Table of Contents State/Territory Name: Hawaii State Plan Amendment (SPA) #: 09-010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEAL TH & HUMAN SERVICES Centers for Medicare & Medicaid Services Region IX Division of Medicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (SW) San Francisco. CA 94103-6706 AUG 2 3 2010 Lillian B. Koller, Esq. Director, Department of Human Services P.O. Box 339 Honolulu, HI 96809-0339 Dear Ms. Ko lier: Enclosed is an approved copy of Hawaii State Plan (SPA) No. 09-010, which reduces the amount of medical and remedial expenses that may be deducted in the post-eligibility process to zero if they were incurred as the resuh of the imposition of a transfer of asset penalty period. This SPA is effective October I, 2009. If you have any questions regarding this SPA, please contact Brian Zolynas at (415) 744- 3601 or by email at Brian.Zolynas@cms.hhs.gov. Sincerely, G oria Nag e · Associate Regional Administrator Division of Medicaid & Children's Health Operations Cc: Kenneth Fink, Med-QUEST Administrator Michele Bower, CMS CMCS (two copies) Mary Rydell, Pacific Area Representative

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

1, TRANSMITTAL NUMBER: 09-010

2. STATE HAWAII

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

MEDICAL ASSISTANCE TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION October 1, 2009

DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One):

(] NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

{& AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Dofiet Reduction Act of 2005 under Pic. 109-175 ; . Section 1902(r)(1)(A)(ii) of the Social Securi

7. FEDERAL BUDGET IMPACT: a. FFY 2010 $ Wk Statbee LY b. FFY 2011 $ 900--$219,113.72

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: "

Supplement 3 to Attachment 2.6-A, page |

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 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT ([f Applicable):

Supplement 3 to Attachment 2.6-A, page |

10. SUBJECT OF AMENDMENT:

To disallow the deduction of medical and remedial expenses that were incurred as the result of the imposition of a transfer of assets penalty

period.

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

(4) OTHER, AS SPECIFIED: AS APPROVED BY GOVERNOR

12. SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: LILLIAN B. KOLLER.

14. TITLE: DIRECTOR

16. RETURN TO:

FOR REGIONAL OFFICE USE ONLY

17, DATE RECEIVED:

~- -DEG-2.8 2009

18. DATE APPROVED: _“Auqust 23,2010

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: October 1, 2009

21. TYPED NAME:

Gloria Nagle

Associate ‘Regional Administrator

23. REMARKS:

Pen-and-ink changes to box 6 and 7 as requested in: the RAI response dated. 6/29/10.

4

FORM HCFA-179 (07-92)

Revision: HCFA-PM-85-3 (BERC) SUPPLEMENT 3 to ATTACHMENT 2.6-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State HAWAII

REASONABLE LIMITS ON AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL CARE NOT COVERED UNDER MEDICAID

The deduction for medical and remedial care expenses that were incurred as the result of the imposition of a transfer of asset penalty period is limited to zero.

TN No. 09-010 j ‘si Supersedes Approval Date: 6 4 13-56 Effective Date: 10/01 TN No. 85-9 A

HCFA ID: 4093E/0002P

Table of Contents State/Territory Name: Hawaii State Plan Amendment (SPA) #: 09-012 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEAL m & HUMAN SERVICES Centers for Medicare & Medicaid Services Lillian B. Koller, Esq. Director, Department of Human Services P.O. Box 339 Honolul~ HI 96809-0339 Dear Ms. Ko Iler: SEP 7 2010 Region IX Division of Medicaid & Children's Health Operations 90 Seventh Streec. Suite 5-300 (SW) San Francisco. CA 94103-6706 Enclosed is an approved copy of Hawaii State Pl an Amendment (SPA) No. 09-012, which implements the changes in the treatment of transfers of assets for less than fair market value required by the Deficit Reduction Act of 2005. This SPA is effective October 1, 2009. If you have any questions, please contact Brian Zolynas at (415) 744-3601 or Brian.Zolynas@cms.hhs.gov. Sincerely, Gloria Nagle Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Kenneth Fink, Med-QUEST Administrator Michele Bowser, CMS Center for Medicaid and State Operations (two copies) Mary Rydell, Pacific Area Representative

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 9938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | !. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 09-012 HAWAII

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

5. TYPE OF PLAN MATERIAL (Check One): (NEW STATE PLAN

(AMENDMENT TO BE CONSIDERED AS NEW PLAN

[) AMENDMENT

———__ COMPLETE BLOCKS 6. FEDERAL STATUTE/REGULATION CITATION: Ee nett at nt the OCT Sa

f_the Social Security Act

G THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

by gy MPs ~$1 557,393.32 bLFFY 2011 wang -$1,442,043 .22

5 EAE Risen OF TRE PLAN SECTION OR ATTACHMENT:

Seppiemienh Iho Sein 8. Bee Ti | Ger?

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

x Seepmleme nal ae A ivenbenoen 2 ons Bek pI IX

10. SUBJECT OF AMENDMENT:

To adhere to section 1917(c) of the Social Security Act, this applies (0 certain individuals who dispose of assets for less than fair market

value which may be subject to a penalty,

11. GOVERNOR'S REVIEW (Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

(CUNO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

(] OTHER, AS SPECIFIED: ‘AS APPROVED BY GOVERNOR

LILLIAN B, KOLUBR eer

14. TITLE: DIRECTOR

1S. DATESUBMITTeD: (eC. | . ni treo

17. DATE RECEIVED; ————-—.

16, RETURN TO:

DEC 3 09

PLAN APPROVED - ON 19. EFFECTIVE DATE OF APPROVED MATERIAL: '

= 12009 24. NAME:

Gloria Nagle” 23. REMARKS:

Pen-and-ink changes include:

Box 6 deleted: Deficit Reduction Act of 2005 under PL. 108-171 added sect ton 1917te)

of the Social Security Act

‘

Box 7 deleted: $0.00 for FFY 2010 and FFY 2011 added -$1,557, 303 32 for 2010 and

cull

Box’ delete):

Page 5 Box 9° deleted: Sontoneat 9(b) to Attachment 2.6-A page 1 to page 6

FORM HCFA-179 (07-92)

SUPPLEMENT 9(b) to ATTACHMENT 2.6-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State HAWAII

TRANSFER OF ASSETS

1917(c) FOR TRANSFERS OF ASSETS FOR LESS THAN FAIR MARKET VALUE MADE ON OR AFTER FEBRUARY 8, 2006, the agency provides for the denial of certain Medicaid services.

4 Institutionalized individuals are denied coverage of certain Medicaid services upon disposing of assets for less than fair market value on or after the lookback date.

The agency does not provide medical assistance coverage for institutionalized individuals for the following services:

« Nursing facility services;

¢ Nursing facility level of care provided in a medical institution;

¢ Home and community-based services under a 1915(c) or (d) waiver.

2. Non-institutionalized individuals:

The agency applies these provisions to the following non- institutionalized eligibility groups. These groups can be no more restrictive than those set forth in section 1905(a) of the Social Security Act:

The agency withholds payment to non-institutionalized individuals for the following services:

e Home health services (section 1905(a)(7));

e Home & community care for functionally disabled elderly adults (section 1905(a)(22));

e Personal care services furnished to individuals who are not inpatients in certain medical institutions, as recognized under agency law and specified in section 1905(a)(24).

The following other long-term care services for which payment for medical assistance is otherwise made under the agency plan:

TN No. 09-012 Supersedes Approval Date: SEP 7 2010 Effective Date: 10/01/09 TN No. NEW

SUPPLEMENT 9(b) to ATTACHMENT 2.6-A Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State HAWAII

TRANSFER OF ASSETS (cont.)

3. Penalty Date—The beginning date of each penalty period imposed for an uncompensated transfer of assets is:

. For individuals applying for Medicaid payment of long-term care services, the date on which the individual is eligible for medical assistance under the State plan and would otherwise be receiving institutional level of care services described in paragraph 1 that, were it not for the imposition of the penalty period, would be covered by Medicaid (based on an approved application for such care);

. For individuals receiving Medicaid payment for long-term care services, the first day of the month following timely advance notice of the penalty period.

and

. Which does not occur during any other period of ineligibility for

services by reason of a transfer of assets penalty. 4. Penalty Period - Institutionalized Individuals In determining the penalty for an institutionalized individual, the agency uses:

X The average monthly cost to a private patient of nursing facility services in the State at the time of application;

The average monthly cost to a private patient of nursing facility services in the community in which the individual is institutionalized at the time of application.

§, Penalty Period - Non-institutionalized Individuals The agency imposes a penalty period determined by using the same method as is used for an institutionalized individual, including the use of the average

monthly cost of nursing facility services:

Imposes a shorter penalty period than would be imposed for institutionalized individuals, as outlined below:

TN No. 09-012 Supersedes Approval Date: SEP 7 2010 Effective Date: 10/01/09 TN No. NEW

SUPPLEMENT 9(b) to ATTACHMENT 2.6-A Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State HAWAII

TRANSFER OF ASSETS (cont.)

6. Penalty period for amounts of transfer less than cost of nursing facility care

Xx Where the amount of the transfer is less than the monthly cost of nursing facility care, the agency imposes a penalty for less than a full month, based on the option selected in item 4.

=>. The state adds together all transfers for less than fair market value made during the look-back period in more than one month and calculates a single period of ineligibility that begins on the earliest date that would otherwise apply if the transfer had been made in a single lump sum.

ts Penalty periods - transfer by a spouse that results in a penalty period for the individual

(a) The agency apportions any existing penalty period between the spouses using the method outlined below, provided the spouse is eligible for Medicaid. A penalty can be’assessed against the spouse, and some portion of the penalty against the individual remains.

When both spouses are eligible for long-term care services, the State will use the following method to apportion the penalty period:

Apportion the penalty period equally between the spouses; If one spouse dies or no longer requires long-term care services prior to the expiration of their share of the penalty period, the remainder of the penalty period will be assigned to the spouse who is still receiving long-term care services; ° The penalty months served by the institutionalized spouses shall not exceed the length of the original penalty period.

(b) If one spouse is no longer subject to a penalty, the remaining penalty period must be served by the remaining spouse.

TN No. 09-012 Supersedes Approval Date: SEP 7 2010 Effective Date: 10/01/09 TN No. NEW

SUPPLEMENT 9(b) to ATTACHMENT 2.6-A Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State HAWAII

TRANSFER OF ASSETS (cont.)

8. Treatment of a transfer of income

When income has been transferred as a lump sum, the agency will calculate the penalty period on the lump sum value.

When a stream of income or the right to a stream of income has been transferred, the agency will impose a penalty period for each income payment.

Xx For transfers of individual income payments, the agency will impose partial month penalty periods using the methodology selected in 6. above.

X For transfers of the right to an income stream, the agency will base the penalty period on the combined actuarial value of all payments transferred as described below.

The agency will consider the amount of income expected to be received during the individual's lifetime when the right to receive a stream of income was transferred. The total amount of income is calculated by multiplying the annual amount of income by the individual's life expectancy based on the life expectancy tables established by the Social Security Administration's Office of the Actuary.

9. Imposition of a penalty for an undue hardship The agency does not impose a penalty for transferring assets for less than fair

market value in any case in which the agency determines that such imposition would deprive the individual of:

(a) Medical care such that the individual's health or life would be endangered; or (b) Food, clothing, shelter, or other necessities of life. TN No. 09-012 Supersedes Approval Date: SEP 7 2010 Effective Date: 10/01/09

TN No. NEW

10.

11.

SUPPLEMENT 9(b) to ATTACHMENT 2.6-A Page 5

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State HAWAII

TRANSFER OF ASSETS (cont.)

Procedures for Undue Hardship Waivers

The agency has established a process under which hardship waivers may be requested that provides for:

(a) Notice to a recipient subject to a penalty that an undue hardship exception exists;

(b) A timely process for determining whether an undue hardship waiver will be granted; and

(c) A process, which is described in the notice, under which an adverse determination can be appealed.

The procedures shall permit the facility in which the institutionalized individual is residing to file an undue hardship waiver application on behalf of the individual with the consent of the individual or the individual's personal representative.

Bed Hold Waivers for Hardship Applicants

The agency provides that while an application for an undue hardship waiver is pending in the case of an individual who is a resident of a nursing facility:

Payments to the nursing facility to hold the bed for the individual will be made for a period not to exceed days (may not be greater than 30).

TN No. Supersedes TN No.

09-012

NEW

Approval Date: SEP 7 201lettective Date: 10/01/09

Table of Contents State/Territory Name: Hawaii State Plan Amendment (SPA) #: 10-001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Region IX Division ofMedicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 MAY 2 8 2010 Lillian B. Koller, Esq. Director, Department ofHuman Services P.O. Box 339 Honolulu, HI 96809-0339 Dear Ms. Koller: Enclosed is an approved copy of Hawaii State Plan Amendment (SPA) No. 10-001, which changes the resource limit for Qualified Medicare Beneficiaries (QMB), Specified Low­ Income Medicare Beneficiaries (SLMB) and Qualifying Individuals (QI) to conform to the resource limit for individuals who qualify for the full subsidy Medicare Part D LIS as required by section 112 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). This SPA is effective January 1, 2010. If you have any questions, please contact Sue Castleberry at (415) 744-3599 or susan.castleberry@cms.hhs.gov. ' Sincerely,

Gloria Nagle Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Kenneth Fink, Med-QUEST Administrator Michele Bowser, CMS Center for Medicaid and State Operations (two copies) Mary Rydell, Pacific Area Representative

• • •• DEPARTMENT OF HEALTH AND HUMAN SERVICES fORM APPROVED HEALtH CARB FINANCING ADMINISTRATION OMS NO. 0938-0193 'TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMIITAL NUMBER: TN No. 10-001 2. STATE HAWAII FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) MEDICAL ASSISTANCE TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE January I, 2010 5. TYPE OF PLAN MATERIAL (Check One): o NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN I8JAMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment 6. FEDERAL STATUTEIREGULATION CITATION! .------­ 1905(p)(l)(C) of the Act 1860D-14(a)(3)( D) Attachment 2.2-A. page 9b, 9b I. and 9b2 Attachment 2.ti-A. page 22 & 22a 7. FEDERAL BUDGET IMPACT: a. FFY 2010 $ 73,200.00 b. FFY 2011 $ 83,555.00 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR AITACHMENT (IfApplicable): Attachment 2.2-A, page 9b. 9bI, and 9b2 Attachment 2.ti-A, page 22 aaa-2;ta.­ 10. SUBJECT OF AMENDMENT: To increase the resource standards for Qualified Medicare Beneficiaries, Specified Low Income Beneficiaries, and Qualifying Individuals. 1I. GOVERNOR'S REVIEW (Check One): o GOVERNOR'S OFFICE REPORTED NO COMMENT 1m OTHER, AS SPEClFIBD: o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED AS APPROVED BY GOVERNOR o NO Y RECEIVED WITHIN 45 DAYS OF SUB MITTAL , 16. Rh"'TURN TO; Pen..and-ink chan.ges include: aox~6 added: 1902{a)(lO)(A)(ii){E)(i)-(iv) Box 8 added: &22a FORM HCFA-179 (07-92)

ATTACHMENT 2.6-A Page 22 State: ___...&.H.awuai..!_____ Citation Condition or Requirement 7. Resource Standard -Medically Needy a. Resource standards are based on family size. b. A single standard 1& employed in detennining resource 1902(a)(10)(C)(I) eligibility for all groups. of the Act o c. In 1902(f) States, the resource standards Is more restrictive than in 7.b. above for- Aged Blind DI8abIed Suppl~ 2 to ATTACHMENT 2.6-A specifies the resource standards for all covered medically needy groups. If the agency chooses more restrictive levels under 7.c., Supplement 2.80 indicates • . 8. Resource Standard - Qualified Medicare Beneficiaries" Specified Low-Income Medicare Beneficiaries and Qualifying Individuals 1902(a)(10)(E), 1905(p)(1)(C), For qualified Medicare beneficiaries covered under section 1905(p)(2)(B) and 1902(a)(10)(E)(I) of the Act, Specified Low-Income Medicare 18600-14(a)(3)(0) Beneficiaries covered under section 1902{a)(10)(E)(IiI) of the of the Act Act, and Qualifying Individuals covered under 1902(a)(10(E)(iv) of the Act, the resource standard 1& three times the SSI resource limit. adjusted annually since 1996 by the Increase In the consumer price index. TN No. .1a::Q.Q1 Supersedes Effective Date: OllOmO TN No. .i1:.21

ATTACHMENT 2.2·A Page 9b SB~: ______~Ha.waa.I!~______ Agency· Cltation(s) Groups Covered A. Maogatorv Cgyerage - Categorically Naedy and Other ReqLllred §peel" Groups (Continued) 25. Qualified Medicare beneficiaries ­ 1902(a)(10)(E)(I), 1905(p) and 1860[)'14(a)(3)(D) of the Act a. Who are entitled to hospltallneurance benefits under Medicare Part A. (but not pursuant to an enrollment under section 181M of the Act); b. Whose Income d088 not exceed 100 percent of the Federal poverty Level: and c. Whose resources do not exceed three times the SSI resource limit. adjusted annuaHy by the increase in the consumer price index. (Medical assistance for this group is limited to Medicare cost-eharlng as defined in item 3.2 of this plan) 26. Qualmed disabled and wortdng individuals •• 1902(a)(10)(E)(ii) and 1905(s) of the Act a. Who are entitled to hospital insurance benefits under Medicare Part A under section 1818A of the Act; b. Whose Income does not exceed 200 percent of the Federal poverty level; and c. Whose resources do not exceed two times the SSI resourCe limit. d. Who are not otherwise eligible for medical assistance under Title XIX of the Act. (Medical assistance for this group is limited to Medicare Part A premiums under section 1818A of the.Act.) •Agency that determines eligibility for coverage. TN No. lQ.QQl MAY 2 8 2010 Supersedes Approval Date: EffectIve Date: 0110111Q TN No. 93..Q3

ATTACHMENT 2.2-A Page8b2 State: ___--LH.IIIawW8:aiu.,i____ Agency· Citation(s) Groups Covered A. Mandatory Coyerage - categorically Needy and Other Required Spacial Groups (ContInued) 1634(e) of the Act 29. a. Each person to whom SSI benefits by reason of disability are not payable for any month solely by reason 01 clause (I) or (v) of SectIon 1611(e) (3)(A) shall be treated, for purposes of title XIX, as receiving SSI benefits for the month. A. b. The State applies more restrictive eligibility standards than those under SSI. . Individuals whose eligibility for S81 benefits are based solely on disabitity who are not payable for any months solely by reason of clauses (I) or (v) of Section 1611(e)(3)(A), and who continue to meet the more restrictive requirements for Medicaid eligibility under the State plan, are eligible for Medicaid as categorically needy. •Agency that determines eligibility for coverage. TN No. lQ..Q01 MAy 2 8 71)111 Supersedes Approval Date: Effeclive Date: 0110112010 TN No. 93-03

Table of Contents State/Territory Name: Hawaii State Plan Amendment (SPA) #: 10-002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEAL TH & HUMAN SERVICES Centers for Medicare & Medicaid Services Lillian B. Koller, Esq. Director, Department of Human Services P.O. Box 339 Honolulu, ID 96809-0339 Dear Ms. Koller: Region IX Division of Medicaid & Oiildren's Health Operations 90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706 Enclosed is an approved copy of Hawaii State Plan Amendment (SPA) No. 10-002, which prohibits the estate recovery of Medicare cost sharing benefits for dual eligible beneficiaries age 55 and over. This SPA is effective April 1, 2010. If you have any questions, please contact Brian Zolynas at (415) 744-3601 or Brian.Zolynas@cms.hhs.gov. Sincerely, Gloria Nagle Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Kenneth Fink, Med-QUEST Administrator Michele Bowser, CMS Center for Medicaid and State Operations (two copies) Mary Rydell, Pacific Area Representative

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL AN No, 0-002 BHAWAN 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: HEALTH CARE FINANCING ADMINISTRATION TOCHAL CREAT Hier eta MEDICAL ASSISTANCE TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION | Janwary-1-2010— DEPARTMENT OF HEALTH AND HUMAN SERVICES April 1,2010

‘5. TYPE OF PLAN MATERIAL (Check One): (NEW STATE PLAN

[1 AMENDMENT TO BE CONSIDERED AS NEW PLAN

(AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT:

Social Security Act 1917(b\1XBXii) aFFY 2010 $0.00 b.FFY 2011 $0.00

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

General Program Administrative, page 53a-1 (new) General Program Administration, page 53a

General Program Administration, page 53b

General Program Administration, page 53a s© ? 632a/ General Program Administration, page 53b

10, SUBJECT OF AMENDMENT: To comply with the requirements of section 1917(b(1)(B)(ii) of the Social Security Act, this State Plan Amendment prohibits the estate recovery of Medicare cost sharing benefits for the following categories of dual eligibles, age 55 or over:

QMB, SLMB, QI, QDWI, QMB+ and SLMB+.

