 0 FFY 2020: 0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-A, Pages 15-17 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Not Applicable

10. SUBJECT OF AMENDMENT: Specifically defines the "DSH limit" as it is used in the Medicaid DSH allocation methodology. 11. GOVERNOR’S REVIEW (Check One):

GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED:

COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Single State Agency Comments Attached

NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO:

Department of Community Health Division of Medicaid 2 Peachtree Street, NW, 36th Floor Atlanta, Georgia 30303-3159 13. TYPED NAME: LYNNETTE R. RHODES, ESQ. 14. TITLE: EXECUTIVE DIRECTOR, MEDICAL ASSISTANCE PLANS 15. DATE SUBMITTED: 09/29/19 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 09/30/19

18. DATE APPROVED: 12/05/19 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 07/01/19 20. SIGNATURE OF REGIONAL OFFICIAL: /s/ 21. TYPED NAME: Kristin Fan 22. TITLE: Director, FMG

23. REMARKS:

Attachment 4.19 – A Page 15 State: Georgia

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT SERVICES

15 TN No. 19-0005 Supersedes Approval Date: 12/05/19 Effective Date: July 1, 2019 TN No. 13-002

III. Disproportionate Share Hospitals (DSH)

A. Eligibility

Effective for DSH payment adjustments made on or after December 1, 2007, hospitals that are eligible to receive DSH payment adjustments under federal DSH criteria per Social Security Act Section 1923(d) will be eligible to receive an allocation of available DSH funds.

Federal Criteria: 1. The hospital has a Medicaid inpatient utilization rate of at least 1%; AND

2. The hospital has at least two (2) obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to Medicaid recipients. This requirement does not apply to a hospital of which the inpatients are predominately individuals under 18 years of age or to hospitals which did not offer non-emergency obstetric services to the general population as of December 22, 1987. In the case of a hospital located in a rural area, the term "obstetrician" includes any physician with staff privileges at the hospital to perform non-emergency obstetric procedures. For rural hospitals subject to a federal requirement to provide obstetric services, as an alternative to determining whether deliveries are provided at the hospital, the Department will consider the following factors: a. The hospital must have two or more physicians with staff privileges that are: i. Enrolled in the Medicaid program; ii. Credentialed to provide OB services at the hospital in family practice, general practice, or obstetrics; and iii. Located within 25 miles of the hospital or in an office in the hospital network or must attest to attendance at the hospital on some routine basis; and b. The hospital must be able to provide at least one obstetric service that is currently covered by · Medicaid and appropriate to be provided in a hospital-based setting.

For federal DSH criteria, a hospital will be considered a rural hospital if a hospital's county is not in a Metropolitan Statistical Area, as defined by the United States Office of Management and Budget, OR is a county having a population of less than 35,000 according to the United States decennial census; provided, however, that for counties which contain a military base or installation, the military personnel and their dependents living in such county shall be excluded from the total population of that county.

B. Allocation Methodology

Effective for DSH payment adjustments made on or after December 1, 2007, the following methodology will be used for determining payment amounts: 1. For each federal fiscal year, the amount of funds available for DSH payments will be determined based on the state's federal allotment and required state matching contribution.

2. Hospitals that meet federal DSH eligibility criteria will be eligible to receive an allocation of available DSH allotment funds.

3. The maximum amount of DSH payments (i.e., DSH Limit) for each hospital will be the hospital's loss incurred for services provided to Medicaid and uninsured patients. Medicaid patients will be defined as patients enrolled in either in-state or out-of-state Medicaid fee-for-service or in-state or out-of-state Medicaid Managed Care Organization

Attachment 4.19 – A Page 16 State: Georgia

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT SERVICES

16 TN No. 19-0005 Supersedes Approval Date: 12/05/19 Effective Date: July 1, 2019 TN No. 13-002 (MCO) as their primary or non-primary insurance. Medicaid costs will be determined by applying total per diem costs to Medicaid covered inpatient days and total ratios of cost to charges to Medicaid inpatient and outpatient charges grouped by cost center. The patient day and charge amounts will be determined by Medicaid and Medicaid MCO HS&R reports of paid claims or internal hospital records, while per diem costs and ratios of cost to charges will be determined by available 2552 cost reports. Medicaid payments will include actual claim payments related to Medicaid days and charges, from Medicaid, Medicaid MCOs, Medicare, Medicare Advantage plans, third party insurance, patient payments, the portion of Medicare cost report settlements applicable to Medicare crossover payments, non-claim based Medicaid, Medicaid MCO, and Medicare payments related to inpatient and outpatient hospital services, outpatient settlement estimates and non-DSH rate adjustments. Uninsured costs will be determined by applying the uninsured days and charges reported on the DSH data survey to the same per diems and cost to charge ratios used to calculate Medicaid costs Uninsured payments will include patient payments received on uninsured services accounted for on a cash basis. The DSH data surveys will also be used to determine amounts received for services provided to uninsured patients. DSH data surveys are conducted annually and subject to desk reviews and onsite reviews of supporting documentation, as warranted.