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

[4] OTHER, AS SPECIFIED: AS APPROVED BY GOVERNOR

12. SIGNA’ OF STATE AGENCY OFFICIAL:

“LILLIAN B. KOLLER

16. RETURN TO:

FORM HCFA-179 (07-92)

Page 53a Revision: HCFA-PM-95-3 (MB) May 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: HAWAII

(b) Adjustments or Recoveries

The State complies with the requirements of section 1917(b) of the Act and regulations at 42 CFR 433.36 (h)-(i).

Adjustments or recoveries for Medicaid claims correctly paid are as follows:

(1) _ For permanently institutionalized individuals, adjustments or recoveries are made from the individual’s estate or upon sale of the property subject to a lien imposed because of medical assistance paid on behalf of the individual for services provided in a nursing facility, ICF/MR, or other medical institution.

D4 Adjustments or recoveries are made for all other medical assistance paid on behalf of the individual.

(2) The State determines “permanent institutional status” of individuals under the age of 55 other than those with respect to whom it imposes liens on real property under §1917 (a) (1) (B) (even if it does not impose those liens).

(3) For any individual who received medical assistance at age 55 or older, adjustments or recoveries of payments are made from the individual’s estate for nursing facility services, home and community- based services, and related hospital and prescription drug services.

xX In addition to adjustment or recovery of payments for services listed above, payments are adjusted or recovered for other services under the State Plan as listed below:

All services listed in State Plan Section 3,

“Services General Provisions”, Attachment 3.1-A and Attachment 3.1-B, for applicable individuals age 55 and over, with the exception of Medicare cost sharing identified at 4.17(b)(3)(Continued).

:

AUG 26 2010 Approval Date: Effective Date: 04/01/2010

TN No. 1 Supersedes TN No.

a

53a-1

Revision: HCFA-PM-95-3 (MB) May 1995

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: HAWAII

4.17(b)(3) (Continued)

1917(b)(1)(B)(ii) Limitations on Estate Recovery - Medicare Cost

of the Act Sharing:

(i)

(ii)

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

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

TN No.: 10-002 AUG 26 2010 Supersedes Approval Date: Effective Date: 04/01/2010

TN No.: _New

53b REVISION: HCFA-PM-95-3 (MB) May 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: HAWAII

(4) _____ The State disregards assets or resources for individuals who receive or are entitled to receive benefits under a long term care insurance policy as provided for in Attachment 2.6 — A, Supplement 8b.

X The State adjusts or recovers from the ‘individual’s estate on account of all medical assistance paid for nursing facility and other long term care services provided on behalf of the individual. (States other than California, Connecticut, Indiana, lowa and New York which provide long term care insurance policy-based asset or resource disregard must select this entry. These five States may either check this entry or one of the following entries.)

The State does not adjust or recover from the individual’s estate on account of any medical assistance paid for nursing facility or other long term care services provided on behalf of the individual.

The State adjusts or recovers from the assets or resources on account of medical assistance paid for nursing facility or other long term care services provided on behalf of the individual to the extent described below:

TN No. 10-002 G Supersedes Approval Date: AUG 26 200 Effective Date: 04/01/2010

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

Region IX

Division of Medicaid & Children’s Health Operations

90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706

MAY 0 5 2011

Patricia McManaman

Director, Department of Human Services P.O. Box 339

Honolulu, HI 96809-0339

Dear Ms. McManaman:

Enclosed is an approved copy of Hawaii State Plan Amendment (SPA) 11-001. This SPA was submitted to my office on March 31, 2011 requesting to add a new Supplement 16 to Attachment 2.6-A to describe how the State will implement an Asset Verification System (AVS) to comply with Section 1940 of the Social Security Act.

This SPA is effective September 30, 2011.

Enclosed are the following approved SPA pages that should be incorporated into your approved State Plan:

e Supplement 16 to Attachment 2.6-A, Pages | to 3

If you have any questions, please contact Brian Zolynas by phone at (415) 744-3601 or by email at Brian.Zolynas @cms.hhs.gov.

Sincerely,

v

Gloria Nagle, Ph.D., MPA ~ Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosure

cc: Kenneth Fink, Med-QUEST Administrator Keith McNamara, CMS Center for Medicaid, CHIP and Survey & Certification Mary Rydell, Pacific Area Representative

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED OMB NO. 0938-0193

HEALTH CARE FINANCING ADMINISTRATION

TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL TN 11-01 HAWAT . 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: HEALTH CARE FINANCING ADMINISTRATION SOCIAL SECURITY ACT (MEDICAID) MEDICAL ASSISTANCE TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION September 30, 2011 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): (1) NEW STATE PLAN (] AMENDMENT TO BE CONSIDERED AS NEW PLAN {] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Supplemental Appropriations Act of 2008, Section 1940 of the Social aFFY 2011 S$ 1,138,837.50 Security Act b.FFY 2012 764,99) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: _| 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTIO} OR ATTACHMENT (if Applicable): oe Supplement 16 to Attachment 2.6-A, Pages 1,2, and 3 NIA ngs

10. SUBJECT OF AMENDMENT: To implement an Asset Verification System (AVS) for the purpose of determining Medicaid eligibility for aged, blind, and disabled Medicaid applicants and recipients as required under Section 1940 of the Social Security Act.

11. GOVERNOR'S REVIEW (Check One): (2 GOVERNOR'S OFFICE REPORTED NO COMMENT [2] OTHER, AS SPECIFIED: [1] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED AS APPROVED BY GOVERNOR

(NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. — OF STATE AGENCY OFFICIAL: 16. RETURN TO:

13. TYPED NAME: PATRICIA McCMANAMAN 14, TITLE: DIRECTOR 15. DATE SUBMITTED:

March 31, 2011

FORM HCFA-179 (07-92)

Revision: SUPPLEMENT 16 TO ATTACHMENT 2.6-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Hawaii

ASSET VERIFICATION SYSTEM

1940(a) 1. The Agency will provide for the verification of assets for purposes of determining or redetermining Medicaid eligibility for aged, blind and disabled Medicaid applicants and recipients using an Asset Verification System (AVS) that meets the following minimum requirements:

A. The request and response system must be electronic:

(1) Verification inquiries must be sent electronically via the internet or similar means from the Agency to the financial institution (Fl).

(2) The system cannot be based on mailing paper-based requests.

(3) | The system must have the capability to accept responses electronically.

B. The system must be secure, based on a recognized industry standard of security (e.g., as defined by the U.S. Commerce Department's National Institute of Standards and Technology, or NIST).

Cc. The system must establish and maintain a database of Fis that participate in the Agency's AVS.

D. Verification requests also must be sent to Fis other than those identified by applicants and recipients, based on some logic such as geographic proximity to the applicant's home address, or other reasonable factors whenever the Agency determines that such requests are needed to determine or redetermine the individual's eligibility.

E. The verification requests must include a request for information on both open and closed accounts, going back up to 5 years.

TN No. 11-001 Supersedes Approval Date: MAY ) 5 211 Effective Date: September 30, 2011 TN No. . NEW

Revision: , SUPPLEMENT 16 TO ATTACHMENT 2.6-A Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Hawaii ASSET VERIFICATION SYSTEM 2. System Development A. The Agency itself will build and maintain an AVS.

In 3 below, describe how the system will meet the requirements in Section 1.

B. X____ The Agency will hire a contractor to build and maintain an AVS.

In 3 below, identify the contractor, if known, and describe how the system will meet the requirements in Section 1.

The Agency will be joining a consortium to develop an AVS.

In 3 below, identify the States participating in the consortium. Also identify the contractor, if known, who will build and maintain the consortium’s AVS, and how the system will meet the requirements in Section 1.

D. The Agency already has a system in place that meets the requirements for an acceptable AVS:

In 3 below, describe how the system meets the requirements in Section 1.

E. Other alternative not included in A. — D. above.

In 3 below, describe this alternative approach how it will meet the requirements in Section 1.

TN No. 14-001 Supersedes Approval Date: MAY 0 5 2011 Effective Date: September 30, 2011 TN No. NEW

Revision: SUPPLEMENT 16 TO ATTACHMENT 2.6-A Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Hawaii

ASSET VERIFICATION SYSTEM

3. Provide the AVS implementation description and other information requested for the implementation approach checked in Section 2.

A Request For Proposal (RFP) shall be issued to solicit participation by qualified contractors to design, develop, implement and operationalize an Asset Verification System (AVS) for purposes of determining Medicaid eligibility for aged, blind, and disabled Medicaid applicants and recipients as required under 1940 of the Social Security Act.

The AVS shall meet the requirements in Section 1 of Supplement 16 to attachment 2.6-A of the State Plan securing authorization from the applicant or recipient (and such other person, as applicable) at no cost.

The contractor shall provide the State with data reports; such as, but not limited to the following:

Number of verification requests;

Number of responses provided;

Amount of undisclosed assets discovered; and

Any other data reports necessary to meet federal reporting requirements.

aeop

TN No. 11-001 Supersedes Approval Date: MAY () 5 2011 ettective Date: September 30, 2011

TN No. NEW

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

San Francisco Regional Office (tf ° 90 Seventh Street, Suite 5-300 (5W) i San Francisco, CA 94103-6706 N

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

SEP 1 32013

Patricia McManaman

Director, Department of Human Services P.O. Box 339

Honolulu, HI 96809-0339

Dear Ms. McManaman:

Enclosed is an approved copy of Hawaii’s State Plan Amendment (SPA) 13-0007-MM1, which was submitted to CMS on July 9, 2013. SPA 13-0007-MM1 incorporates MAGI-based eligibility groups into Hawaii’s Medicaid State Plan in accordance with the Affordable Care Act. 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 Hawaii’s approved State plan:

S14, Pages 14-1, $14-2, $14-3, $14-4, $14-5, and $14-6 $25, Pages S25-1, S25-2 and $25-3

$28, Pages S28-1 and S28-2

$30, Pages $30-1, S30-2, S30-3, S30-4 and $30-5

S32, Pages $32-1 and $32-2

$33, Page S33-1

$50, Page S50-1

S51, Pages S51-1, $51-2 and $51-3

$52, Page S52-1

S53, Page S53-1

S54, Pages S54-1, 54-2 and $54-3

$55, Page S55-1

S57, Page S57-1

$59, Page S59-1

Attachment 2 (HI: Converted Thresholds), Pages Attachment 2-1, Attachment 2-2

In addition, enclosed is a summary of State Plan pages which are superseded by SPA-13-0007- MM1, which should also be incorporated into a separate section in the front of the State Plan:

e Superseding Pages of State Plan Material, 13-0007-MM1 Pages 1 and 2

Page 2 - Patricia McManaman, Director

If you have any questions, please contact Christy Bonstelle at (415)744-3522, or christy.bonstelle@cms.hhs.gov.

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

ce: Kenny Fink, Med-QUEST Administrator Tom Durran, CMS Pacific Area Representative

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0007-MM1

STATE:

Hawaii

Pages or sections of pages being superseded by S25, S28, S30, S51, S52, S53, S54, S55 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 9c, B.1 remove Page 4a “Caretaker relatives” _ Page 12 and “Pregnant women” Attachment 2.2-A Page 13 Page 20, B.14 Page 13a Page 23c, B.19 Page 14 Page 23c, B.22 Page l4a Page 25, C.4 Page 21 Page 23 Page 23b Supplement 1 to Attachment 2.2-A | Page 1 Page 3b Page 1, A.2.a(i) and Page lla (iii) Page 16 Page 6 related to AFDC Page 19 recipients, pregnant _ Page 19a women, infants, and Attachment 2.6-A Page 19b children Page 21 Page 7, 1.a(1) and (2) Page 12, 5.e(2) and (3) Page 18, 5.e Page 25, 11.a(3) Supplement 1 to Attachment 2.6-A Pages 1-4 Supplement 2 to Attachment 2.6-A Pages 1-5

Supplement 5a to Attachment 2.6-A

Page 1, “Pregnant women and children - no limit on resources”

Supplement 8a to Attachment 2.6-A

Page 1, #1

Page 1, #2 delete citations for AFDC- related groups

Page 2, delete citations for AFDC- related groups

Supplement 14 to Attachment 2.6-A

Page 1

Supplement 15 to Attachment 2.6-A

Pages 1-3

‘Hi: converted thresholds date: 09-APR-2013

jundt: original] ipopulation/type applicant type citiation size standaxd| converted standard Family - 2988 - applicant AFDC 5/1/1988 a $327 $493 : ° 2 430 $653 3 515 $795 a 601. $938 5 689 $1,083 6 780 $1,232 7 B82 $1,391, 8 942 $2,508 9 1, 000 $1,623, x0 1,059 $1,739 aL 1,439 ° $1,857 2 1,179 1, 974, 43, 2,239 2,093, Fry 1,299 2,208 5 1,359 2,925, : addon [§60 $410 4 montha AFDC 5/1/1988 x i327 397 2 430 524 3 515 633 a 601. 744 5 689 $856 G 780 ig974 7 B82 $2,097 8 942 1,181, 9 1, 000 1,263 10 1, 059 2,347 aa. 2,219 1,434 12 4,179 1,515, a3 2,239 1,599 a 1,299 1, 693 5 1,359 $1,767 addon, [$60 sai ben _8 months IAFDC 5/1/1988 a $327 388 et B 430 512 3 515 618 4 601 725 5 $689 e34 6 $780 947 ‘ 7 B82 1, 070 8 942 1,151 9 2,000 $1,230 10 1, 059 $4,320 aa 1,419 [$1,392 a2 4,179 $4,472 a3 1,239 $1,553, Fr $2,299 $1, 634 a5 $2,359 $1.715, . addon [$60 $78 Family - 1996 applicant ABDC 7/16/1996 x 418 630 2 565 ja52 3 712 2,074 a 859 2,292 5 $1, 006 $2,522 ~ G $1,153 $1,732 7 $1,300 $1,952 G 4, 446 [2,471 9 1,593 $2,392 10 1,740 $2,612 aa 1,887 $2,832 Fr $2,034 3,052 FE] 2,181 3,273 ia $2,328 3, 493 15 $2,475 3,713 addon [$146 220 ben 4 months AFDC 7/16/1996 we aie 479 a 2 565 $647 3 g7i2 $815

TN No: 13-0007-MM1 Hawaii

Approval Date: 09/13/2013 Attachment 2-1

Effective Date: 1/01/2014

TN No: Hawaii

13-0007-MM1

o $859 $983 5, $1, 006 $1,152 6 61,153 $1,319 a $1,300 $1,487 B 1, 446 $1, 654 9 1,593 $1, 823 110. 1, 740 $1,991, 44. 2, 887, $2,159, 12 $2,034 $2,327 * 43. $2,181 2,495, 24 $2,328 2, 663 15, $2,475, 2, 831 addon. 146 164 ben 8 months AFDC 7/16/1996 2 418 469 " 2 565, 634 13 3712 799 4 [$959 964 5 2,006" $1,429 6 $1,153 1, 293. 7 1,300 1, 458 8 1 446 31, 622 Ey 31, 593. 1, 787 10 2,740 $1, 952. 22 $1, 687 $2,126 12 2,034 2, 283. 13 2.1.83 2, 446 ery 2,328 32, 610 15 2 475, $2,775, addon, 246 $161 11902 (a) (10) (A) (4) (IV ) mandatozy poverty level related pregnant women icovered for Ipregnancy-related services and mandatory poverty- level related infan Pri tt and children <i 185% FPL 191% FPL 1902 (a) (10) (A) (4) (VI ) mandatory poverty- Level related children aged 1-5 Chiid 1-5 1338 FPL 139% FPL 2902 (a) (10) (A) (2) (VI I) mandatory poverty+ Level related children aged 6-18 Chita 6-18 100% FPL 105% FPL Adult 19-64 1115. 200% FPL 208% FPL IM-CHIP children <19 4.902 (a) (10) (A) (34) (X [Children <19 (>150/133/1008 ev) 300% FPL 308% FPL

Approval Date: 09/13/2013

Attachment 2-2

am

Effective Date: 1/01/2014

Enter the AFDC Standards below. All states must enter:

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

AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

The standard is as follows: © Statewide standard CO Standard varies by region © Standard varies by living arrangement © Standard varies in some other way

Medicaid Eligibility

”, OMB Control Number 0938-1148

‘OMB Expiration date: 10/31/2014

TN No: 13-0007-MM1

Hawaii

Approval Date: 09/13/2013

$14-1

Effective Date: 1/01/2014

Medicaid Eligibility

Additional incremental amount Household size | Standard ($) @ Yes ONo 493 Increment amount $ |110 653 18 _ 938 1,083 1,232 1,391 1,508 1,623 i 10 1,739 : re 1,857 4 12 1,974 113 2,091 : 14 2,208 | 15 2,325 The dollar amounts increase automatically each year O Yes @No

The standard is as follows: © Statewide standard © Standard varies by region

© Standard varies by living arrangement

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $14-2

Medicaid Eligibility

© Standard varies in some other way

Household size

Standard ($)

1418

565

712

859

1,006

1,153

1,300

1,446

1,593

#10

1,740

11

1,887

By 12

2,034

113

2,181

2,328

2,475

Additional incremental amount

@ Yes ONo

Increment amount $

146

O Yes @No

The dollar amounts increase automatically each year

The standard is as follows: CO Statewide standard

TN No: 13-0007-MM1

Hawaii

Approval Date: 09/13/2013

$14-3

Effective Date: 1/01/2014

Medicaid Eligibility

© Standard varies by region © Standard varies by living arrangement © Standard varies in some other way

The dollar amounts increase automatically each year

OYes ONo

The standard is as follows: © Statewide standard © Standard varies by region

© Standard varies by living arrangement © Standard varies in some other way

The dollar amounts increase automatically each year

© Yes ONo

The standard is as follows: © Statewide standard © Standard varies by region

© Standard varies by living arrangement © Standard varies in some other way

The dollar amounts increase automatically each year

© Yes © No

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Hawaii $14-4

Effective Date: 1/01/2014

Medicaid Eligibility

The standard is as follows: © Statewide standard CO Standard varies by region CO Standard varies by living arrangement

O Standard varies in some other way

The dollar amounts increase automatically each year

OQ Yes ONo

The standard is as follows: CO Statewide standard © Standard varies by region

© Standard varies by living arrangement

© Standard varies in some other way

The dollar amounts increase automatically each year

O Yes ONo

The standard is as follows: CO Statewide standard © Standard varies by region

© Standard varies by living arrangement © Standard varies in some other way

The dollar amounts increase automatically each year

© Yes ONo

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Hawaii $14-5

Effective Date: 1/01/2014

TN No: 13-0007-MM1

Hawaii

Medicaid Eligibility

PRA Disclos tement 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.

Approval Date: 09/13/2013 Effective Date: 1/01/2014 $14-6

Medicaid Eligibility

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

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

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

The state attests that it operates this eligibility group in accordance with the following provisions: a 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, [Xl provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

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

The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated.

Oo

Definition of domestic partner:

The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage.

O

Description of other relatives:

The definition of caretaker relative includes any adult with whom the child is living and who assumes < primary responsibility for the dependent child's care. .

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

The state elects to eliminate the requirement that a dependent child must be deprived of parental support or @ care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent.

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

.@)

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $25-1

Medicaid Eligibility

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

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

[Hl Income standard used for this group [Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in $14 AFDC Income Standards.

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

[i] Maximum income standard —

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

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

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

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115

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

© demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

TN No: 13-0007-MM1 Effective Date: 1/01/2014

Hawaii

Approval Date: 09/13/2013 $25-2

Medicaid Eligibility

© A percentage of the federal poverty level: |100 %

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

° standard is described in $14 AFDC Income Standards.

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage © increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards.

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

© Other dollar amount

[MH Income standard chosen: Indicate the state's income standard used for this eligibility group: © The minimum income standard @ The maximum income standard

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage © increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards.

© Another income standard in-between the minimum and maximum standards allowed [Mf] There is no resource test for this eligibility group. [Ml] 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.

OYes @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: 13-0007-MM1

>: Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii

$25-3

TN No: 13-0007-MM1 Approval Date: 09/13/2013

Hawaii

Medicaid Eligibility

‘- OMB Control Number 0938-1148 OMB Expiration dat 10/31/2014

42 CFR 435.116 1902(a)(10)(A)@)() and (IV) 1902(a)(10)(A)Gi)@), @V) and (XX) 1931(b) and (d)

1920

[i] Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. [Z] The state attests that it operates this eligibility group in accordance with the following provisions: [Hf 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

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

[Income standard used for this group

[i] Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

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

@ Yes ONo

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

{®] Maximum income standard

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

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

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

families), 1902(a)(10)(A)(i)@L) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- re) related pregnant women), 1902(a)(10)(A)(ii)(X) (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)(1V)

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

Effective Date: 1/01/2014 $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)(@)() (qualified pregnant women), 1902(a)(10)(A)(i)IV) {mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(LX) (optional poverty level-related pregnant women), 1902(a)(10)

© (A)Gi)( (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(Gi)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Oo 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.

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

© 185% FPL

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

[@ Income standard chosen Indicate the state's income standard used for this eligibility group: © The minimum income standard ©@© The maximum income standard © Another income standard in-between the minimum and maximum standards allowed. [lf There is no resource test for this eligibility group. [il] 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.

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

[ij Presumptive Eligibility

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

© Yes @No

PRA Disclosure Statement

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

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014

Hawaii

$28-2

TN No: 13-0007-MM4 Approval Date: 09/13/2013 Hawaii

Medicaid Eligibility

* OMB Control Number 0938-1148 _OMB Expiration date:

42 CFR 435.118

1902(a)(10)(A)(i)@D), (IV), CVI) and (VID) 1902(a)(10)(A)(ii)(IV) 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.

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

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

[Hl Income standard used for infants under age one [ Minimum income standard

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

@ Yes ONo

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

[] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for infants MZ] 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)(I1) (qualified children), 1902(a)(10)(A)(i)(TV) (mandatory poverty level-related

©) infants), 1902(a)(10)(A)Gi)(LX) (optional poverty level-related infants) and 1902(a)(10)(A)(i)QV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

$30-1 Effective Date: 1/61/2014

‘

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)(@)(H) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

@ infants), 1902(a)(10)(A)(ii)(X) (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.

re) 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.

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

© 185% FPL

Enter the amount of the maximum income standard: }191 % FPL

[i] 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)()() (qualified children), 1902(a)(10)

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

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

\e) (A)G@)(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 under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

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

re} 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.

[Mf Income standard for children age one through age five, inclusive

{Minimum income standard

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014

Hawaii

$30-2

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 staridard(s) for children [Z] age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five.

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-

oO income families), 1902(a)(10)(A)()(I) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(LV) (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-

@ income families), 1902(a)(10\(A)()() (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.

re 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.

re! 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: |139 % 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)(IM1) (qualified children),

© 1902(a)(10)(AXi)(VD) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (LV) (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)(ID) (qualified children), 1902(a)(10)(A)()(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.

oO

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014

Hawaii

$30-3

Medicaid Eligibility

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

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

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

o age one through five under a Medicaid 1115 demonstration as of December 3}, 2013, converted to a MAGI- equivalent percent of FPL. °

oO 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. [i] Income standard for children age six through age eighteen, inclusive [Hf] Minimum income standard The minimum income standard used for this age group is 133% FPL.

[i] 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

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

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 re) (low-income families), 1902(a)(10)(A)(i)(I) (qualified children), 1902(a)(10)(A)(i)(VI) (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.

fo) 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.

fo) 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: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $30-4

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)(D) (qualified children),

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

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(0) (qualified children),

2) 1902(a)(10)(A)(i)(VL) (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

1) 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.

1@)

fe) 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.

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

[i] Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity. © Yes @No

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

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Hawaii 530-5 Effective Date: 1/01/2014

Medicaid Eligibility

"OMB Control Number 0938-1148 ‘OMB Expiration date: 10/31/2

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

The state covers the Adult Group as desoribed at 42 CFR 435.119. @ Yes ONo oe fn Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. [Z| The state attests that it operates this eligibility group in accordance with the following provisions: [lf Individuals qualifying under this eligibility group must meet the following criteria:

[| Have attained age 19 but not age 65.

[Mf Are not pregnant.

[Hj Are not entitled to or enrolled for Part A or B Medicare benefits.

cl Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B.

Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible.

[i] Have household income at or below 133% FPL.

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

[Wf There is no resource test for this eligibility group.

Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is [i receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4.

OwUnder age 19, or @A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: O©vUnder age 20 @Under age 21 [ml 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.

© Yes @No

TN No: 13-0007-MM1 Hawaii

Effective Date: 1/01, Approval Date: 09/13/2013 ate: 1/01/2014

$32-1 ~

Medicaid Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148, The time required to complete this information collection is estimated to average 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: 13-0007-MM1 Effective Date: 1/01/2014

A . Hawaii Pproval Date: 09/13/2013

$32-2

CcmMsS Medicaid Eligibility

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

42 CFR 435.150 1902(a)(10)(A)G)EX)

, im 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.

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

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

{W] Are under age 26. ry 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 [Ml 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.

©OyYes @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.

OYes @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: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $33-1

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/201

1902(a)(10)(A)Gi)CKX) 1902(hh) 42, CFR 435.218

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

© Yes @No

P isclosure 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: 13-0007-MM1 Effective Date: 1/01/2014 Approval Date: 09/13/2013 $50-1

Hawaii

Medicaid Eligibility

" . QMB Control Number 0938-1148 OMB Expiration date: 10/3 1/2014

42 CFR 435.220 1902(a)(10)(A)Gi)q)

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 éstablished by the state and in accordance with provisions described at 42 CFR 435.220.

@® Yes ©No

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

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

ry Would be eligible under the state plan for the mandatory eligibility group, Parents and Other Caretaker Relatives, except for income.

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

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

[] Income standard used for this group

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

@® Yes ONo

[fl Minimum income standard

The income standard used for this eligibility group must exceed the income standard established for the mandatory

Parents and Other Caretaker Relatives eligibility group (42 CFR 435.110). Please refer as necessary to $25 Parents and Other Caretaker Relatives for the income standard chosen for that group.

[i] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for [J optionally eligible 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:

o Tbe state's effective income level for optionally eligible parents and other caretaker relatives 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 optionally eligible parents and other caretaker relatives under the Medicaid

Ostate plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii S51-1

Medicaid Eligibility

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

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

Enter the amount of the maximum income standard:

@A percentage of the federal poverty level: |200 /%

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent O standard. If this standard has not been completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

The state's TANF payment standard, converted to a MAGI-equivalent standard. If this standard has not Obeen completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

© Other dollar amount

{Hl Income standard chosen Indicate the state's income standard used for this eligibility group:

© The maximum income standard ©@ Another income standard in-between the minimum and maximum standards allowed.

The state's AFDC payment standard in effect as of July 16, 1996, not converted to a MAGI-equivalent Ovstandard. If this standard has not been completed in S14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

The state's TANF payment standard, not converted to a MAGI-equivalent standard. If this standard has not Obeen completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. Ifit has already been completed, refer to it as necessary.

If not chosen as the maximum income standard, the state's AFDC payment standard in effect as of July 16,

Oo 1996, converted to a MAGI-equivalent standard. If this standard has not been completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

If not chosen as the maximum income standard, the state's TANF payment standard, converted to a MAGI- Cequivalent standard, If this standard has not been completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

@ Other income standard in-between the minimum and the maximum standards allowed.

The amount of the income standard for this eligibility group is:

@ A percentage of the federal poverty level: 105 |%

C© Other dollar amount

[Ml There is no resource test for this eligibility group.

TN No: 13-0007-MM1

Ne: Approval Date: 09/13/2013 Effective Date: 10/01/2013

$51-2

Medicaid Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $51-3

Medicaid Eligibility

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

42 CFR 435.222

1902(a)(10)(A)Gi)@) 1902(a)(10)(A)G)CV)

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

© Yes © No

Dis State 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.

. Effective Date: N No: 13-0007-MM1 e Date: 1/01/2 wai Approval Date: 09/13/2013 /01/2014

$52-1 -

42 CFR 435.227 1902(a)(10)(A)Gi)(VIN)

Medicaid Eligibility

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

Children with Non [V-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.

O No The state attests that it operates this eligibility group in accordance with the following provisions:

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

[Bi] Are under the following age (see the Guidance for restrictions on the selection of an age):

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.

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

[lH There is no resource test for this eligibility group.

The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care;

@© Under age 21 © Under age 20 © Under age 19 © Under age 18

© No

ml 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.

© 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: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014

$53-1

Medicaid Eligibility

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

1902(a)(10)(A)(i)CXTV) 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 Jow income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229.

@ Yes ONo [7] The state attests that it operates this eligibility group in accordance with the following provisions: [ll Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group.

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.

The state covered this eligibility group in the 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 state plan as of March 23, 2010. © Yes ONo

ml Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover additional individuals. Effective October 1, 2019, states may reduce or eliminate coverage for this group.

[MJ Individuals are covered under this eligibility group, as follows: @ All children under age 18 or 19 are covered: ©@ Under age 19 © Under age 18

© The reasonable classification of children covered is: [l Income standard used for this classification [i] Minimum income standard

The income standard for this classification of children must exceed the lowest income standard chosen for children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group. ‘

[il] Maximum income standard

Approval Date: 09/13/2013 TN No: 13-0007-MM1 i TN No: 54-1 Effective Date: 1/01/2014

Medicaid Eligibility

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

>

re) 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.

© 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.

oO 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.

re) 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.

© 200% FPL.

oO A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points.

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

308 {%FPL

[Wf Income standard chosen, which must exceed the minimum income standard Individuals qualify under the following income standard:

@ The maximum income standard.

fe} The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective

© income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective © income level for this eligibility group under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective © income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

CO If higher than the effective income level used under the state plan as of March 23, 2010, 200% FPL.

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Hawaii $54-2 Effective Date: 1/01/2014

Medicaid Eligibility

If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the O FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points.

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

The income standard for this eligibility group is: 308 % FPL

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

[i] Presumptive Eligibility

Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children [Ml under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions.

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.

Approval Date: 09/13/2013 TN No: 13-0007-MM1 $54-3 Hawaii Effective Date: 1/01/2014

1902(a)(10)(A)Gi)@M)

1902(z)

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

© 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: 13-0007-MM1 Approval Pate: 79/13/2023

Hawaii Effective Date: 1/01/2014

’ [Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age

Medicaid Eligibility

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

42 CFR 435.226 1902(a)(10\(A)Gi)CXVID

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.

O Yes @No

TN No: Hawaii

PRA Di e 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.

13-0007-MM1 Approval Date: 09/13/2013 $57-1 Effective Date: 1/01/2014

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XXI) 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.

OYes @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.

Approval Date: TN No: 13-0007-MM1 Pprova ate: Oo/ 13/2013

Hawaii Effective Date: 1/01/2014

Que, Rene R. (CMS/CMCHO)

From: sea@cms.hhs.gov Sent: Friday, September 13, 2013 3:04 PM To: CMS SPA_Waivers_SanFrancisco_RO9; Corddry, Mary C. (CMS/CMCS); Dillon, Kristin C.

(CMS/CMCHO); Bonstelle, Christy A. (CMS/CMCHO); Billy, Indy A. (CMS/CMCS); Lloyd, Beth E. (CMS/CMCS); cynthia.hentz@cms.hhs.gov - Subject: State Plan / Waiver HI-13-0007MM1 has been approved

Dear RO Administrator,

This e-mail is to inform you that the State Plan/Waiver HI-13-0007MM1 from State HI and Action Due Date 10/7/2013 has been Approved.

Thank you,

SEA Admin

DO NOT REPLY TO THIS EMAIL. This email is generated from an unmonitored email account. If you received this in error or have any questions, please notify SEATechSupport@cms. hhs.gov then delete all copies of the message.

The information contained in this email message, including any attachments, is privileged information. It is intended only for the use of the individual and/or entity identified in the address of this email message. If you are not the intended recipient, or an employee or agent responsible to deliver it to the intended recipient, you are forbidden (not authorized) to read, print, retain, copy or disseminate this message or any part of it.

HI.0190.R00.00 - Jan 01, 2014

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Hawaii

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.

|HI-13-0007 ~mm|_ |

Proposed Effective Date (01/01/2014 | (mm/dd/yyyy)

8

Federal Statute/Regulation Citation 42 CFR. 435.4, 435.110, 435.116, 435.118, 435.119, 435.150, 435.218, 435.220, 435.214, 435.226, 435.227, 4:

Federal Budget Impact Federal Fiscal Year Amount ‘ lSeaoonaan nn First Year {2014 | $85392536.00 Second Year [201s $1 19936664.00 Subject of Amendment

The proposed amendments to the State Plan would implement provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010. The proposed amendments implements the following: 1) New Medicaid eligibility groups; 2) Establishes financial methodologies for determining Medicaid eligibility based on modified adjust gross income (MAGI); 3) Establish simplified and date-driven renewal polices for individuals who eligibility is based on MAGI; 4) Simplifies residency, citizenship and immigration status; and 5) Allows presumptive eligibility conducted by hospitals for certain Medicaid eligibility groups.

Note on the federal budget impact: The budget impact included on this form is the combined impact for 13- 0007MM1 - 13-0007MM7.

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: As approved by the Governor

Signature of State Agency Official Submitted By: ‘ Aileen Befitel Date Submitted: Sep 6, 2013

DATE RECEIVED:

7/09/2013

DATE APPROVED:

9/13/2013

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL:

01/01/2014

SIGNATURE OF REGIONAL OFFICIAL:

TYPED NAME

Gloria Nagle

SA pp Vr

TITLE

Associate Regional Administrator , &

Table of Contents State/Territory Name: Hawaii State Plan Amendment (SPA) #: 13-0007-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 er Centers for Medicare & Medicaid Services

San Francisco Regional Office (tf ° 90 Seventh Street, Suite 5-300 (5W) i San Francisco, CA 94103-6706 N

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

SEP 1 32013

Patricia McManaman

Director, Department of Human Services P.O. Box 339

Honolulu, HI 96809-0339

Dear Ms. McManaman:

Enclosed is an approved copy of Hawaii’s State Plan Amendment (SPA) 13-0007-MM1, which was submitted to CMS on July 9, 2013. SPA 13-0007-MM1 incorporates MAGI-based eligibility groups into Hawaii’s Medicaid State Plan in accordance with the Affordable Care Act. 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 Hawaii’s approved State plan:

S14, Pages 14-1, $14-2, $14-3, $14-4, $14-5, and $14-6 $25, Pages S25-1, S25-2 and $25-3

$28, Pages S28-1 and S28-2

$30, Pages $30-1, S30-2, S30-3, S30-4 and $30-5

S32, Pages $32-1 and $32-2

$33, Page S33-1

$50, Page S50-1

S51, Pages S51-1, $51-2 and $51-3

$52, Page S52-1

S53, Page S53-1

S54, Pages S54-1, 54-2 and $54-3

$55, Page S55-1

S57, Page S57-1

$59, Page S59-1

Attachment 2 (HI: Converted Thresholds), Pages Attachment 2-1, Attachment 2-2

In addition, enclosed is a summary of State Plan pages which are superseded by SPA-13-0007- MM1, which should also be incorporated into a separate section in the front of the State Plan:

e Superseding Pages of State Plan Material, 13-0007-MM1 Pages 1 and 2

Page 2 - Patricia McManaman, Director

If you have any questions, please contact Christy Bonstelle at (415)744-3522, or christy.bonstelle@cms.hhs.gov.

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

ce: Kenny Fink, Med-QUEST Administrator Tom Durran, CMS Pacific Area Representative

HI.0190.R00.00 - Jan 01, 2014

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Hawaii

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.

|HI-13-0007 ~mm|_ |

Proposed Effective Date (01/01/2014 | (mm/dd/yyyy)

8

Federal Statute/Regulation Citation 42 CFR. 435.4, 435.110, 435.116, 435.118, 435.119, 435.150, 435.218, 435.220, 435.214, 435.226, 435.227, 4:

Federal Budget Impact Federal Fiscal Year Amount ‘ lSeaoonaan nn First Year {2014 | $85392536.00 Second Year [201s $1 19936664.00 Subject of Amendment

The proposed amendments to the State Plan would implement provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010. The proposed amendments implements the following: 1) New Medicaid eligibility groups; 2) Establishes financial methodologies for determining Medicaid eligibility based on modified adjust gross income (MAGI); 3) Establish simplified and date-driven renewal polices for individuals who eligibility is based on MAGI; 4) Simplifies residency, citizenship and immigration status; and 5) Allows presumptive eligibility conducted by hospitals for certain Medicaid eligibility groups.

Note on the federal budget impact: The budget impact included on this form is the combined impact for 13- 0007MM1 - 13-0007MM7.

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: As approved by the Governor

Signature of State Agency Official Submitted By: ‘ Aileen Befitel Date Submitted: Sep 6, 2013

DATE RECEIVED: 7/09/2013

DATE APPROVED:

9/13/2013

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL:

01/01/2014

SIGNATURE OF REGIONAL OFFICIAL:

TYPED NAME

Gloria Nagle

TITLE ;

Associate Regional Administrator , &

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0007-MM1

STATE:

Hawaii

Pages or sections of pages being superseded by S25, S28, S30, S51, S52, S53, S54, S55 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 9c, B.1 remove Page 4a “Caretaker relatives” _ Page 12 and “Pregnant women” Attachment 2.2-A Page 13 Page 20, B.14 Page 13a Page 23c, B.19 Page 14 Page 23c, B.22 Page l4a Page 25, C.4 Page 21 Page 23 Page 23b Supplement 1 to Attachment 2.2-A | Page 1 Page 3b Page 1, A.2.a(i) and Page lla (iii) Page 16 Page 6 related to AFDC Page 19 recipients, pregnant _ Page 19a women, infants, and Attachment 2.6-A Page 19b children Page 21 Page 7, 1.a(1) and (2) Page 12, 5.e(2) and (3) Page 18, 5.e Page 25, 11.a(3) Supplement 1 to Attachment 2.6-A Pages 1-4 Supplement 2 to Attachment 2.6-A Pages 1-5

Supplement 5a to Attachment 2.6-A

Page 1, “Pregnant women and children - no limit on resources”

Supplement 8a to Attachment 2.6-A

Page 1, #1

Page 1, #2 delete citations for AFDC- related groups

Page 2, delete citations for AFDC- related groups

Supplement 14 to Attachment 2.6-A

Page 1

Supplement 15 to Attachment 2.6-A

Pages 1-3

Enter the AFDC Standards below. All states must enter:

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

AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

The standard is as follows: © Statewide standard CO Standard varies by region © Standard varies by living arrangement © Standard varies in some other way

Medicaid Eligibility

”, OMB Control Number 0938-1148

‘OMB Expiration date: 10/31/2014

TN No: 13-0007-MM1

Hawaii

Approval Date: 09/13/2013

$14-1

Effective Date: 1/01/2014

Medicaid Eligibility

Additional incremental amount Household size | Standard ($) @ Yes ONo 493 Increment amount $ |110 653 18 _ 938 1,083 1,232 1,391 1,508 1,623 i 10 1,739 : re 1,857 4 12 1,974 113 2,091 : 14 2,208 | 15 2,325 The dollar amounts increase automatically each year O Yes @No

The standard is as follows: © Statewide standard © Standard varies by region

© Standard varies by living arrangement

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $14-2

Medicaid Eligibility

© Standard varies in some other way

Household size

Standard ($)

1418

565

712

859

1,006

1,153

1,300

1,446

1,593

#10

1,740

11

1,887

By 12

2,034

113

2,181

2,328

2,475

Additional incremental amount

@ Yes ONo

Increment amount $

146

O Yes @No

The dollar amounts increase automatically each year

The standard is as follows: CO Statewide standard

TN No: 13-0007-MM1

Hawaii

Approval Date: 09/13/2013

$14-3

Effective Date: 1/01/2014

Medicaid Eligibility

© Standard varies by region © Standard varies by living arrangement © Standard varies in some other way

The dollar amounts increase automatically each year

OYes ONo

The standard is as follows: © Statewide standard © Standard varies by region

© Standard varies by living arrangement © Standard varies in some other way

The dollar amounts increase automatically each year

© Yes ONo

The standard is as follows: © Statewide standard © Standard varies by region

© Standard varies by living arrangement © Standard varies in some other way

The dollar amounts increase automatically each year

© Yes © No

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Hawaii $14-4

Effective Date: 1/01/2014

Medicaid Eligibility

The standard is as follows: © Statewide standard CO Standard varies by region CO Standard varies by living arrangement

O Standard varies in some other way

The dollar amounts increase automatically each year

OQ Yes ONo

The standard is as follows: CO Statewide standard © Standard varies by region

© Standard varies by living arrangement

© Standard varies in some other way

The dollar amounts increase automatically each year

O Yes ONo

The standard is as follows: CO Statewide standard © Standard varies by region

© Standard varies by living arrangement © Standard varies in some other way

The dollar amounts increase automatically each year

© Yes ONo

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Hawaii $14-5

Effective Date: 1/01/2014

TN No: 13-0007-MM1

Hawaii

Medicaid Eligibility

PRA Disclos tement 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.

Approval Date: 09/13/2013 Effective Date: 1/01/2014 $14-6

Medicaid Eligibility

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

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

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

The state attests that it operates this eligibility group in accordance with the following provisions: a 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, [Xl provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

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

The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated.

Oo

Definition of domestic partner:

The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage.

O

Description of other relatives:

The definition of caretaker relative includes any adult with whom the child is living and who assumes < primary responsibility for the dependent child's care. .

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

The state elects to eliminate the requirement that a dependent child must be deprived of parental support or @ care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent.

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

.@)

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $25-1

Medicaid Eligibility

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

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

[Hl Income standard used for this group [Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in $14 AFDC Income Standards.

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

[i] Maximum income standard —

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

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

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

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115

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

© demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

TN No: 13-0007-MM1 Effective Date: 1/01/2014

Hawaii

Approval Date: 09/13/2013 $25-2

Medicaid Eligibility

© A percentage of the federal poverty level: |100 %

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

° standard is described in $14 AFDC Income Standards.

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage © increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards.

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

© Other dollar amount

[MH Income standard chosen: Indicate the state's income standard used for this eligibility group: © The minimum income standard @ The maximum income standard

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage © increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards.

© Another income standard in-between the minimum and maximum standards allowed [Mf] There is no resource test for this eligibility group. [Ml] 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.

OYes @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: 13-0007-MM1

>: Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii

$25-3

TN No: 13-0007-MM1 Approval Date: 09/13/2013

Hawaii

Medicaid Eligibility

‘- OMB Control Number 0938-1148 OMB Expiration dat 10/31/2014

42 CFR 435.116 1902(a)(10)(A)@)() and (IV) 1902(a)(10)(A)Gi)@), @V) and (XX) 1931(b) and (d)

1920

[i] Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. [Z] The state attests that it operates this eligibility group in accordance with the following provisions: [Hf 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

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

[Income standard used for this group

[i] Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

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

@ Yes ONo

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

{®] Maximum income standard

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

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

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

families), 1902(a)(10)(A)(i)@L) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- re) related pregnant women), 1902(a)(10)(A)(ii)(X) (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)(1V)

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

Effective Date: 1/01/2014 $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)(@)() (qualified pregnant women), 1902(a)(10)(A)(i)IV) {mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(LX) (optional poverty level-related pregnant women), 1902(a)(10)

© (A)Gi)( (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(Gi)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Oo 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.

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

© 185% FPL

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

[@ Income standard chosen Indicate the state's income standard used for this eligibility group: © The minimum income standard ©@© The maximum income standard © Another income standard in-between the minimum and maximum standards allowed. [lf There is no resource test for this eligibility group. [il] 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.

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

[ij Presumptive Eligibility

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

© Yes @No

PRA Disclosure Statement

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

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014

Hawaii

$28-2

TN No: 13-0007-MM4 Approval Date: 09/13/2013 Hawaii

Medicaid Eligibility

* OMB Control Number 0938-1148 _OMB Expiration date:

42 CFR 435.118

1902(a)(10)(A)(i)@D), (IV), CVI) and (VID) 1902(a)(10)(A)(ii)(IV) 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.

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

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

[Hl Income standard used for infants under age one [ Minimum income standard

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

@ Yes ONo

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

[] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for infants MZ] 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)(I1) (qualified children), 1902(a)(10)(A)(i)(TV) (mandatory poverty level-related

©) infants), 1902(a)(10)(A)Gi)(LX) (optional poverty level-related infants) and 1902(a)(10)(A)(i)QV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

$30-1 Effective Date: 1/61/2014

‘

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)(@)(H) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

@ infants), 1902(a)(10)(A)(ii)(X) (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.

re) 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.

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

© 185% FPL

Enter the amount of the maximum income standard: }191 % FPL

[i] 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)()() (qualified children), 1902(a)(10)

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

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

\e) (A)G@)(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 under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

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

re} 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.

[Mf Income standard for children age one through age five, inclusive

{Minimum income standard

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014

Hawaii

$30-2

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 staridard(s) for children [Z] age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five.

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-

oO income families), 1902(a)(10)(A)()(I) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(LV) (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-

@ income families), 1902(a)(10\(A)()() (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.

re 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.

re! 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: |139 % 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)(IM1) (qualified children),

© 1902(a)(10)(AXi)(VD) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (LV) (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)(ID) (qualified children), 1902(a)(10)(A)()(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.

oO

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014

Hawaii

$30-3

Medicaid Eligibility

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

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

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

o age one through five under a Medicaid 1115 demonstration as of December 3}, 2013, converted to a MAGI- equivalent percent of FPL. °

oO 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. [i] Income standard for children age six through age eighteen, inclusive [Hf] Minimum income standard The minimum income standard used for this age group is 133% FPL.

[i] 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

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

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 re) (low-income families), 1902(a)(10)(A)(i)(I) (qualified children), 1902(a)(10)(A)(i)(VI) (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.

fo) 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.

fo) 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: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $30-4

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)(D) (qualified children),

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

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(0) (qualified children),

2) 1902(a)(10)(A)(i)(VL) (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

1) 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.

1@)

fe) 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.

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

[i] Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity. © Yes @No

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

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Hawaii 530-5 Effective Date: 1/01/2014

Medicaid Eligibility

"OMB Control Number 0938-1148 ‘OMB Expiration date: 10/31/2

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

The state covers the Adult Group as desoribed at 42 CFR 435.119. @ Yes ONo oe fn Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. [Z| The state attests that it operates this eligibility group in accordance with the following provisions: [lf Individuals qualifying under this eligibility group must meet the following criteria:

[| Have attained age 19 but not age 65.

[Mf Are not pregnant.

[Hj Are not entitled to or enrolled for Part A or B Medicare benefits.

cl Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B.

Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible.

[i] Have household income at or below 133% FPL.

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

[Wf There is no resource test for this eligibility group.

Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is [i receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4.

OwUnder age 19, or @A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: O©vUnder age 20 @Under age 21 [ml 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.

© Yes @No

TN No: 13-0007-MM1 Hawaii

Effective Date: 1/01, Approval Date: 09/13/2013 ate: 1/01/2014

$32-1 ~

Medicaid Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148, The time required to complete this information collection is estimated to average 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: 13-0007-MM1 Effective Date: 1/01/2014

A . Hawaii Pproval Date: 09/13/2013

$32-2

CcmMsS Medicaid Eligibility

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

42 CFR 435.150 1902(a)(10)(A)G)EX)

, im 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.

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

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

{W] Are under age 26. ry 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 [Ml 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.

©OyYes @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.

OYes @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: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $33-1

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/201

1902(a)(10)(A)Gi)CKX) 1902(hh) 42, CFR 435.218

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

© Yes @No

P isclosure 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: 13-0007-MM1 Effective Date: 1/01/2014 Approval Date: 09/13/2013 $50-1

Hawaii

Medicaid Eligibility

" . QMB Control Number 0938-1148 OMB Expiration date: 10/3 1/2014

42 CFR 435.220 1902(a)(10)(A)Gi)q)

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 éstablished by the state and in accordance with provisions described at 42 CFR 435.220.

@® Yes ©No

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

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

ry Would be eligible under the state plan for the mandatory eligibility group, Parents and Other Caretaker Relatives, except for income.

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

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

[] Income standard used for this group

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

@® Yes ONo

[fl Minimum income standard

The income standard used for this eligibility group must exceed the income standard established for the mandatory

Parents and Other Caretaker Relatives eligibility group (42 CFR 435.110). Please refer as necessary to $25 Parents and Other Caretaker Relatives for the income standard chosen for that group.

[i] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for [J optionally eligible 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:

o Tbe state's effective income level for optionally eligible parents and other caretaker relatives 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 optionally eligible parents and other caretaker relatives under the Medicaid

Ostate plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii S51-1

Medicaid Eligibility

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

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

Enter the amount of the maximum income standard:

@A percentage of the federal poverty level: |200 /%

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent O standard. If this standard has not been completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

The state's TANF payment standard, converted to a MAGI-equivalent standard. If this standard has not Obeen completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

© Other dollar amount

{Hl Income standard chosen Indicate the state's income standard used for this eligibility group:

© The maximum income standard ©@ Another income standard in-between the minimum and maximum standards allowed.

The state's AFDC payment standard in effect as of July 16, 1996, not converted to a MAGI-equivalent Ovstandard. If this standard has not been completed in S14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

The state's TANF payment standard, not converted to a MAGI-equivalent standard. If this standard has not Obeen completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. Ifit has already been completed, refer to it as necessary.

If not chosen as the maximum income standard, the state's AFDC payment standard in effect as of July 16,

Oo 1996, converted to a MAGI-equivalent standard. If this standard has not been completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

If not chosen as the maximum income standard, the state's TANF payment standard, converted to a MAGI- Cequivalent standard, If this standard has not been completed in $14 AFDC Income Standards, complete and submit it with this eligibility group. If it has already been completed, refer to it as necessary.

@ Other income standard in-between the minimum and the maximum standards allowed.

The amount of the income standard for this eligibility group is:

@ A percentage of the federal poverty level: 105 |%

C© Other dollar amount

[Ml There is no resource test for this eligibility group.

TN No: 13-0007-MM1

Ne: Approval Date: 09/13/2013 Effective Date: 10/01/2013

$51-2

Medicaid Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014 Hawaii $51-3

Medicaid Eligibility

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

42 CFR 435.222

1902(a)(10)(A)Gi)@) 1902(a)(10)(A)G)CV)

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

© Yes © No

Dis State 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.

. Effective Date: N No: 13-0007-MM1 e Date: 1/01/2 wai Approval Date: 09/13/2013 /01/2014

$52-1 -

42 CFR 435.227 1902(a)(10)(A)Gi)(VIN)

Medicaid Eligibility

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

Children with Non [V-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.

O No The state attests that it operates this eligibility group in accordance with the following provisions:

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

[Bi] Are under the following age (see the Guidance for restrictions on the selection of an age):

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.

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

[lH There is no resource test for this eligibility group.

The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care;

@© Under age 21 © Under age 20 © Under age 19 © Under age 18

© No

ml 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.

© 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: 13-0007-MM1 Approval Date: 09/13/2013 Effective Date: 1/01/2014

$53-1

Medicaid Eligibility

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

1902(a)(10)(A)(i)CXTV) 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 Jow income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229.

@ Yes ONo [7] The state attests that it operates this eligibility group in accordance with the following provisions: [ll Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group.

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.

The state covered this eligibility group in the 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 state plan as of March 23, 2010. © Yes ONo

ml Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover additional individuals. Effective October 1, 2019, states may reduce or eliminate coverage for this group.

[MJ Individuals are covered under this eligibility group, as follows: @ All children under age 18 or 19 are covered: ©@ Under age 19 © Under age 18

© The reasonable classification of children covered is: [l Income standard used for this classification [i] Minimum income standard

The income standard for this classification of children must exceed the lowest income standard chosen for children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group. ‘

[il] Maximum income standard

Approval Date: 09/13/2013 TN No: 13-0007-MM1 i TN No: 54-1 Effective Date: 1/01/2014

Medicaid Eligibility

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

>

re) 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.

© 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.

oO 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.

re) 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.

© 200% FPL.

oO A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points.

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

308 {%FPL

[Wf Income standard chosen, which must exceed the minimum income standard Individuals qualify under the following income standard:

@ The maximum income standard.

fe} The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective

© income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective © income level for this eligibility group under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective © income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

CO If higher than the effective income level used under the state plan as of March 23, 2010, 200% FPL.

TN No: 13-0007-MM1 Approval Date: 09/13/2013 Hawaii $54-2 Effective Date: 1/01/2014

Medicaid Eligibility

If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the O FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points.

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

The income standard for this eligibility group is: 308 % FPL

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

[i] Presumptive Eligibility

Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children [Ml under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions.

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.

Approval Date: 09/13/2013 TN No: 13-0007-MM1 $54-3 Hawaii Effective Date: 1/01/2014

1902(a)(10)(A)Gi)@M)

1902(z)

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

© 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: 13-0007-MM1 Approval Pate: 79/13/2023

Hawaii Effective Date: 1/01/2014

’ [Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age

Medicaid Eligibility

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

42 CFR 435.226 1902(a)(10\(A)Gi)CXVID

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.

O Yes @No

TN No: Hawaii

PRA Di e 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.

13-0007-MM1 Approval Date: 09/13/2013 $57-1 Effective Date: 1/01/2014

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XXI) 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.

OYes @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.

Approval Date: TN No: 13-0007-MM1 Pprova ate: Oo/ 13/2013

Hawaii Effective Date: 1/01/2014

‘Hi: converted thresholds date: 09-APR-2013

jundt: original] ipopulation/type applicant type citiation size standaxd| converted standard Family - 2988 - applicant AFDC 5/1/1988 a $327 $493 : ° 2 430 $653 3 515 $795 a 601. $938 5 689 $1,083 6 780 $1,232 7 B82 $1,391, 8 942 $2,508 9 1, 000 $1,623, x0 1,059 $1,739 aL 1,439 ° $1,857 2 1,179 1, 974, 43, 2,239 2,093, Fry 1,299 2,208 5 1,359 2,925, : addon [§60 $410 4 montha AFDC 5/1/1988 x i327 397 2 430 524 3 515 633 a 601. 744 5 689 $856 G 780 ig974 7 B82 $2,097 8 942 1,181, 9 1, 000 1,263 10 1, 059 2,347 aa. 2,219 1,434 12 4,179 1,515, a3 2,239 1,599 a 1,299 1, 693 5 1,359 $1,767 addon, [$60 sai ben _8 months IAFDC 5/1/1988 a $327 388 et B 430 512 3 515 618 4 601 725 5 $689 e34 6 $780 947 ‘ 7 B82 1, 070 8 942 1,151 9 2,000 $1,230 10 1, 059 $4,320 aa 1,419 [$1,392 a2 4,179 $4,472 a3 1,239 $1,553, Fr $2,299 $1, 634 a5 $2,359 $1.715, . addon [$60 $78 Family - 1996 applicant ABDC 7/16/1996 x 418 630 2 565 ja52 3 712 2,074 a 859 2,292 5 $1, 006 $2,522 ~ G $1,153 $1,732 7 $1,300 $1,952 G 4, 446 [2,471 9 1,593 $2,392 10 1,740 $2,612 aa 1,887 $2,832 Fr $2,034 3,052 FE] 2,181 3,273 ia $2,328 3, 493 15 $2,475 3,713 addon [$146 220 ben 4 months AFDC 7/16/1996 we aie 479 a 2 565 $647 3 g7i2 $815

TN No: 13-0007-MM1 Hawaii

Approval Date: 09/13/2013 Attachment 2-1

Effective Date: 1/01/2014

TN No: Hawaii

13-0007-MM1

o $859 $983 5, $1, 006 $1,152 6 61,153 $1,319 a $1,300 $1,487 B 1, 446 $1, 654 9 1,593 $1, 823 110. 1, 740 $1,991, 44. 2, 887, $2,159, 12 $2,034 $2,327 * 43. $2,181 2,495, 24 $2,328 2, 663 15, $2,475, 2, 831 addon. 146 164 ben 8 months AFDC 7/16/1996 2 418 469 " 2 565, 634 13 3712 799 4 [$959 964 5 2,006" $1,429 6 $1,153 1, 293. 7 1,300 1, 458 8 1 446 31, 622 Ey 31, 593. 1, 787 10 2,740 $1, 952. 22 $1, 687 $2,126 12 2,034 2, 283. 13 2.1.83 2, 446 ery 2,328 32, 610 15 2 475, $2,775, addon, 246 $161 11902 (a) (10) (A) (4) (IV ) mandatozy poverty level related pregnant women icovered for Ipregnancy-related services and mandatory poverty- level related infan Pri tt and children <i 185% FPL 191% FPL 1902 (a) (10) (A) (4) (VI ) mandatory poverty- Level related children aged 1-5 Chiid 1-5 1338 FPL 139% FPL 2902 (a) (10) (A) (2) (VI I) mandatory poverty+ Level related children aged 6-18 Chita 6-18 100% FPL 105% FPL Adult 19-64 1115. 200% FPL 208% FPL IM-CHIP children <19 4.902 (a) (10) (A) (34) (X [Children <19 (>150/133/1008 ev) 300% FPL 308% FPL

Approval Date: 09/13/2013

Attachment 2-2

am

Effective Date: 1/01/2014

Table of Contents State/Territory Name: Hawaii State Plan Amendment (SPA) #: 13-0007-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

San Francisco Regional Office

90 Seventh Street, Suite 5-300 (5W)

San Francisco, CA 94103-6706

a I,

-CMS

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

Patricia McManaman SEP 1 3 2013 Director, Department of Human Services

P.O. Box 339 ,

Honolulu, HI 96809-0339

Dear Ms. McManaman:

Enclosed is an approved copy of Hawaii’s State Plan Amendment (SPA) 13-0007-MM6, which was submitted to CMS on July 9, 2013. SPA 13-0007-MM6 incorporates citizenship and non- citizen eligibility requirements into Hawaii’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of the SPA is October 1, 2013.

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

e $89, Pages S89-1, S89-2 and $89-3

In addition, enclosed is a summary of State Plan pages which are superseded by SPA-13-0007- MM6, which should also be incorporated into a separate section in the front of the State Plan:

e Superseding Pages of State Plan Material, 13-0007-MM6

If you have any questions, please contact Christy Bonstelle at (415)744-3522, or christy.bonstelle@cms.hhs.gov.

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

cc: Kenny Fink, Med-QUEST Administrator Tom Durran, CMS Pacific Area Representative

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Hawaii

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. :

Proposed Effective Date (10/01/2013 i(mm/dd/yyyy)

°

Federal Statute/Regulation Citation (42 CFR. 435.4, 435.110, 435.116, 435,118, 435.119, 435.150, 435.218, 435.220, 435.214, 435.226, 435.227, 4.

Federal Budget Impact Federal Fiscal Year Amount First Year [2014 __| 9(85392536.00 | / Second Year [2015] s(f19936664.00 | Subject of Amendment

The proposed amendments to the State Plan would implement provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010. The proposed amendments implements the following: 1) New Medicaid eligibility groups; 2) Establishes financial methodologies for determining Medicaid eligibility based on modified adjust gross income (MAGI); 3) Establish simplified and date-driven renewal polices for individuals who eligibility is based on MAGI; 4) Simplifies residency, citizenship and immigration status; and 5) Allows presumptive eligibility conducted by hospitals for certain Medicaid eligibility groups.

Note on the federal budget impact: The budget impact included on this form is the combined impact for 13- 0007MM1 - 13-0007MM7.

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:

As approved by the Governor

Signature of State Agency Official

Submitted By: ' Aileen Befitel Date Submitted: Sep 6, 2013

DATE RECEIVED:

7/09/2013

DATE APPROVED: 9/13/2013

PLAN APPROVED - ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL:

10/1/2013

SIGNATURE OF REGIONAL OFFICIAL:

TYPED NAME

Gloria Nagle

a. ll Ue

Associate Regional Administrator

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0007-MM6 Hawaii

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT : ;

S89 Citizenship and Non-Citizenship Eligibility Template

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

.

Attachment 2.6-A: Page 2, item (3), paragraphs (a) , (b), and (c), TN 09-003

Attachment 2.6-A: Page 3, item (3) (d), (e), and (£), TN 09-003

Oe _ CemMs. Medicaid Eligibility

* “OMB Control Number 0938-1148 OMB Expiration

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 [7] CER 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status.

[il 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 [ml] 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 im 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 ONo

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 C©No The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. ©The date the reasonable opportunity notice is sent.

© Other date, as described:

TN No: 13-0007-MMG6 Approval Date: 09/13/2013 Effective Date: 10/01/2013 $89-1

Hawaii

cms. 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 ONo

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.

@®yYes ONo Pregnant women Individuals under age 21: OIndividuals under age 21 O Individuals under age 20 @ Individuals under age 19

im 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.

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

2. Is anon-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 | year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

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

rl 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;

[MH] Granted employment authorization under 8 CFR 274a.12(c);

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

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

{ll Granted an administrative stay of removal under 8 CFR 241;

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

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

[ll Has been granted employment authorization; or

[Wil Is under the age of 14 and has had an application pending for at least 180 days;

TN No: 13-0007-MM6 Approval Date: 09/13/2013 Effective Date: 10/01/2013 Hawaii $89-2 coments

Medicaid Eligibility

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 ULS.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));

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.

(11 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:

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

ia 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.

Approval Date: 09/13/2013 Effective Date: 10/01/2013 TN No: 13-0007-MM6 S89-3 Hawaii

Table of Contents State/Territory Name: Hawaii State Plan Amendment (SPA) #: 13-0007 MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

November 18, 2015 Dr. Judy Mohr Peterson Med-QUEST Division Administrator MQD/Admin P.O. Box 700190 Kapolei, HI 96709-0190

Dear Dr. Peterson,

Enclosed is an approved copy of Hawaii’s State Plan Amendment (SPA) 13-0007-MM7, which was submitted to my office on July 9, 2013. This SPA proposes to implement presumptive eligibility conducted by hospitals in the Medicaid state plan in accordance with the Affordable Care Act. The approval of this SPA is effective January 1, 2014.

Attached are copies of the State Plan pages to be incorporated into Hawaii’s approved State Plan: • S21, page 1-3 • Hospital PE Application • Hospital PE Training Materials

Please note that there is also a companion letter included in this approval package. This companion letter specifies the anticipated implementation date of Hawaii’s hospital-based presumptive eligibility program.

If you have any questions, please contact Christy Bonstelle at (415) 744-3522 or christy.bonstelle@cms.hhs.gov.

Sincerely,

/s/

Henrietta Sam-Louise

Acting Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Cc: Tom Duran, CMS Pacific Area Representative

Edie Mayeshiro, Med-QUEST Program and Policy Development Office

Aileen Befitel, Med-QUEST Program and Policy Development Office

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

November 18, 2015

Dr. Judy Mohr Peterson Med-QUEST Division Administrator MQD/Admin P.O. Box 700190 Kapolei, HI 96709-0190

Dear Dr. Peterson,

This letter is being sent as a companion to our approval of Hawaii’s State Plan Amendment (SPA) 13-0007-MM7, which proposes to implement presumptive eligibility conducted by hospitals in the Medicaid state plan in accordance with the Affordable Care Act. This amendment was submitted on July 9, 2013 and has an effective date of January 1, 2014.

Section 1902(a) of the Social Security Act (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 describing the nature and scope of the state’s Medicaid Program and that it contain all information necessary for the Centers for Medicare & Medicaid Services (CMS) to determine whether the plan can be approved to serve as the basis for Federal financial participation (FFP) in the state program. While the SPA is approvable, CMS’ analysis determined that additional changes related to the state’s implementation of the hospital presumptive eligibility provision are needed in the Hawaii Medicaid state plan.

As set forth in Section 1902(a)(47)(B) of the Social Security Act, states must provide a program for hospitals that choose to provide hospital presumptive eligibility determinations, effective January 1, 2014, as codified in the Section 2202 of the Affordable Care Act. Hawaii has provided sufficient SPA pages and supporting materials in the HI-13-0007-MM7 submission to show that it has policies in place and can begin to train hospitals as qualified entities, allowing CMS to approve this SPA. CMS acknowledges that Hawaii plans to start training hospitals in November 2015. Further, the state expects to begin accepting hospital PE determinations from qualified hospitals and allowing hospital PE determinations on or before December 1, 2015, so we are giving the state time to come into compliance with its approved state plan, which has an effective date of January 1, 2014.

Within 30 days of this letter, please reply to CMS to acknowledge receipt and provide an update on the state’s training and implementation efforts. If you have any questions, please contact Christy Bonstelle at (415) 744-3522 or christy.bonstelle@cms.hhs.gov.

Sincerely,

/s/

Henrietta Sam-Louise

Acting Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

cc: Tom Duran, CMS Pacific Area Representative

Edie Mayeshiro, Med-QUEST Program and Policy Development Office

Aileen Befitel, Med-QUEST Program and Policy Development Office

State/Territory name: Hawaii Submitted By: Aileen Befitel Last Revision Date: Nov 9, 2015 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. HI-13-0007 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 C.F.R. 435.4, 435.110, 435.116, 435.118, 435.119, 435.150, 435.218, 435.220, 435.214, 435.226, 435.227, 4 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 85392536.00 Second Year 2015 $ 119936664.00 Subject of Amendment The proposed amendments to the State Plan would implement provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010. The proposed amendments implements the following: 1) New Medicaid eligibility groups; 2) Establishes financial methodologies for determining Medicaid eligibility based on modified adjust gross income (MAGI); 3) Establish simplified and date-driven renewal polices for individuals who eligibility is based on MAGI; 4) Simplifies residency, citizenship and immigration status; and 5) Allows presumptive eligibility conducted by hospitals for certain Medicaid eligibility groups. Note: The Federal Budget Impact, Federal Statute/Regulation Citation, and the Subject of Amendment fields included on this CMS-179 form is combined information for SPAs 13-0007MM1 to 13-0007MM7. 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: As approved by the Governor Signature of State Agency Official

Page 1 of 3 Medicaid Eligibility Transmittal Number: 13 State Name: Hawaii OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 07 - 0000 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ 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 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. Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: ■ Pregnant Women ■ Infants and Children under Age 19 ■ Parents and Other Caretaker Relatives ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 TN No: 13-0007-MM7 Hawaii Approval Date S21-1 Effective Date: January 1, 2014 November 18, 2015

Page 2 of 3 Medicaid Eligibility The state establishes standards for qualified hospitals making presumptive eligibility determinations. Yes No Select one or both: The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. Description of standards: 1. An 85% accuracy rate for correctly determined applications for HPE. This will be determined analyzing the HPE applications submitted by the hospital and evaluated for accuracy by EB staff; 2. 90% of individuals are offered help from hospital PE staff to complete the full Medicaid application; 3. 90% of hospital PE applicants will either submit a DHS 1100 application or an attestation sheets (completed by hospital staff for individuals who did not want to apply for regular Medicaid); and 4. 90% of hospital PE application packets shall be submitted timely (within 5 days from submission of HPE application) by the participating hospital to Med-QUEST Eligibility Branch. 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. The presumptive period begins on the date the determination is made. ■ 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. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No 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. An attachment is submitted. TN No: 13-0007-MM7 Hawaii Approval Date S21-2 Effective Date: January 1, 2014 November 18, 2015

Page 3 of 3 Medicaid Eligibility 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 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) ■ 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 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. ✔ 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. V.20140415 TN No: 13-0007-MM7 Hawaii Approval Date S21-3 Effective Date: January 1, 2014 November 18, 2015

State of Hawaii Department of Human Services Med-QUEST Division Please use this form to apply if you are a patient of the hospital, a patient’s family member, or a community member. Application for Presumptive Eligibility for Medicaid Use this form to find out quickly if you qualify for presumptive eligibility for Medicaid. Presumptive eligibility offers you and your family immediate access to health care while you apply for regular Medicaid or other health coverage. To find out if you qualify for regular Medicaid or other health coverage, you must complete the Hawaii Application for Health Coverage & Help Paying Costs. While you wait to learn if you qualify for regular Medicaid or other health coverage, you can get your health services through presumptive eligibility for Medicaid. You can also apply for regular Medicaid and other health coverage online at mybenefit.hawaii.gov, via telephone, in person, or by mail. Who can qualify for presumptive eligibility for Medicaid? You can qualify for presumptive eligibility for Medicaid if you meet all of these rules: • Your income is below the applicable monthly limit. • You are a U.S. citizen, U.S. national, or eligible non-citizen. • You do not already have Medicaid. • You have not had presumptive eligibility for Medicaid in the past 12 months. • If you are pregnant, you have not had presumptive eligibility for Medicaid during this pregnancy. • You are in one of the groups that qualifies for presumptive eligibility for Medicaid: • Children under 19 years of age • Parents and caretaker relatives • Pregnant women • Other adults age 19 – 64 years • People under age 26 who were in foster care How can I get help with this application? Ask your hospital representative or call us toll free at 1-800-316- 8005. If you need help in a language other than English, call toll free at 1-800-316-8005 and tell the customer services representative the language you need. We will get you help at no cost to you. TTY/TTD users call toll free at 1-800-603-1201. TN No: 13-0007 MM7 Approval Date: Effective Date: January 1, 2014 Hawaii

HPE Application - 1 November 18, 2015

TN No: 13-0007 MM7 Approval Date: Effective Date: January 1, 2014 Hawaii

HPE Application - 2 This is an important letter from the Department of Human Services. Please call the phone number located on the letter. When you call, you will be asked what language you speak and your call will be put on hold for an interpreter. You can also call 1-800-316-8005 for all DHS services. English 這是一封從人類服務部門發出的重要信件。請撥打信上的電話號碼。當你打電話時，你將會被詢問你講什麼語言，您的通話 將被擱置直到接通翻譯服務。其他人類服務部門的服務, 您可以致電到 1-800-316-8005. Cantonese Ei taropwe mi auchchea seni ewe putain tumwunun aramas (Department of Human Services). Kose mwochen kokkori na nampan foon won na taropwe. Nupwen omw kokko, repwe eisinuk menni kkapas ke sine pwe repwe kkutta ngonuk emon choon chiaku. Ka pwan tongeni kokkori 1-800-316-8005 ren meinisin aninnis seni DHS. Chuukese Ceci est une lettre importante du Department of Human Services (DHS). S'il vous plaît, faire un appel téléphonique au numéro de téléphone situé sur la lettre. Lorsque vous téléphonez, quelqu'un va vous demander quelle langue vous parlez, et votre appel sera mis en attente pour un interprète. Vous pouvez aussi téléphoner 1-800-316-8005 pour tous les services de DHS. French Dies ist eon wichtiger Brief von der Abteilung Menschlicher Dienste (DHS). Bitte rufen Sie die Telefonnummer, die auf dem Brief gefunden wurde. Wenn Sie rufen, werden Sie gefragt werden, welche Sprache Sie sprechen, und Ihr Anruf wird auf Wartestellung für einen Dolmetscher geschaltet werden. Sie können 1-800-316-8005 für alle DHS Dienste auch rufen. German He leka ko'iko'i keia mai ka 'Oihana Lawelawe Kanaka (Department of Human Services). E kelepona mai i ka helu kelepona ma luna o ka leka. Ke kelepona 'oe, e ninau 'ia ana 'oe he aha kau 'olelo 'oiwi a laila e kali 'oe a loa'a ke kanaka mahele 'olelo. Hiki pu ia 'oe ke kelepona i 1-800-316-8005 no na lawelawe a pau a ka 'Oihana Lawelawe Kanaka (DHS). Hawaiian Daytoy ket importante nga surat nga naggapu iti Department of Human Services. Pangaasi nga tawagan yo iti numero iti telepono nga nakakabil iti daytoy nga surat. Nu umawag kayo, saludsuden da nu anya iti panagsasao yo ket urayen yo nga maiyallatiw iti tawag yo iti intepreter. Mabalin kayo nga umawayg iti 1-800-316-8005 para kadagiti amin nga serbisyo iti DHS. Ilocano ハワイ州人道的奉仕局からの大切なお知らせです。 この紙面に書かれている番号にお電話ください。 電話を された時 に、貴方がどの言語を話されているかを聞かれます、 通訳に接続 されるまでしばらくお待ち ください。 ＤＨＳのどの サービスにも、 この電話番号 1-800-316-8005 で対応いたします. Japanese 인간 서비스 부서에서 보내는 중요한 편지 입니다. 이편지에 기재된 전화번호로 전화를 하시요. 당신이 전화를 할때 당신이 사용하는 언어를 물을것이고 그언어의 통역인에게 연결할것 입니다. 당신은 모든 인간 서비스 부서(디에이치에스)에 도움을 받기 위해서1-800-316-8005 로 전화 할수 있읍니다 Korean 这是一封从人类服务部门发出的重要信件。请拨打信上的电话号码。当你打电话时，你将会被询问你讲什 么语言， 您的通话将被搁置直到接通翻译服务。其他人类服务部门的服务, 您可以致电到 1-800-316-8005。 Mandarin Juon in kojela im elap an aurok im ej itok jen ra eo an department of human services. Jouij im call e nomba in im ej bed ilo pepa in ak letta in. Ne koj call, renej kajitok ibbem kin kain kajin eo am im elikin am ba renej ba kwon kottar bwe ren lewoj juon am ri okok. Komaron call 1-800-316-8005 non aolepen ra ko kajojo ilo DHS services. Marshallese O se fa'asilasilaga ta'ua lenei mai le Ofisa o le Human Services. Fa'amolemole, vala'au mai i le numera lea o lo'o i luga o lenei tusi. A e vala'au mai, o le a fesili atu po'o le a le gagana e te mo'omia, ona tu'u sa'o lea o lau telefoni i se tagata e mafai ona fesoasoani ia oe. E mafai fo'i ona e vala'au i le number 1-800-316-8005 mo nisi 'au'aunaga mai lenei Ofisa." Samoan Ésta es una carta importante de la Sección de Servicios Humanos (DHS). Por favor llame el número de teléfono localizado en la carta. Cuando usted llama, usted se preguntará qué idioma usted habla y su llamada se pondrá en espera para un intérprete. Usted también puede llamar 1-800-316-8005 para todos los servicios de DHS. Spanish Ito ay mahalaga na sulat na galling sa Department of Human Services. Mangyaring tawagan ang numero na nakalagay sa sulat na ito. Kung kayo ay tatawag , tatanungin kung ano ang iyong wika at hintayin ninyo hanggat may sumagot na tagasalin. Pwede ninyong tumawag sa 1-800-316-8005 para sa lahat ng serbisio sa Tagalog Ko e tohi mahu'inga eni mei he Potungaue Ngaue Ma'ae Kakai. Kataki 'o telefoni ki he fika 'oku ha 'i he tohi ni. 'E fehu'i atu pe ko e ha e fa'ahinga lea 'oku ke lea'aki 'i he taimi te ke ta mai ai pea tnitokoe ke tali kae 'oua kuo ma'u ha toko taha fakatonu lea. Te ke lava 'o ta ki he ki he ngaahi tokoni kotoa 'a e DHS. Tongan Ðây là lá thơ quang trọng từ các Bộ Phục Vụ Nhân Dân (DHS). Làm ơn gọi xố điện thoại nằm trên lá thơ. Khi bạn gọi, bạn sẻ được hỏi ngôn ngữ nào bạn nói và cú điện thoại của bạn sẻ chờ người thông dịch. Ðồng thời bạn củng có thể gọi số 1- 800-316-8005 cho các phục vụ DHS. Vietnamese Việt Nam Kini importante nga sulat gikan sa Department of Human Services (DHS). Palihug tawagi ang numero sa maong telepono nga nahimutang sa sulat. Sa imong pagtawag, ikaw pangutan-on kun unsa ang imong pinulongan ug ang imong tawag ilang ipahulat para sa usa ka taghubad sa pinulongan. Mahimo usab nga imong tawagan ang 1-800- 316-8005 para sa tanang mga serbisyo sa DHS. Visayan November 18, 2015

STEP 1 STEP 2

We need one adult in the family to be the contact person for your application. 1. First Name Middle name Last name Suffix 2. Home address (Leave blank if you don’t have one.) 3. Apartment or suite number 4. City 5. State 6. ZIP code 7. County 8. Mailing address (if different from home address) 9. Apartment or suite number 10. City 11. State 12. ZIP code 13. County 14. Phone number ( ) 15. Other phone number ( ) 16. Do you want to get information about this application by email? Yes No Email address: _________________________________________________ 17. What is your preferred spoken language (if not English)? 18. What is your preferred written language (if not English) List yourself and the members of your immediate family who live with you. Include your spouse, your children under the age of 19 years if they live with you and anyone you include on your tax return, even if they don’t live with you. Name (first, middle, last) Date of birth (XX/XX/XXXX) Relationship to you Applying for presumptive eligibility for Medicaid? (Yes or No) Already has Medicaid or other medical insurance? (Yes or No) U.S. Citizen, U.S. National or eligible Non-citizen? (Yes or No) Resident of Hawaii (Yes or No) Social Security Number (SSN) (You don’t have to provide this now, but it helps us determine eligibility for regular Medicaid faster) Answer for family members who are applying. If a person is not applying, you do not have to answer these questions for that person. (Same as above) (Self) Tell us about yourself. Tell us about your family. TN No: 13-0007 MM7 Approval Date: Effective Date: January 1, 2014 Hawaii

HPE Application - 3 November 18, 2015

STEP 3 STEP 4

Answer these questions for yourself and your family members listed in Step 2. Your answers will make it easier to find out if you and any family member(s) qualify. Is anyone pregnant who is applying for presumptive eligibility for Medicaid? Yes  No If yes, who?__________________________________________________________________ How many babies does she expect?________ Is anyone who is applying for presumptive eligibility for Medicaid receiving Medicare or Social Security Income (SSI)? Yes  No If yes, who?__________________________________________________________________ Is anyone who is applying for presumptive eligibility for Medicaid a parent or caretaker relative? For example, a grandparent who is the main person taking care of a child. Yes  No If yes, who?__________________________________________________________________ Was anyone who is applying for presumptive eligibility for Medicaid in foster care at age 18? Yes  No If yes, who? __________________________________________________________________

Write the total income before taxes are taken for all family members listed in Step 2. ♦ Job income: For example, wages, salaries, and self-employment income. Amount $ How often? (check one)  Weekly  Biweekly  Monthly  Yearly ♦ Other income For example, unemployment checks, alimony, or disability payments from the Social Security Administration (“SSDI”). Do not include Supplemental Security Income (“SSI payments”) or any child support you receive. Amount $ How often? (check one)  Weekly  Biweekly  Monthly  Yearly Other questions. Tell us about your family’s income. TN No: 13-0007 MM7 Approval Date: Effective Date: January 1, 2014 Hawaii

HPE Application - 4 November 18, 2015

STEP 5 STEP 6 STEP 7

• I’m signing this application under penalty of perjury which means I’ve provided true answers to all questions this form to the best of my knowledge. I know that I may be subject to penalties under state or federal law if I provide false or untrue information. • I understand that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, secual orientation, gender identity, or disability. I can file a compliant of discribmiation by visiting www.hhs.gov/ocr/office/file. • The person who filled out Step 1 should sign this application. Signature Date (mm/dd/yyyy)

• You will get a notice from the hospital saying you were approved. • You can start using your presumptive eligibility for Medicaid coverage right away for Medicaid covered services such as doctor visits, hospital care, and some prescription drugs. You can go to any health care provider who accepts Medicaid starting the day you are approved. To start using your presumptive eligibility for Medicaid, use your approval notice from the hospital saying you are approved. • To see if you qualify for regular Medicaid or other health coverage, the hospital will help you fill out the Hawaii Application for Health Coverage & Help Paying Costs, if you choose. You can also apply for regular Medicaid and other health coverage online at mybenefit.hawaii.gov, via telephone, in person, or by mail. • Your presumptive eligibility will end on the date your application for Medicaid is either approved or denied. If you are denied, you will be referred to the Connector for other affordable insurance programs. • If you do not fill out and submit the Hawaii Application for Health Coverage & Help Paying Costs to see if you qualify for regular Medicaid or other health coverage, your presumptive eligibility for Medicaid coverage will end on the last day of the month after the month you are approved. For example, if you qualified for presumptive eligibility for Medicaid in January, it will end on the last day of February.

You will get a notice from the hospital saying you were not approved. You cannot appeal the hospital’s decision. But you can still apply for regular Medicaid or other health coverage using the Hawaii Application for Health Coverage & Help Paying Costs. Read & sign this application. If you qualify for presumptive eligibility for Medicaid, what happens next? If you do not qualify for presumptive eligibility for Medicaid, what happens next? TN No: 13-0007 MM7 Approval Date: Effective Date: January 1, 2014 Hawaii

HPE Application - 5 November 18, 2015

Hospital Presumptive Eligibility in Hawaii TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 1 November 18, 2015

Overview • What is Hospital Presumptive Eligibility (HPE)? • How hospitals can participate in HPE • Hospital staff eligible to make HPE determinations • Who is eligible and what are the HPE benefits? • How the HPE Process works • Contact information TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 2 November 18, 2015

ACA Coverage Changes The Affordable Care Act (ACA) was signed into law in March 2010; it makes major changes to how people secure health coverage in the U.S. Coverage changes include: – Medicaid and CHIP expansion and improvements – Health insurance marketplaces for individuals and small businesses – Private insurance market reforms TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 3 November 18, 2015

The New Vision for Medicaid and CHIP • Medicaid Coverage Expansion – Covers adults 19-64 with incomes up to 133% FPL who are not eligible and enrolled in a mandatory group • Single, Streamlined Application – Individuals can apply for Marketplace coverage and all insurance affordability programs (Medicaid, CHIP, premium tax credits) on one application • Simplified Eligibility and Enrollment Rules – Modified Adjusted Gross Income (MAGI) is the new income methodology based on IRS- defined concepts of income and household to determine Medicaid and CHIP eligibility for children, pregnant women, parents and caretaker relatives, and adults 19-64 • Modernized Eligibility Systems – Increases use of automated rules engines to enable real-time eligibility determinations; individuals can apply for coverage online • Children’s Coverage Improvements – All children up to age 19 with family incomes up to 133% FPL are now Medicaid-eligible • Hospital Presumptive Eligibility – Hospitals can now determine individuals to be presumptively eligible for Medicaid 4 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

HPE Overview TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 5 November 18, 2015

What Is Hospital Presumptive Eligibility (HPE)? • As of January 1, 2014, hospitals can immediately determine Medicaid eligibility for certain individuals who are likely to be eligible. • Eligibility under HPE is temporary but allows immediate access to coverage for eligible individuals. • The policies and procedures for determining HPE may differ from the current policies and procedures for determining regular Medicaid assistance. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 6 November 18, 2015

Terms and Definitions • Application Signature: The application must be signed by an adult household member (age 18 or over) or by an authorized representative. • Application Submission: Applications may be submitted in person, by mail, or by fax. • Certain Individuals Needing Treatment for Breast or Cervical Cancer: An individual who has been screened by an authorized CDC approved facility and requires treatment for breast or cervical cancer or a precancerous condition of the breast or cervix. • Dependent Child: A child from birth to age 19 • Eligibility Determination: An approval or denial of eligibility. • Family Size Using Modified Adjusted Gross Income (MAGI) Methodology: Means the number of persons counted as members of an individual’s household. When determining the family size of individuals who have a pregnant woman in their household, the pregnant woman is counted just as herself. 7 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

Terms and Definitions • Former Foster Care Child: An individual who is 18 to 26 years of age, not eligible for any other Medicaid coverage group, and was covered under Medicaid and in foster care when they turned age 18 or out of foster care. • Modified Adjusted Gross Income (MAGI): The methodology used to determine financial eligibility. • Non-Applicant: An individual who is not seeking an eligibility determination for himself or herself and is included in an applicant’s or client’s household to determine eligibility for such applicant or client. • Non-Filer: Individuals who do not intend either to file taxes or to be claimed as a tax dependent. 8 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

Terms and Definitions • Parent/Caretaker Relative: A relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care, and who is one of the following: The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece; The spouse of such parent or relative including same sex marriage, even after the marriage is terminated by death or divorce; or Another relative of the child based on blood, adoption, or marriage; the domestic partner of the parent or caretaker relative; or an adult with whom the child is living and who assumes primary responsibility for the dependent child’s care. 9 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

Terms and Definitions • Pregnant Woman Hospital Presumptive Eligibility: Medical coverage for an individual eligible in the Pregnant Women group is limited to prenatal services that are provided on an outpatient basis. For coverage of full Medicaid benefits, a pregnant woman must apply for regular Medicaid assistance. • Tax Dependent: An individual for whom another individual claims a deduction for a personal exemption for a taxable year. • Tax Filer: Individuals who intend to file a federal tax return for the coverage year and who do not intend to be claimed as a tax dependent by another taxpayer. 10 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

How HPE Works to Get People Connected to Coverage and Care • HPE improves individuals’ access to Medicaid and necessary services by providing another channel to apply for medical coverage. • Hospitals will be reimbursed for services provided during the PE period. • HPE is not about short-term coverage; it provides individuals with an opportunity to get connected to longer-term coverage options. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 11 November 18, 2015

How Hospitals Can Participate in HPE TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 12 November 18, 2015

How Hospitals Can Participate in HPE • Hospital participation in HPE is optional, but States must provide a mechanism for a hospital to become qualified to offer the HPE program. • To make HPE determinations, a hospital must: Participate in the Medicaid program; Notify the State of its election to make HPE determinations by contacting the Program Administrator; Designated staff must complete HPE training modules; Agree to make HPE determinations consistent with policies and procedures of the State by signing an attestation form; Maintain performance standards set by State; and Have a signed Memorandum of Agreement (MOA) with the Department on file. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 13 November 18, 2015

Hospital Staff Eligible to Make HPE Determinations • Once a hospital is a qualified entity: Any hospital employee who is properly trained and certified can make HPE determinations. • Participating hospitals may not delegate HPE determinations to non-hospital staff: Third party vendors or contractors may not make HPE determinations. • Eligibility determinations will be based on MAGI non-filer rules: The household’s size will be determined by counting the individual plus their spouse and natural, adopted and step-children under age 19, or up to age 26 if a full time student, who are living together in the same household and who are not expected to be claimed by another tax-filer. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 14 November 18, 2015

How Will Hospitals Be Trained? The Department will use a Medicaid training module consisting of: • This powerpoint presentation, which provides an overview of the Hospital Presumptive Eligibility (HPE) program and application for full Medicaid requirements for participating hospital staff; • HPE Workshop conducted by assigned DHS staff. The Department will conduct additional training(s) to address hospital deficiencies after initial implementation of HPE : • Department staff will monitor hospital ability to meet performance standards; • Additional training will focus on areas that need improvement or additional guidance. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 15 November 18, 2015

Workshop and Training will include: • Overview of HPE and regular Medicaid programs; • Roles and responsibilities for the Hospital and Eligibility branch; • Explanation of performance standards and requirements; • Eligibility requirements for HPE, Children, Pregnant Women, Parent Caretaker Relatives, Adults, Former Foster Care Children and Certain Individuals Needing Treatment for Breast or Cervical Cancer * coverage groups; • How to complete the HPE application form, DHS 1100, and other applicable Medicaid forms; • The HPE eligibility determination process using MAGI non-filer rules for household composition and income eligibility; • How to prepare and submit the HPE packet to EB for processing; • All bases of coordination between hospital and Med-QUEST required to process for HPE (assigned staff, contact numbers, etc). * Hospital must be designated as a CDC approved screening site for BCCEDP TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 16 November 18, 2015

Process for Staff Training and Certification • Hospitals must select staff for training and certification and provide list of names for Department; • Hospitals must coordinate with Med-QUEST to arrange for training of staff; • Selected staff must attend Department approved HPE/Medicaid Workshop and Training; • Staff must complete Department approved workshop and training and become certified in order to make HPE determinations; • Staff must sign agreement to comply with all MOA requirements for participation in the HPE program; • Certified hospital staff will be able to determine eligibility and issue notice of approval for HPE coverage to eligible individuals. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 17 November 18, 2015

HPE Accuracy and Performance Standards Hospitals shall be required to maintain the following performance standards to participate in the HPE program: 1) An 85% accuracy rate for correctly determined applications for HPE. This will be determined analyzing the HPE applications submitted by the hospital and evaluated for accuracy by EB staff; 2) 90% of individuals are offered help from hospital PE staff to complete the full Medicaid application; 3) 90% of hospital PE applicants will either submit a DHS 1100 application or an attestation sheets (completed by hospital staff for individuals who did not want to apply for regular Medicaid); and 4) 90% of hospital PE application packets shall be submitted timely (within 5 days from submission of HPE application) by the participating hospital to Med-QUEST Eligibility Branch. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 18 November 18, 2015

HPE Performance Standards • The Department shall initially authorize a “Phase in “ period to help hospitals reach required performance standards without penalty for initial 6-12 months of HPE program implementation. • The Department shall analyze initial performance standards and focus training on areas that are not meeting requirements. Hospitals not meeting HPE program requirements will complete additional training in deficient areas. If still unable to meet standards after additional training, hospital will be subject to disqualification from the HPE program. • The Department has the authority to terminate hospital participation in the HPE program for failure to meet Department policies and established standards, including failure to participate in additional training when deficiencies are identified. 19 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

Who is Eligible to Enroll in Medicaid through HPE? What are the Benefits? TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 20 November 18, 2015

Populations Eligible for Medicaid via HPE Determinations • Individuals who fall into one of the following MAGI groups may be determined for HPE: Children, Pregnant Women, Parents and Caretaker relatives, Adults, Former Foster Care Children and Certain Individuals Certain Individuals Needing Treatment for Breast or Cervical Cancer who are: • Not currently receiving Medicaid benefits and have not had a PE period in the last 12 months or for the same pregnancy (for a pregnant woman); • A Hawaii resident; and • A U.S. citizen or qualified non-citizen who meets Medicaid citizenship status requirements. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 21 November 18, 2015

Criteria for Determining HPE Eligibility The current MAGI rules are used to determine the following: • Household Size; • Coverage Group; and • Financial Eligibility. • The Department will use non-filer MAGI rules when determining financial eligibility for the HPE program. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 22 November 18, 2015

HPE Income Eligibility Chart 2015 Standards of Assistance HH Size Parents or Caretaker Relatives Adults/ Children 6-19 Children 1 < 6 Pregnant Women/ Child < 1 SCHIP Children < 19 100% 105%* 133% 138%* 139% 144%* 191% 196%* 308% 313%* 1 $1,130 $1,186 $1,502 $1,502 $1,570 $1,626 $2,157 $2,157 $3,478 $3,535 2 $1,528 $1,528 $2,032 $2,032 $2,124 $2,200 $2,918 $2,918 $4,705 $4,782 3 $1,926 $1,926 $2,562 $2,562 $2,677 $2,774 $3,679 $3,679 $5,932 $6,028 4 $2,325 $2,325 $3,092 $3,092 $3,231 $3,347 $4,440 $4,440 $7,159 $7,275 5 $2,723 $2,723 $3,621 $3,621 $3,785 $3,921 $5,200 $5,200 $8,386 $8,522 6 $3,121 $3,121 $4,151 $4,151 $4,338 $4,494 $5,961 $5,961 $9,613 $9,769 7 $3,520 $3,520 $4,681 $4,681 $4,892 $5,068 $6,722 $6,722 $10,840 $11,015 8 $3,918 $3,918 $5,211 $5,211 $5,446 $5,642 $7,483 $7,483 $12,066 $12,262 9 $4,317 $4,317 $5,741 $5,741 $6,000 $6,215 $8,244 $8,244 $13,293 $13,509 10 $4,707 $4,707 $6,270 $6,270 $6,553 $6,789 $9,005 $9,005 $14,520 $14,756 Each Add'l Person $399 $419 $530 $550 $554 $574 $761 $781 $1,227 $1,247 * Maximum allowable income with 5% disregard applied to the income standard as applicable. Note: 1) Former Foster Care Children have no income limit; 2) Financial eligibility for Certain Individuals Needing Treatment For Breast or Cervical Cancer is not subject to Medicaid income limits. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 23 November 18, 2015

Countable Income Includes: • Wages, salaries, tips, etc. ; • Taxable interest; • Alimony; • Business income; • Capital gains; • Unemployment benefits; • Rental real estate, royalties, partnerships, S corporations, etc. ; • Other taxable income. *ASSETS ARE NOT COUNTED FOR THE MAGI ELIGIBILITY GROUPS TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 24 November 18, 2015

Non-Tax Filer MAGI rules Non-Tax filer MAGI rules will be used to determine financial eligibility for HPE applicants, regardless of their actual tax filing status. To determine household size, count the following household members: a. Applicant (and if living with the applicant): • Spouse • Child(ren)* under age 19 years b. If applicant is under age 19 (and if living with the applicant): • Spouse • Child(ren)* under age 19 years; • Parent(s)* • Sibling(s)* under age 19 years *Includes natural or biological, adopted, or step (parent/child/sibling). For sibling, includes half- sibling. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 25 November 18, 2015

Determination of Household size, Income and Coverage Group 1) Evan (age 29) is applying for coverage for himself, his pregnant wife, Keira (age 26), and their daughter, Lilly (age 3) who all live together. Evan states he earns $1800 per month from his job. Keira does not work. Although Evan and Keira intend to file jointly, MAGI non-filer rules are applied to determine eligibility for HPE . 2) Evan and Keira have daughter Lily, so are first determined for eligibility under the Parent/Caretaker Group. If not eligible in this group, would be considered under another applicable coverage group (i.e. Adults). Lilly is under age 6, therefore, she is determined for eligibility under the Childrens Group (Child 1<6). TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 26 November 18, 2015

Determination of Household size, Income and Coverage Group (Cont’d) 3) Using the HPE Income Eligibility chart: • Evan and Keira’s income of $1,800 < $1,926 Parent/Caretaker Group standard for a household size of 3, therefore, they are eligible under this coverage group. • Lilly’s income of $1,800 < $2,677 Children Group standard for a household size of 3, therefore she is eligible under this group. 4) Tax household composition, size and coverage groups for Evan, Keira, & Lilly are shown below: HH Evan Keira Lilly Family Size Income Coverage Group Evan X X X 3 $1,800 Parent/Caretaker Keira X X X 3 $1,800 Parent/Caretaker Lilly X X X 3 $ 1,800 Children TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 27 November 18, 2015

What are the Benefits? Individuals approved for presumptive eligibility receive the same Medicaid services as the group they are approved for under the Medicaid State Plan and 1115 Waiver as applicable. However, for individuals eligible in the Pregnant Women group, presumptive eligibility is limited to ambulatory prenatal care only. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 28 November 18, 2015

Duration of Eligibility under HPE • The HPE period begins with, and includes, the day on which the hospital makes the HPE determination. • The HPE period ends on: The day on which the eligibility site makes the eligibility determination for full Medicaid; or The last day of the month following the month in which the hospital makes the HPE determination if the individual did not apply for Medicaid. • The HPE period is limited to one in a 12 month period and/or once per pregnancy for a pregnant woman. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 29 November 18, 2015

How The HPE Process Works TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 30 November 18, 2015

Hospital PE Application • The HPE application is a short application form for individuals to apply for hospital presumptive eligibility. It requests minimal information such as: Contact information Household members Total income for the household • For individuals with no previous Medicaid ID number, a temporary ID number will be created using the hospital’s provider ID + the last 4 digits of the individual’s SSN until a Medicaid ID number is generated by Med-QUEST staff; • Hospital shall log all HPE applications and send monthly data to Med-QUEST for monitoring purposes. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 31 November 18, 2015

Verification of Eligibility Criteria • Hospital Presumptive Eligibility determinations will be based on self- attestation of required information; • Individual cannot be required to provide proof/documentation of any HPE eligibility criteria (e.g., can’t require medical verification of pregnancy); • Hospital/Department must accept self-attestation of income, citizenship/immigration status, State residency and household size. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 32 November 18, 2015

The HPE Determination Process At the individual’s initial visit, trained hospital staff shall: • Check for current Medicaid eligibility by contacting the Enrollment Call Center for applicable information (Medicaid status, Medicaid ID number, Health plan); • If already a Medicaid recipient, refer applicant to appropriate health plan for assistance, not eligible for HPE; • If not a Medicaid recipient, determine if individual meets HPE eligibility requirements for appropriate coverage group; • Self-attestation of previous or current Medicaid eligibility shall be accepted during non-business hours; • If HPE requirements are met, help the individual complete the HPE application form for HPE. If determined ineligible for HPE, explain benefits of “regular” Medicaid and offer to help applicant complete the DHS 1100, “Application for Health Coverage & Help Paying Costs” form for submission to Med-QUEST if interested in applying; TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 33 November 18, 2015

The HPE Determination Process (cont’d) • Complete HPE eligibility determination and give applicant approval notice verifying applicant’s HPE eligibility, coverage group and effective date of HPE coverage; • Explain to applicant that the notice will serve as verification of eligibility for applicant; • Offer assistance to applicant to apply for regular Medicaid by completing the DHS 1100 form. • If applicant chooses not to apply for Medicaid, indicate this on the “Attestation sheet for DHS 1100” and sign in the field indicated on the bottom of the sheet. • If applicant wants to apply for regular Medicaid, assist with application form and have HPE applicant sign and date the “Attestation sheet for DHS 1100”; and • Submit with the HPE packet to the EB unit. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 34 November 18, 2015

Create HPE packet to send to Med- QUEST Upon completion of the HPE determination, hospital staff shall: 1) Create HPE packet to fax to appropriate EB office consisting of: • Completed and signed HPE packet cover sheet; • Completed HPE application • HPE decision notice; • Completed DHS 1100 if applicable; and • Completed Attestation sheet for DHS 1100 2) Record HPE application on hospital HPE log and date information is faxed to EB; 3) Fax complete packet to the appropriate Med-QUEST office within 5 days for HPMMIS input and determination of regular Medicaid; and 4) Keep hard copies of HPE packets for future reference. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 35 November 18, 2015

Hospital PE Application TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 36 November 18, 2015

Hospital PE Application TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 37 November 18, 2015

Hospital PE Application TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 38 November 18, 2015

Sample Approval Letter TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 39 November 18, 2015

Sample Denial Letter 40 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

Attestation Sheet for DHS 1100 41 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

Sample of Cover Letter 42 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 November 18, 2015

DHS 1100 Application for Health Coverage & Help Paying Costs TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 43 November 18, 2015

DHS 1100 Application for Health Coverage & Help Paying Costs TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 44 November 18, 2015

DHS 1100 Application for Health Coverage & Help Paying Costs TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 45 November 18, 2015

DHS 1100 Application for Health Coverage & Help Paying Costs TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 46 November 18, 2015

DHS 1100 Application for Health Coverage & Help Paying Costs TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 47 November 18, 2015

DHS 1100 Application for Health Coverage & Help Paying Costs TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 48 November 18, 2015

DHS 1100 Application for Health Coverage & Help Paying Costs TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 49 November 18, 2015

Med-QUEST Responsibilities Upon receipt of the HPE packet sent by the participating hospital, the Med-QUEST office shall: • Log receipt of HPE packet and input information from HPE application and decision notice into the KOLEA system within 48 hours of receipt; • Review DHS 1100 and determine eligibility for regular Medicaid or pend for verifications if needed; • Upon receipt of required verifications, complete eligibility determination for regular Medicaid. • Send appropriate Medicaid approval or denial notice to HPE beneficiary and a copy to HPE hospital staff who submitted the HPE packet • Terminate HPE benefits pursuant to hospital PE period from date the eligibility determination for regular Medicaid is determined. • If an HPE application is received with no DHS 1100 attached, input information in KOLEA, and terminate HPE effective the last day of the month following the month of HPE application. TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 50 November 18, 2015

Connecting to Full Medicaid Coverage Outside the Hospital Individuals can also apply for full Medicaid coverage as follows: • Online at mybenefits.Hawaii.gov or by calling 1-877-628-5076; • In-person at the nearest Med-QUEST Eligibility Branch office; • By mailing the paper application to the Med-QUEST Eligibility Branch office closest to their home; • By faxing the paper application to 587-3543; or • By calling Medicaid customer service on Oahu: 524-3370 , TDD: 692- 7182, Neighbor Islands : 1-800-316-8005, TDD: 1-800-603-1201 TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 51 November 18, 2015

Contact Information For questions or more information on Hawaii’s Hospital Presumptive Eligibility policies, providers may contact: Policy and Program Development Office Phone: 808-692-8058, Fax: 808-692-8173 Information is also available on the Department’s website: www.Med-QUEST.us- Program information TN NO: 13-007-MM7 Approval Date Effective Date: January 1, 2014 52 November 18, 2015

Table of Contents State/Territory Name: Hawaii State Plan Amendment (SPA) #: 13-0008-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services a San Francisco Regional Office i 90 Seventh Street, Suite 5-300 (5W) .

San Francisco, CA 94103-6706 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

Patricia McManaman, Director Oct 9 5 2013 Department of Human Services ‘

P.O. Box 339

Honolulu, HI 96809-0339

Dear Ms. McManaman:

Enclosed is an approved copy of Hawaii’s State Plan Amendment (SPA) 13-0008-MM, which was submitted to CMS on July 12, 2013. SPA 13-0008-MM incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Hawaii’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA 13-0008-MM includes full approval of your state’s paper alternative single streamlined application. The State is using an interim online alternative single streamlined application and by March 31, 2014 will implement a revised online alternative single streamlined application that addresses CMS’ concerns outlined in the companion letter issued with this SPA approval.

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

e Alternative single, streamlined paper application: Application for Health Coverage and Help Paying Costs; Things to Know page and pages 1-7; Appendix A, Health Coverage from Jobs; Employer Coverage Tool; Appendix B, American Indian or Alaska native Family Member (AI/AN); Appendix C, Assistance with Completing this Application;

e Application for Health Insurance & Help Paying Costs (Short Form), Things to Know and pages 1-3; Appendix C Assistance with Completing this Application

e S94, pages $94-1 and S94-2; which includes the statements noted below:

o Statement related to Coordination of Eligibility and Enrollment o Statements of use with respect to the alternative single, streamlined online application

Page 2 - Patricia McManaman, Director

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 Christy Bonstelle at 415-744-3522, or by e-mail at Christy.Bonstelle@cms.hhs.gov.

Sincerely,

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

ce: Kenny Fink, Med-QUEST Administrator Tom Duran, CMS Pacific Area Representative

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Hawaii

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. 13-0008 ~ mM |

Proposed Effective Date 10/01/2013

(mm/dd/yyyy)

Federal Statute/Regulation Citation ‘42 C.F.R. 435, Subpart J and Subpart M

Federal Budget Impact Federal Fiscal Year Amount . moan. | First Year [2014 $0.00 | Second Year {2015 $0.00 | Subject of Amendment

The proposed amendments to the State Plan would implement provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010. The proposed amendments implements the new eligibility process as described in 42 C.F.R 435, Subpart J and Subpart M.

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: As approved by the Governor

Signature of State Agency Official Submitted By: Aileen Befitel Last Revision Date: Oct 16, 2013 Submit Date: Jul 12, 2013

DATE RECEIVED: DATE APPROVED:

7/12/2013 10/25/2013 PLAN APPROVED — ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: 10/1/2013 . TYPED NAME TITL

Gloria Nagle Associate Regional Administrator

Medicaid Eligibility

OMB Control Number 0938-1148

OMB Expiration date: 10/31/2014 1894)

42 CFR 435, Subpart J and Subpart M

Eligibility Process

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

Application Processing

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

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

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

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

An 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

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

RZ 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: 13-0008-MM

Approval Date: 10/25/2013 Effective Date: 10/1/2013 Hawaii

$94-1

Page 1 of 2

Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description Facsimile The agency accepts applications received via facsimile. E-mail The agency accepts applications received via e-mail.

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

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

[®] Once every 12 months

im 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.

cl 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 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 tesources, 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: 13-0008-MM Approval Date: 10/25/2013 Effective Date: 10/1/2013 Hawaii $94-2 Page 2 of 2

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application & Online Application TRANSMITTAL NUMBER: STATE: 13-0008-MM Hawaii

Through March 31, 2014, the state is using an interim online alternative single streamlined application. After March 31, 2014, the state will use a revised online alternative single streamlined application, which will address the issues outlined in the CMS letter dated October 1, 2014 concerning the state’s application. The revised application will be incorporated by reference into the state plan.

— Tab

At ects resronce

Application for Health Coverage & Help Paying Costs

Heatth Core .gov —> mybenchts, hawaii . Ary 1-BOO- UXK-WUKK—P 1- F717 - 023 -Se7o

PLEASE REFER TO ATTACHMENT 3

v. 7/12/13

THINGS TO KNOW

.?)

Use this application to see what coverage choices you qualify for

Who can use this application?

Apply faster online

What you may need to apply

Why do we ask for this information?

What happens next?

Get help with this application

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

* Anew tax credit that can immediately heip pay your premiums for health coverage

* Free or low-cost insurance from Medicaid or the Children's Health insurance Program (CHIP) You may qualify for a free or low-cost program even If you earn as much as $94,000 a year (for a family of 4).

* Use this application to apply for anyone in your family.

* Apply even if you or your child already has health coverage. You could be eligible for iower-cost or free coverage.

* tf you're single, you may be able to use a short form.

Visit HealthCare.gov.

* Families that include immigrants can apply. You can apply for your child even if you aren't eligible for coverage. Apptying won't affect your immigration status or chances of becoming a permanent resident or citizen.

* If someone is helping you fill out this application, you may need to complete Appendix C.

Apply faster online at HeaithCare.gov.

+ Social Security Numbers (or document numbers for any legal immigrants who need insurance)

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

« Policy numbers for any current health insurance

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

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

Send your complete, signed application to the address on page 7.

If you don’t have all the Information we ask for, sign and submit your application anyway. We'll follow-up with you within 1-2 weeks. You'll get instructions on the next steps to complete your health coverage. If you don’t hear from us, visit HeaithCare.gov or call 1-8O0-XXX-XXXX. Filling out this application doesn’t mean you have to buy health coverage.

* Online: HealthCare.gov

* Phone: Cail our Help Center at 1-800-XXX-XXXX.

* In person: There may be counsetors in your area who can help. Visit our website or Call 1e800-XXX-XXXX for more information.

.

En Espafiol. Liame-a-nueste-eente-de-ayuda.qiatiea PBOOKNKIOREE

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX, Mara-aonek-yue-GeMa-de-etten

If you need help in a language other than English, cafl 1+B8OO-XXX-XXXX and tell the

customer service representative the language you need We'll get you help at no cost to you TTY users should call 1-8OO-XXX-XXXX

TN No: 13-0008-MM Hawaii

Approval Date: 10/25/13 Effective Date 10/1/2013

Alternative Single Streamlined Paper Application - 1

sage

yourself.

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

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

2 Home address (Leave blank if you don’t have one) 3 Apartment or suite number 4 City 5 State 6 ZIP code 7 County

8 Maiing address (if different from home address) 9. Apartment or suite number 10 City Wi State —~*( 12. ZIP code 113. County

14, Phone number 15 Other phone number

Cc 2) - a) -

16. Do you want to get information about this application by emai? (Jyes []No

Email address.

17 Preferred spoken or wntten language (if not English)

4

Tell us about your

‘aT family.

“STEP 2

Who do you need to Include on this application?

Teli us about ali the famiiy members who tive with you, If you file taxes, we need to know about everyone on your tax return. (You don't need to file taxes to get health coverage).

DO Include: You DON’T have to include: + Yourself + Your unmarried partner who doesn’t need health « Your spouse coverage * Your children under 21 who live with you + Your unmarried partner's chidren « Your unmarried partner who needs health coverage + Your parents who live with you, but file their own tax * Anyone you include on your tax return, even if they return (if you're over 21) don't live with you * Other adult relatives who file their own tax return * Anyone else under 21 who you take care of and lives with you

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

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

NEED HELP WITH YOUR APPLICATION? visit HealthCare.gov or call us at 1-8OO-XXX-XXXX. RarerekwererarPtopre-de-este. fa » if you need help in a language other than English, cai! 1-8OO-XXX-XXXX and tell the customer service representative the language you need. We'll get you help at no cost to you TTY users shauid Cail 1-8OO-XXX-KXXX Page !of7 TNNo: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 2

(Start with yourself)

Complete Step 2 for yourself, your spouse/partner and children who tive with you and/or anyone on your same federal income tax return if you file one See page 1 for more information about who to inciude. if you don't file a tax return, remember to still add family members who five with you

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

3 Date of birth (mm/dd/yyyy) 4 Sex (jMale ([)Femaie

S. Social Security number (SSN) - -

We need this !f you want health coverage and have an SSN. Providing your SSN can be helpful f you don’t want health coverage too since it can speed up the appiication process, We use SSNs to check income and other information to see who's eligible for help with heaith coverage costs If someone wants help getting an SSN, cali 1-800-772-1213 or visit soctalsecurity.gov. TTY users should cali 1-800-325-0778.

6. Do you pian to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return )

DD vés. If yes, piease answer questions a-c (FD NO. if no, skip to question ¢ a Will you file jointiy with a spouse? [JYes (No if yes, name of spouse’... b Will you claim any dependents on your tax return? Clyes (No if yes, list name(s) of dependents. 3 c. Wil! you be claimed as a dependent on someone's tax return? (J Yes (]No if yes, please list the name of the tax filer How are you related to the tax filer? .

7 Are you pregnant? [] Yes [No a ff yes, how many babies are expected during this pregnacy? Eapecied Dur Bete

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

DO YES. if yes, answer al) the questions below. Ce (1 No. If no, SKIP to the income questions on page 3 =>) Leave the rest of this page blank

9 Do you have a physical, mental, or emotional health condition that causes imitations in activities (like bathing, dressing, datly chores, etc) or live in a medical facthty or nursing home? [J Yes ONo be you havea Ais aba lity? Q Yec ano T

10. Are you a U.S citizen or U.S national? [J Yes [No N. If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? oO Yes. Fill in your document type and (D number below. :

a Immigration document type - b Document ID number

c. Have you lived in the U.S, since 1996? 0 Yes oO No + d. Are you, or your spouse or parent 4 veteran or an active-duty 2 ona atrien Tht SeAtrled States of Miumane member of the U.S. military? Dyes [No e

12, Do you want help paying for medical bills from the tast 3 months? (] ves [No

13, Oo you live with at least one chiid under the age of 19, and are you the main person taking care of this child? (1) ves oO NO

we Nemlsiaaiaabnar blink uicthdiShitat 2nd Ximadeatlilbcine hhs Were you in foster care at age 18 or olderA|_} Yes 6 No

16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) OMexican [)Mexican American []Chicano/a [)Puerto Rican (Cuban (Other

17 Race (OPTIONAL—check ail that apply.)

D white (CD American indian or OC Fitipino (0 Vietnamese (0 Guamanian or Chamorro DO Black or African Alaska Native (CD Japanese (J Other Asian (0 samoan American D Asian indian O Korean DD Native Hawanan DD Other Pacific isiander ©) Chinese 0 other

NEED HELP WITH YOUR APPLICATION? Visit HeaithCare.gov or cali us at 1-8BOO-XXX-XXXX RarscblonemimacanaRdease

formulaic Es pahelHa Rol SOO XLHK If you need help in a ianguage other than English, call 1-800-XXX-XXXX and tell the

customer service representative the (anguage you need. We'll get you heip at no cost to you TTY users should call 1-BOO-XXX-XAXXX Page 2017

TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013

Hawaii Alternative Single Streamlined Paper Application - 3

(Continue with yourself) Current Job & income Information

O Employed (CD Not employed 0D Self-employed If you’re currently employed, tell Skip to question 28 Skip to question 27. us about your income. Start with question 18.

CURRENT JOB I. 18 Employer name and address

19. Employer phone number 20. Wages/tips (before taxes) [JHourly (JWeekly [Every 2 weeks [1] twice amonth ()Monthiy ( Yearly

$

21. Average hours worked each WEEK

CURRENT JOB 2: (if you have more jobs and need more space, attach another sheet of paper.) 22 Employer name and address

23. Employer phone number 24. Wages/tips {before taxes) C] Hourly (JWeekly [Jeévery 2weeks [J] twiceamonth [Monthly L Yeariy

$

25, Average hours worked each WEEK

26. In the past year, did you: (J) Change jobs (Stop working (Start working fewer hours [1] None of these

27 It self-employed, answer the following questions: a Type of work b, How much net income (profits once business expenses are Pasd) will you get from this self-employment this month?

$

28 OTHER INCOME THIS MONTH: Check ali that apply. and give the amount and how often you get it NOTE: You don’t need te tell us about chiid support, veteran's payment, or Supplemental Security income (SS!) CO none

OD unempioyment $ How often? Cnet farming/tishing How often? (J Pensions $ How often? C) net rental/royaity $ How often? (2 Social Security $ How often? Dotner income $ How often? (Retirement accounts $ How often? Type:

OD Alimony recerved $ How often?

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

If you pay for certain things that can be deducted on a federai income tax return, telling us about them could make the cost of health coverage a littie lower

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 27b) Di alimony paid $ How often? (Other deductions $ How often? Co Student ioan interest $ How often? Type

30 YEARLY INCOME: Complete only if your income changes from month to month. if you don’t expect changes to your monthly income, skip to the next person.

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

THANKS! This is all we need to know about’ you.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare,gov or cali us at 1-800-XXX-XXXX Pere-cetenerenerceprede-asie—

formuteritres-bepahel-iame+-G8OIHFEKK. If you Need help in a language other than English, call 1*8O0O0-XXX-XXXX and tell the

customer service representative the language you need. We'll get you heip at no cost to you TTY users should call 1-BOO-XXX-XXXX 3of7

Page TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 4

Complete Step 2 for yourself, your spouse/partner, and children who five with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include If you don't file a tax return, remember to still add family members who live with you.

1 First name, Middle name, Last name, & Suffix 2. Relationship to you? 3. Date of birth (mm/dd/yyyy) 4 Sex []Male [J Femate 5. Social Security number (SSN) - -

We need this if you want health coverage and have an SSN. 6. Does PERSON 2 live at the same address as you? [Yes []No

if no, list address:

7. Does PERSON 2 pian to file a federal Income tax return NEXT YEAR? (You can still apply for health insurance even :f you don't file a federal income tax return }

0 YES. If yes, please answer questions a-c. ONO. If no, skip to question a. Will PERSON 2 file jointly with a spouse? (] Yes [JNo

If yes, name of spouse’... b. Will PERSON 2 claim any dependents on his or her tax return? C] Yes (No

If yes, list name(s) of dependents: 7

c. Wili PERSON 2 be claimed as a dependent o on someone's tax return? (] Yes (No if yes, please list the name of the tax filer’ How ts PERSON 2 related to the tax filer?

& Is PERSON 2 pregnant? o Yes CINo alf yes, how many babies are expected during this pregnacy? Expated Dur Dete

9 Does PERSON 2 need health coverage? (Even if they have Insurance, there might be a program with better coverage or lower costs.)

O vest yes, answer all the questions below. © OD No. If no, SKIP to the income questions on page 5. Leave the rest of this page blank.

10 Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (ike bathing, dressing daily chores, etc) or live in a medical facility or nursing home? [J Yes [No Does PERSOM 2 have a disavilhy 7 OVes DNO Nn. Is PERSON 2 a US. citizen or U.S national? J yes [No 12. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status? Oo Yes. Fill in their document type and IO number below. a, Document type ~ b, Document 10 number

¢ Has BERSON ved in the S. since 067 ves, }No 4. is PERSON 2, or their spouse or parent a veteran or an active- ____ Oe Rapateite of Tas Plans duty member in the U.S. mihtary? [yes [No 13. Does PERSON 2 want help paying for }14. Does PERSON 2 live with at least one chiid 15 Was PERSON 2 1n foster care at medical bills from the last 3 months? under the age of 19, and are they the main age 16 or olderin thewel, 2 Oyes No person taking care of this child? Oves CINo Oves Ono

Please answer the following questions if PERSON 2 Is 22 or younger: 16. Did PERSON 2 have insurance through a Job and lose it within the past 3 months? (] Yes [No a If yes, end date: 2. «Reason the insurance ended:

ete PERSOMnaSetntimoctudant2. [ser —TIl

18. if Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Omexican (Mexican American ()Chicano/a [Puerto Rican [)Cuban (other

19 Race (OPTIONAL—check all that apply.)

0 white OD American indian or O Finpino D vietnamese (2 Guamanian or Chamorro CD Black or African Alaska Native ( Japanese © Other Asian (2) Samoan American CO Asian indian () Korean O Native Hawauan (C2 Other Pacific islander () Chinese DO otner

Now, tell us about any income from PERSON 2 on the back. +)

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or cail us at 1-800-XXX-XXXX Peraenteneroneceprrde ste (Ost aLO.a-R6e PERO HtsRe-+-OOO7HHEIHHE If you need help in a language other than English, cali 1-8OO-XXX-XXXX and tell the customer service representative the language you need We'll get you help at no cost to you TTY users should call 1-8OO-XXX-XXXX. Page 4 of 7 IN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 5

Current Job & Income Information

0 Empioyed ( Not employed {J Self-employed If you're currently employed, tell Skip to question 30, Skip to question 29. us about your income. Start with question 20

CURRENT JOB 1:

20 Empioyer name and address 21 Employer phone number 22 Wages/tips (before taxes) [Hourly [|] Weekly Clevery 2weeks [JTwicea month [)Monthly [) veary

$

23 Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space. attach another sheet of paper)

24. Empioyer name and address 25 Employer phone number 26. Wages/tips (before taxes) [JHourly [)Weekly [JEvery 2 weeks [twice amonth (C)Monthly ( veariy

$

27 Average hours worked each WEEK

28. In the past year, did PERSON 2: [1] Cnange jobs (1) Stop working (7) Start working fewer hours (1) None of these

29 If self-employed, answer the following questions: a Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month?

$

30. OTHER INCOME THIS MONTH: Check aii that apply, and give the amount and how often you get tt NOTE: You don’t need to tel! us about child support. veteran’s payment, or Supplemental Security Income (SS) CO Nnone

(1) Unempioyment $ How often? (CNet farming/fishing § How often? (7 Penstons $ How often? 0 net rentai/royaity $ How often? (Social Secunty $ How often? 0 Other income $ How often? (Retirement accounts $ How often? Type

D Alimony received $ How often? .

3) DEDUCTIONS: Check ail that apply, and give the amount and how often you get It

if PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a litte ower.

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 29b). oO Alimony paid $ How often? . CO other deductions $ How often? {student toan interest $ How often? Type:

32 YEARLY INCOME: Complete only if PERSON 2's income changes from month to month. if you do not expect changes to PERSON 2 (pages 4 and 5) and compiete.

PERSON 2's total income this year PERSON 2's total income next year (if you think it will be different)

$ $

THANKS! This is all we need to know about PERSON 2. if you have more than two people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-8OO-XXX-XXXX Pererobtenerennrcupnr ye este fonnviane-en-keperte tenn hBOOIHE HEN, If you need help in a language other than English, call 1-8OO-XXX-XXXX and tell the customer service representative the language you need We'll get you heip at no cost to you. TTY users should call 1-8O00-KXXX-XXXX. Page S of 7 TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 6

). Are you or is anyone in your family American Indian or Alaska Native?

DI No, skip to Step 4 Oes. if yes, go to Appendix B

Answer these questions for anyone who needs health coverage

1. Is anyone enrolted in health coverage now from the following? oO YES. If yes, check the type of coverage and write the person(s) name(s) next to the coverage they have 0 NO.

D Medicaia - CO Employer insurance O cup Name of heaith insurance’ O meaicare Policy number.

Is this COBRA coverage? [] Yes (]Neo ls this a retiree health plan? CT] ves [No D other

© va heath care programs Name of health insurance. Policy number

O TRICARE (Don't check if you have direct care or Line of Duty)

O Peace Corps . is this a limited-benefit plan (like a schoo! accident policy)?

Oves (No

2. ls 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 @ parent or spouse.

DYES. If yes, you'll need to complete and include Appendix A Is this a state employee benefit plan? (1 Yes (]No ONO. if no, continue to Step 5.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information untess it displays a valid OMB controt number The valid OMB control number for this information coflection ts O936-XXXX The time required to complete this information collection 1s estimated to average (insert Time (hours or minutes)} per response, including the time to review instructions, search existing data resources, gather the Gata 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.

NEED HELP WITH YOUR APPLICATION? Visit HeaithCare.gov or call us at 1-800-XXX-XXXX Pereomtenorune-cope-deeste—

fonmmterronen-Sepaol UsmelBOG-K-MHEK. If you nead help in a language other than English, call 1-800-XXX-XXXX and tell the

customer service representative the language you need We'll get you help at no cost to you TTY users should Call 1-8O00-XXX-XXXX. Page 6 of 7

TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 7

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

« [know that! must tell the Health Insurance Marketplace tf anything changes (and is different than) what ! wrote on this application. | can visit HealthCare. gov or call 1-800-XXX-XXXX to report any changes. | understand that a change in my information could affect the eligibility for member(s) of my household,

+ | know that under federal iaw, discrimination isn’t permitted on the basis of race, color, national origin, sex. age. sexual orientation, gender identity, or disability { can file a compiaint of discrimination by visiting www.hhs.gov/ocr/office/file.

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

- _— is incarcerated

(name of person)

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We'll check

your answers using information in our electronic databases and databases from the Interna! Revenue Service (IRS),

Sociai Security, the Department of Homeland Security, and/or a consumer reporting agency. if the information doesn't

match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for heip paying for heaith coverage in future years, | agree to allow the Marketplace to use income data, inciuding information from tax returns. The Marketplace will send me a notice, let me make any changes, and | can opt out at any time

Yes, renew my eligibility automatically for the next

(5 years (the maximum number of years aiiowed), or for a shorter number of years:

O4years O3years O2years Ciiyear ODor't use information from tax returns to renew my coverage

if anyone on this application is eligible for Medicaid

* 1am giving to the Medicaid agency our rights to pursue and get any money from other heaith insurance, legal settiements, or other third parties. | am aiso giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent

+ Does any chiid on this application have a parent living outside of the home? Oyes Ono

* If yes, | know ! will be asked to cooperate with the agency that coi!ects medica! support from an absent parent If! think that cooperating to coliect medicai support will harm me or my children, | can teil Medicaid and | may not have to cooperate.

My right to appeal

If | think the Health insurance Marketplace or Medicaid/Children’s Health Insurance Program (CHIP) has made a mistake, | can appeai its decision To appeal means to tell someone at the Heaith Insurance Marketplace or Medicaid/CHIP that | think the action is wrong, and ask for a fair review of the action | know that | can find out how to appeal by contacting the Marketpiace at 1*8OO-XXX-XXXxX. | know that | can be represented in the process by someone other than myself My eligibility and other important information will be explained to me.

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

Signature Date (mm/dd/yyyy)

STEP (3 Mail completed application.

Mail your signed application to:

Health Insurance Marketplace

Tep |1005 xyz Drive

Washington, DC 20005

If you want to register to vote, you can complete a voter registration form at XXXXX.gov

NEED HELP WITH YOUR APPLICATION? Visit HeatthCare.gov or cail us at 1-BOO-XXX-XXXX Rase-estenertme-copsrede-este ~ . If you need help in a language other than English, call 1-8O0-XXX-XXXX and tell the customer service representative the language you need We'll get you heip at no cost to you TTY users should call 1-800-XXX-XXXX Page 7 of 7

TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 8

APPENDIX A

Health Coverage from Jobs

You DON’T need to answer these questions uniess someone in the household is eligible for heaith coverage from a job. Attach a copy of this page for each job that offers coverage. Tell us about the job that offers coverage

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer

these questions. You only need to include this page when you send In your application, not the Employer Coverage Tool.

EMPLOYEE Information

1 Employee name (First, Middle, Last) 2 Employee Social Security number

EMPLOYER Information

3, Employer name : : 14. Employer fon Number (EIN) s Employer address i * ‘ : | 6. Employer phone number 7 City ® ee. 2 : is 8 State” a 9. ZIP code

10. Who can we contact dbout employee health coverage at this job?

TL Phone number (if different from above) | 12. Email address ¢ 2 =.

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? © Yes (Continue)

13a. if you're in a waiting or probationary period, when can you enroll in coverage?

(mm/aa/\ a] List the names of anyone else who Is etigibie for coverage from this job. itll

Name Name Name:

Ci Ne (Stop here and go te Step 5 in the appiication)

Tell us about the health plan offered by this employer.

14. Does the employer offer a health plan that meets the'minimum value standard*? Oves 0 No é

15. For the lowest-cost plan that meats the minimum value standard* offered only to the employee (don’t include family plans): if the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs. and did not receive any other discounts based on weliness programs.

8. How much would the employee have to pay in premiums for this plan? $0 b. How often? C) Weekly Clevery 2.weeks [twice a month (Cauarterly ©) Yearly

16. What change will the employer make for the new plan year (if known)? OD Employer won't offer health coverage

Oo Employer will start offering health coverage to empioyees or change the premium for the lowest-cost plan avaiiabie only to the employee that meets the minimum value standard * (Premium should reflect the discount for wellness programs. See question 15.)

a@ How much will the employee have to pay in premiums for that pian? $ b. How often? Weekly DMlevery 2 weeks DC twiceamonth Clauarteriy ( Yearly Date of change (mm/dd/yyyy):

” An employer-sponsored health plan meets the “minimum value standard” if the plan's share of the total allowed benefit costs covered by the » pian is no less than GO percent of such costs (Section 36B(¢)(2)(C)(n) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or cali us at 1*800-XXX-XXXX Raroblenomineeoperde-este foomutenc-erresparrot-nmet-ROO%MHEMIEER. If you need help in a fanguage other than English, call 1-8O0-XXX-XXXX and tell the customer service representative the language you need We'll get you heip at no cost to you. TTY users should cali 1*8O00-XXX-XXXX

TN No: 13-0008-MM Approval Date: 10/25/13 . Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 9

EMPLOYER COVERAGE TOOL 70 exit re.ronce Marketplace

Use this tool to help answer questions in Appendix A about any employer health coverage that you're eligible for (even if it’s from another person's job, like a parent or spouse), The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A

Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one too! for each employer that offers health coverage.

EMPLOYEE Information

The employee needs to fill out this section. 1. Employee name (First, Middle, Last) 2. Sociat Security Number

EMPLOYER Information

Ask the employer for this information.

3.Employername . 14. Employer identification Number (EIN) 5. Employer address the’ Marketplace will send notices to this address) 6. Employer phone number 7, City 8 State 49. ZIP code

10. Who can we contact about employee health coverage at this job?

11, Phone number (if different from above) |12. Email address

CD) =

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligibie in the next 3 months? O yes (Continue) 13a, if the empioyee 1s not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) 0 No (STOP and return this form to employee)

Tell us about the health plan offered by this employer

Does the employer offer a health pian that covers an employee's spouse or dependent? ClYes Which people? () Spouse [] Dependentis) CINo

(Go to question 14)

14. Does the employer offer a health plan that meets the minimum vaiue standard*? "DD Yes (Go to question 15) (No (STOP and return form to employee)

15. For.the lowest-cost plan that meets the minimum value. ‘standard® offered only to’ the employee (don’t include family plans): if the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum alscount for any tobacco cessation programs, and didn’t receive any. other discounts based on wellness programs.

a, How. much would the employee have to pay In premiums for this plan? $ b. How often? C) Weekly Clevery 2 weeks Otwicea month Oauarterly D Yearly

if the plan year will end soon and you know that the health plans offered wif! change, go to question 16 If you don't know. STOP and return form to employee.

16. What change will the employer make for the new plan year? C Employer won't offer heaith coverage

0 Employer wiil start offering health coverage to employees or change the premium for the lowest-cost pian avaiiabie only to the employee that meets the minimum vaiue standard.’ (Premium should reflect the discount for wellness programs See question 15.)

a, How much will the employee have to pay in premiums for that plan? $ b. How often? 0 Weekly Overy 2 weeks Owicea month O Quarterly QO Yearly

Date of change (mm/dd/yyyy):

“An employer-sponsored health plan meets the “minimum value standard” if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)di) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX Rerd-ebtener-une-cope- de rsTy forematerte-<n-Espeket Herre BOONE If you need help in a language other than English, call 1*-8OO-XXX-XXXX and tell the customer service representative the language you need We'll get you help at no cost to you TTY users should cat! #BOO-XXX-XXXX

TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 10

APPENDIX B American Indian or Alaska Native Family Member (AI/AN)

Compiete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health Coverage & Help Paying Costs.

Tell us about your American Indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban indian health programs. They also may not have to pay cost sharing and may get speciai monthly enrollment periods. Answer the following questions to make sure your family gets the most heip possible.

NOTE: If you have more people to inciude, make a copy of this page and attach

AI/AN PERSON AI/AN PERSON 2

“| Name ‘TFirst Middle First Middle (First name. Middie name, Last name)

Last : : Last 2 Member of a federatly recognized tribe? O ves Cves tf yes, tribe name { if yes. tnbe name CI No i CINo 3. Has this person ever gotten a service from D ves OJ Yes the Indian Health Service, a tribal heaith program, or urban Indian heaith program. o No o No or through a referrai from one of these If no, is this person eligible to get tf no, is this person eligible to get programs? services from the Indian Health services from the indian Health Service, tribal health programs. or Service, tribal heaith programs. or urban Indian heaith programs. ar urban indian health programs, or through a referral from one of these through a referral from one of these programs? programs? Cres Lino Oves Ono

4 Certain money received may not be $ $ counted for Medicaid or the Children’s

Health Insurance Program (CHIP). List any

income (amount and how often} reported

on your application that inciudes money from these sources’

+ Per capita payments from a tribe that come from natural resources. usage rights, teases, or royalties

+ Payments from natural resources, farming. ranching, fishing, leases. or royalties from land designated as indian trust land by the Department of intertor {including reservations and former reservations)

+ Money from selling things that have cultural significance

| How often? How often?

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov o: cali us at 1-BOO-XXX-XXXX_ Rasd-OOlORaswad COD Ato— te x . ft you need heip in a language other than English, call 18OO-XXX-XXXX and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should Ccalt 1-8OO-XXX-XXXX

TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 11

APPENDIX C

Assistance with Completing this Application

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behaif. This person is called an “authorized representative." If you ever need to change your authorized

representative, contact the Marketplace. If you're a jegally appointed representative for someone on this application. submit proof with the application

1 Name of authorized representative (First name, Middie name. Last name)

2 Address 3 Apartment or sutte number

4 City 15. State 6. ZIP code

7 Phone number a) -

8 Organization name

9 iD number (if apphcable)

By signing. you aliow this person to sign your application, get official information about this application, and act for you on ail future matters with this agency.

10. Your signature

U. Date (mmn/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section :f you're a certified application counselor. navigator agent, or broker filling out this application for somebody else.

1. Apptication start dete (mm/dd/yyyy) ~ ~

2. First name, Middle name, Last name, & Suffix :

3 Organization name 4 ID number ¢f aoplicanie

2) NEED HELP WITH YOUR APPLICATION? Visit HeaithCare.gov or cali us at 1-800-XXX-XXXX Ra-ebtener-unecepre-deeste fe if you need help tn a language other than English, call 1+8OO-XXX-XXXX and tel! the customer service representative the language you need, We'li get you help at no cost to you. TTY users shouid call 1-8OO-XXX-XXXX

TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date 10/1/2013 Hawaii Alternative Single Streamlined Paper Application - 12

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Heettilere. aay > mybsenetite. hawaii -gev }-800 —KOK -XXXK-? 1-977 -

PLEASE REYER TO ATTACHMENT 3

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Application for Health Coverage & Help Paying Costs (Short Form)

THINGS TO KNOW

Use this application to see what coverage you qualify for

Who can use this application?

Apply faster online

What you may need to apply

Why do we ask for this information?

What happens next?

Get help with this application

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

* Anew tax credit that can immediately help pay your premiums for health coverage

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

Single adults who: « Aren't offered health coverage from their employer

* Don't have any dependents and can't be claimed as a dependent on someone else's tax return

NOTE: If any of the following apply, you need to fill out a different form to make sure you get the most benefits possible:

* You're married or have dependent children. * You were in the foster care system, and you're under age 26.

+ You have items that can be deducted from your income. If your onty deduction is student joan interest, you can use this form.

* You're pliniinein Indian or Alaska Native.

* Von hove ans hances Tat require ndash ened Alor.

Apply faster tas ater HealthCare. gov.

* Your Social Security number (or document number if you’re a legai immigrant)

* €mpiloyer and income information (for example, from paystubs, W-2 forms, or wage and tax statements)

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

Send your complete, signed application to the address on page 3, If you don’t have all the information we ask for, sign and submit your application anyway. We'll follow up with you within 1-2 weeks. Filling out this application doesn't mean you have to buy health coverage.

* Online: HealthCare.gov. ¢ Phone: Cali our Help Center at 1-8OO-XXX-XXXX. * {In person: There may be counselors in your area who can heip. Visit HealthCare.gov, or call 1-B8OO-XXX-XXXX for more information. + —~Gr-Espalieistieme-c-nuestie-centin daayuda-greticet BOO IOOEOEK.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare gov or call us at 1-8O0-XXX-XXAX.

BRP AAAI If you need hetp in a language other than English, call 1-8O00-XXX-XXXX and tell the

customer service representative the language you need We'll get you heip at no cost to you TTY users should cail 1-BOO-XXX-XXXX

TN No: 13-0008-MM Hawaii

Approval Date: 10/25/13 Effective Date: 10/1/2013

Application for Health Coverage & Help Paying Costs (Short Form) - 1

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

2. Home address (Leave biank if you don’t have one.) 3 Apartment or suite number

4 City 5. State 16 Zip code [7 County

8 Mailing address (if different from home address) i? Apartment or suite number |

10. City it State 32. ZIP code 1Z County

14 Phone number |15 Other ohone number

( ) = Co -

16. Do you want to get information about this application by emai? Clyes L)No

Email address:

1? Preferred spoken or written language (if not Enghsh)

18 Date of birth (mm/dd/yyyy) 19 Sex (2 mate [J Female

20. Social Security number (SSN) - -

We need this if you want heaith coverage and have an SSN. We use SSNs to check income and other information to see if you're eligible for help with heaith coverage costs if you need heip getting an SSN, call }*800-772-1213 or visit socialsecurity.gov TTY users should call 1-800-325-0778.

21. Are youa US citizen or US national? CJ Yes C)No

22 if you aren't a U.S. citizen or U.S. national, do you have eligible immrgration status? OC Yes Fill in your document type and 10 number below

& Immigration document type

b. Document ID number

c Have you itved in the US. since 1996? [J Yes LNo

d. Are you a veteran or an active-duty member of the U.S, military? Oves CINo aves

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23 Are you pregnant? (]Yes [No if yes, how many babies are expected during this pregnancy? Expected One Mate

24 Do you nave a physical, mental, or emotional health condition that causes imitations in activities (ike bathing, dressing, datly chores, etc.) or live in a medical facility or nursing home? C)Yes [No Do you have a disability? QV¥es ONo

25 If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Omexican (Mexican American []Chicano/a () Puerto Rican [JCuban [J Otner

26. Race (OPTIONAL—check all that apply.)

0 waite (O American Indian or (J Filipino (3 vietnamese (1 Guamanian or Chamorro CO Black or African Alaska Native O Japanese ( Other Asian (1 Samoan Amencan © Asian indian © Korean (DD Native Hawauan (CD Other Pacific istander OC Chinese © Other

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or cali us at 1-800-XXX-XAXXX Man-oblenedadconiade- cee - if you need help in a language other than English, cal! 1-8OO-XXX-XXXX and tell the customer service representative the language you need. We'll get you heip at no cost to you, TTY users should call ~BOO-XXX-XXXX Page lof 3 TN No: 13-0008-MM Approval Date: 10/25/13 Effective Date: 10/1/2013 Hawaii Application for Health Coverage & Help Paying Costs (Short Form) - 2

Current job & income information

bo Employed - If you're currently employed, tell us about your income. Start with question 1. (Not Employed - Skip to question 1.

CURRENT JOB 1: 1. Empioyer name and address