4. The amount of funds available for DSH payments will be allocated among eligible hospitals. Total available DSH funds will be divided into two pools: • Pool I - For FY 2008 DSH payments, Pool 1 will be equivalent to $53,735,261 and used in the calculation of DSH allocations for small, rural hospitals. For DSH payments after FY 2008, Pool I would change relative to changes in the state's federal DSH allotment as compared to the FY 2008 state DSH allotment; • Pool 2 – For FY 2008 DSH payments, Pool 2 will be equivalent to $347,439,065 and used in the calculation of the DSH allocations for all other, eligible hospitals. For DSH payments after FY 2008, Pool 2 would change relative to changes in the state's federal DSH allotment as compared to the FY 2008 state DSH allotment.

5. Each hospital’s DSH limit is subject to the following DSH limit adjustments for allocation purposes: a. For hospitals receiving Upper Payment Limit (UPL) rate adjustments, the allocation basis will be increased by the amount of any intergovernmental transfer or certified public expenditure on behalf of the hospital. b. For hospitals receiving rate adjustment payments related to medical education, neonatal services or services provided under contract with the Georgia Department of Human Resources, the allocation basis will be increased by the amount of such rate adjustments.

6. The department will utilize the following steps to determine the amount each hospital is eligible to receive in DSH payments. a. Step 1: Determine the adjusted DSH limit (as determined in section (III)(B)(5)) as a percentage of total cost for each hospital. b. Step 2: For each hospital, multiply the hospital-specific percentage determined in Step 1 by the hospital's adjusted DSH limit. For private hospitals, the outcome of this calculation will be multiplied by the rate of federal matching funds for Medicaid benefit payments. c. Step 3: For each hospital, divide the hospital-specific amount identified in Step 2 by the aggregate "step 2" amount derived from all hospitals in the applicable pool, as defined in section (III)(B)(4), which will result in a hospital-specific allocation factor. d. Step 4: Apply the hospital's allocation factor calculated in Step 3 to the total amount of DSH funds available in the applicable pool, as defined in section (III)(B)(4). This will result in the hospital's DSH payment. Should the DSH payment amount calculated for a hospital exceed the

Attachment 4.19 – A Page 17 State: Georgia

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT SERVICES

17 TN No. 19-0005 Supersedes Approval Date: 12/05/19 Effective Date: July 1, 2019 TN No. 13-002 hospital's DSH limit, as determined in section (III)(B)(3), the excess amount will be redistributed to the remaining hospita1s in the applicable allocation pool.

7. To mitigate significant increases and decreases in hospital-specific DSH payments as compared to state fiscal year 2007, the following adjustments will be applied for the allocation of DSH funds: • Maximum DSH allocations for all hospitals are set at 75% of their specific adjusted DSH limits; however, for facilities ineligible for DSH payment adjustments prior to December 1, 2007 but newly eligible under the criteria specified in section A above or facilities who did not receive a DSH payment prior to December 1, 2007, their maximum DSH allocation factor, as calculated in Section (III)(B)(6), step 2, effective January 1, 2013 is limited to 75% of the calculated amount. • Final DSH payment amounts for all other hospitals reflects 100% of the allocation calculation based on the methodology specified in section (III)(B)(6). • Effective July I, 2013 the maximum DSH allotment for all hospital are set at 75% as calculated in section (III)(B)(6).

8. For private hospitals that meet the eligibility requirements of Section (III)(A) and meet Social Security Act Section 1923(b) criteria, allocations payments will be made at 100 % of calculated allocation amounts as determined by steps 1 through 7 of Section (III)(B). For private hospitals that meet the eligibility requirements of Section (III)(A) but do not meet Social Security Act Section 1923(b) criteria, allocation payments will be made at 100% of calculated allocation amounts as determined by steps 1 through 7 of Section (III)(B).

9. The state share of DSH payment amounts for state governmental and non-state governmental hospitals will come from intergovernmental transfers made on behalf of or by the hospital.

For allocation of 2010 DSH funds, provider eligibility and DSH limit calculations will be based on information available from hospital fiscal years ending in 2007; for hospitals not in operation during 2007, data for 2008 may be used. For allocation of DSH funds after 2010, eligibility and DSH limit calculations will be based on the most recent year for which comparable data would be available. Audit of Disproportionate Share Payments: As required by Section 1923(j) of the Social Security Act related to auditing and reporting of disproportionate share hospital payments, the Division of Medical Assistance will implement procedures to comply with the Disproportionate Share Hospital Payments final rule issued in the December 19, 2008, Federal Register, with effective date of January 19, 2009, to ensure that the hospital specific DSH limits have not been exceeded.

Any funds recouped as a result of audits or other corrections shall be redistributed to other eligible hospitals within the state, provided each hospital remains below their hospital specific DSH limit. Funds shall be redistributed to hospitals within the pools, as identified in (III)(B)(4) above, for which funds were recouped. The recouped funds within each pool shall be redistributed to the governmental facilities that are still below their hospital specific DSH limit. The funds shall be allocated to those hospitals based on their allocation factor that was derived in (III)(B)(6)(b) above. If the redistribution causes a hospital to exceed their hospital specific DSH limit those excess funds will be redistributed using the same methodology until all funds are expended.

Table of Contents

State/Territory Name: Georgia State Plan Amendment (SPA) #:19-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 61 Forsyth Street S.W. Suite 4T20 Atlanta, Georgia 30303-8909

Atlanta Regional Operations Group

December 18, 2019

Lynette Rhodes, Esq. Executive Director, Medical Assistance Plans Department of Community Health 2 Peachtree Street, NW, Suite 36-450 Atlanta, Georgia 30303

RE: Title XIX State Plan Amendment, GA 19-0006

Dear Ms. Rhodes:

We have reviewed the proposed State Plan Amendment, GA 19-0006, which was submitted to the Atlanta Regional Office originally on June 20, 2019. This amendment proposes to make Graduate Medical Education (GME) paid claims Add-On Payments for Community Service Boards (CSBs) with GME programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME), effective on or after July 1, 2019.

Based on the information provided, the Medicaid State Plan Amendment GA 19-0006 was approved on December 18, 2019. The effective date is July 1, 2019. We are enclosing the approved HCFA- 179 and the plan pages.

If you have any additional questions or need further assistance, please contact Amr Ali at (404) 562-7338 or Amr.Ali@cms.hhs.gov.

Sincerely,

/s/

Davida R. Kimble Acting Deputy Director Division of Medicaid Field Operations South

Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 19-0006 2. STATE Georgia 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE July 1, 2019 5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN [X ] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Section 1917(b) et seq. of the Act, 1917(a)(1)(B) of the Act, and 42 C.F.R. 700 et seq. 7. FEDERAL BUDGET IMPACT: a. FFY 2019 $117,253 b. FFY 2020 $561,181 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Page 1a-21

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

Not Applicable

10. SUBJECT OF AMENDMENT:

: Graduate Medical Education (GME) Supplemental Payments for Community Service Boards (CSBs)

11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT [X] OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: /s/ 16. RETURN TO: Georgia Department of Community Health Division of Medical Assistance Plans 2 Peachtree Street, NW, 36th Floor Atlanta, Georgia 30303-3159

13. TYPED NAME: LYNNETTE R. RHODES, ESQ. 14. TITLE: Executive Director, Medical Assistance Plan 15. DATE SUBMITTED: 06/20/19 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 06/20/19

18. DATE APPROVED: 12/18/19 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 07/01/19 20. SIGNATURE OF REGIONAL OFFICIAL: /s/ 21. TYPED NAME: Davida R. Kimble 22. TITLE: Acting Deputy Director Division of Medicaid Field Operations South 23. REMARKS: Approved with the following changes to blocks #6, 7 and 10 on RAI Response dated 12/16/19.

Block # 6 changed to read: 42 CFR Part 447 Block # 7 changed to read: FFY19 $120,319 and FFY20 $516,475 Block # 10 changed to read: Graduate Medical Education (GME) paid Claims Add-On Payments for Community Service Boards (CSBs)

Attachment 4.19-B Page 1a-21 State: Georgia

TN No. 19-0006

Supersedes Approval Date: 12/18/19 Effective Date: July 1, 2019 TN No. NEW

D. Graduate Medical Education Payments for Community Service Boards

Community Service Boards (CSBs) with Graduate Medical Education (GME) programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME) will be eligible to receive GME supplemental payments. The annual amount of each eligible CSB’s GME payments will be calculated as follows:

(1) Determine the Percentage of the CSB Claims Attributable to Medicaid in the previous fiscal year. (2) Multiply the percentage of the CSB claims attributable to Medicaid by the total GME annual expenses for the current fiscal year. (3) Divide the last four state fiscal years average CSB annual Medicaid claim count into the GME expenses reimbursable by Medicaid. (4) This amount is the per claim GME add-on amount.

Table of Contents State/Territory Name: Arkansas State Plan Amendment (SPA) #: 20-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601

Financial Management Group

Ms. Dawn Stehle Deputy Director for Health and Medicaid Director Arkansas Department of Human Services 112 West 8th Street, Slot S401 Little Rock, Arkansas 72201-4608

RE: Arkansas TN 20-0005

Dear Ms. Stehle: