Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 1 MODEL APPLICATION TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 2 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

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

State/Territory:__________Idaho_____________________________________ (Name of State/Territory)

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

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

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Robin Pewtress

Position/Title: State S/CHIP Coordinator

Policy Specialist,

Division of Medicaid Name: Leslie Clement

Position/Title: State Medicaid Director

Administrator, Division of Medicaid Name: David Butler

Position/Title: Chief Financial Officer

Deputy Director, Division of

Management Services

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 3 estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 4 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

1.1.1

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

1.1.2.

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

1.1.3.

A combination of both of the above.

1.2

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

The State of Idaho assures that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by the Centers for Medicare and Medicaid Services (CMS).

1.3

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

The State of Idaho assures that it complies with all applicable civil rights requirements, including Title VI of the Civil Rights Act of 1964, Title II of the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR, part 80, part 84 and part 91, and 28 CFR part 35.

1.4

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

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 5

Effective date: January 1, 2007

Implementation date: February 1, 2007

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 6 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)- (3)) and (Section 2105)(c)(7)(A)-(B))

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

The following describes the extent to which children in the state, including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10).

Idaho is a predominantly rural state. Of Idaho’s 44 counties, 17 are classified as frontier (less than 6 people per square mile) and an additional 19 are classified as rural (those that do not contain a population center of more than 20,000 people). The rural nature of Idaho has a significant impact on health care issues, including insurance enrollment and health access.

Idaho’s largest ethnic minority is of Hispanic heritage. Southwest, southeast and south-central Idaho in particular have large concentrations of people with Hispanic heritage. Idaho also has five Native American tribes: the Shoshone and Bannock Tribes in eastern Idaho, the Shoshone and Paiute Tribes in Duck Valley, southwestern Idaho, the Nez Perce Tribe in north central Idaho, and the Coeur d’Alene Tribe in northern Idaho.

According to the 2004 Current Population Survey, there are 384,000 children ages 18 or under in Idaho, of whom 33,000 are without health insurance. This is a significant decrease from earlier estimates of uninsured children (51,000 in 2003, 50,000 in 2002, and 45,000 in 2001). The number of children in Idaho living in families with incomes at or below 200% of the Federal Poverty Guideline (FPG) is 169,000, using a three-year average of Current Population Survey data from 2002, 2003 and 2004 (from a three-year average total of 394,000 children). Of those 169,000 children at or below 200% FPG, 30,000 are estimated to have no health insurance.

Model Application Template for the State Children’s Health Insurance Program

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

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

The Idaho Department of Health and Welfare (DHW) strives to increase Idaho children’s enrollment in public health insurance programs by coordinating enrollment efforts across DHW divisions, coordinating with other public agencies, and by coordinating with other stakeholders. These coordination efforts include: • Medicaid & You—a brochure outlining the services available throughout DHW to families, including Title XIX and Title XXI child health programs. • Idaho CareLine—an 800 number providing referral assistance to DHW customers throughout Idaho. The Idaho CareLine has a direct link to CHIP assistance. CHIP makes up the largest segment of callers on a regular basis. 888 KIDS NOW connects directly to the Idaho CareLine. • Coordinated outreach and enrollment activities with the Idaho Department of Education and school lunch and child care food programs. • Partnerships with stakeholder organizations that encourage posting of links to the State’s CHIP website (www.chip.idaho.gov) on stakeholder web sites in order to provide current information to Idaho citizens.

In addition, DHW provides potential enrollees with several types of application assistance by: • Providing mail-in/fax-in applications—the redesigned application allows potential CHIP enrollees to submit their application by mail or fax. Self-reliance specialists make CHIP eligibility determinations without a face-to-face visit. When information is missing, self-reliance specialists contact potentially eligible families by telephone. • Using a simplified Application for Assistance for all benefit

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 8 programs in the Self-Reliance Program (Health Coverage, Cash Assistance, Food Stamps, Child Care, Telephone Service and Nursing Home).

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

N/A

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

The State of Idaho will use routine stakeholder meetings to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 9 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

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

The same method of assuring delivery of insurance products and delivery of health care services is used for Title XXI and Title XIX. Providers are required by contract to assure that services are delivered in accordance with state and federal regulations. CHIP utilizes the same provider panel as Idaho Medicaid. Providers are primarily reimbursed on a fee-for-service basis under a Primary Care Case Management (PCCM) model of managed care.

In addition, Idaho Medicaid will promote wellness by financing preventive services for children in schools. Idaho Medicaid will award grants to schools to facilitate delivery of preventive health services to low-income students. These grants will be issued as Title XXI non- primary expenditures and as an alternative to School-Based Administrative Claiming.

Existing Idaho and federal law obligates Idaho Medicaid to pay schools for covered rehabilitative and health-related services under the Individuals with Disabilities Act (IDEA). These services are listed in Individualized Education Plans (IEPs) for children identified as having special health needs. Idaho Medicaid pays schools on a fee-for-service basis by certifying school funds. In order to provide preventive services through schools, Idaho Medicaid proposes to fund services through Title XXI non-primary expenditures rather than develop an administrative claiming mechanism.

Title XXI non-primary expenditures are those program expenditures that are not medical services provided under the benefit package as described in the Title XXI state plan. Non-primary expenditures are reimbursable at the enhanced federal financial participation rate but are capped at 10 percent of the cost of benefits. Per 42 CFR 457.618, there

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 10 are four categories of non-primary expenditures allowable under Title XXI, which include administrative expenditures, outreach, health initiatives and certain other child health assistance. Health Services Initiatives, defined in 42 CFR 457.10, means “activities that protect the public health, protect the health of individuals, improve or promote a State’s capacity to deliver public health services, or strengthen the human and material resources necessary to accomplish public health goals relating to improving the health of children (including targeted low-income children and other low-income children).”

Initially, Idaho Medicaid will issue grants to ten (10) school districts in state fiscal year 2007 to assist schools with the salary expenses of registered nurses (RNs) working in schools or with related resource needs. Idaho Medicaid has partnered with the Idaho Department of Education and the Division of Health, Idaho Department of Health and Welfare, to establish criteria for school nurse programs eligible for Medicaid grant funding and to distribute these grants. Currently, 33 out of 114 Idaho school districts maintain school nurse programs, and Idaho schools’ current RN to student ratio in Idaho is 1:2,393 (the national standard is 1:750 for the general, non-special-needs student population.) Increasing the nurse to student ratio will result in increased health counseling and education, health screenings, prevention services, health coordination, referral to care outside of school, and applications to and enrollment in Title XIX and Title XXI health coverage programs.

Grant criteria will include the percentage of low-income students and need for increased access to health services. Idaho Medicaid will fund grant amounts proportionate to percentages of low-income students in each grantee district. Idaho Medicaid will require semi-annual reports from grantee schools on provision of preventive health services and achievement of health services objectives as outlined in the grant program scope of work. Grant agreements will stipulate that grantee districts may not expend grant funds on services that may be billed through existing school-based services under a child’s Individualized Education Plan.

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

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 11

This State Plan uses utilization controls from the Title XIX program, including prior approval controls, peer reviews, claims processing edits, post-audit and review procedures. Primary care providers are charged with making referrals for medically necessary specialty services. Health services providers are provided a handbook describing the benefit package including limitations. Participants are issued an identification card delineating the applicable benefit package. The card is used to determine covered services and service limitations.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 12 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan: This State Plan applies to the entire State of Idaho. 4.1.2.

Age: Children are eligible from birth through the month of the 19th birthday. 4.1.3.

Income: Children with family incomes over 133% through 185% FPL are eligible for Idaho’s stand-alone SCHIP under Title XXI. Children who have family incomes over 100% through 133% FPL are eligible for Idaho’s Medicaid- expansion SCHIP under Idaho’s Title XIX State Plan from the month of their 6th birthday through the month of the 19th birthday. 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): There are no resource limits for children served by the plan. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state) : Children served are residents of the State of Idaho.

4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): No child will be denied eligibility based on disability status. If the child receives SSI, the child will be denied coverage based on their eligibility for Medicaid, not for reasons of disability status. 4.1.7.

Access to or coverage under other health coverage: A child will be ineligible for coverage under this plan if they have access to or are enrolled in other health coverage, including the following scenarios. • The child is covered by creditable health insurance at the time of application. • The child has been voluntarily dropped from creditable coverage in the six months preceding application with the intention of qualifying for public coverage.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 13 • The child is eligible under Idaho’s Title XIX State Plan. • The child is eligible to receive health insurance benefits under Idaho’s state employee benefit plan.

4.1.8.

Duration of eligibility: The duration of eligibility is 12 months unless the child is terminated for one of the reasons described below. • The child loses his or her Idaho residency. • The child attains 19 years of age. • The child becomes eligible for and is enrolled in Medicaid. • The child’s parent or adult who is legally responsible for the child’s health care makes a written request to terminate coverage. • The application is found to have inaccurate information which effected an incorrect eligibility determination. • The child dies.

• 4.1.9.

Other standards (identify and describe): • At the time of application, a) the child must not be a patient in an institution for mental diseases, or b) an inmate of a public institution. • The Social Security number, proof of application for a Social Security number or resident alien card number must be provided for applicants who are requesting coverage. Individuals on the application that are not requesting coverage are not required to provide Social Security numbers. • The State does not exclude individuals based on citizenship or nationality, to the extent that the child is a U.S. citizen, U.S. national or qualified alien (as defined at section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, as amended by the BBA of 1997, except to the extent that section 403 of PRWORA precludes them from receiving Federal means-tested public benefits).

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

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children,

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 14 these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 15 4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

Methods of establishing eligibility and continuing enrollment include a combined application for all Idaho children’s health insurance programs. The application can be mailed to DHW. Face-to-face interviews are not required. All eligibility determinations will be made within the 45 days following receipt of the application. All applicants are notified in writing regarding the outcome of their eligibility and enrollment status.

An annualized gross income figure is used to determine eligibility. There are no earned income disregards. There is no resource limit. The number of persons in the family determines the applicable income standard.

The eligibility redetermination process entails checking all available interfaces and databases for current pertinent information prior to contacting the participant by phone. If the renewal is not completed at this point, a renewal form is sent to the family at least 45 days before their health coverage will end. The form instructs the family to review the information on the form, provide any updated information, sign and return the form or call and report that there are no changes.

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

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

4.4. Describe the procedures that assure that:

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

The State of Idaho will ensure that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. The application for

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 16 assistance requires information on when the child was last covered by health insurance. Creditable insurance determinations are made if the applicant indicates current health insurance coverage. Place of employment is also required on the application which is used to determine if the applicant is a dependent of a State employee with access to coverage.

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

The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX.

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

Through the single application process, all children are first reviewed for Title XIX eligibility. Those that are found eligible are enrolled in Title XIX. Those who are ineligible for Title XIX and meet the income standards for Title XXI are considered for Title XXI enrollment. Eligibility determinations for both Medicaid and SCHIP are handled by State employees.

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

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

The insurance provided under the state child health plan does not substitute for coverage under group health plans. A six month period of uninsurance is incorporated as an eligibility requirement for CHIP.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 17 The application requires information on when the child was last covered by health insurance. Exceptions to the period of uninsurance will be made if the applicant lost private insurance through no fault of their own (i.e., due to employer decisions) or due to hardship. The State monitors the number of eligibility denials of children that have creditable insurance who subsequently become eligible within six months.

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

Not applicable.

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

Not applicable.

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

Idaho’s premium assistance programs are described in and administered under Idaho’s Section 1115 HIFA waiver.

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

Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. Indian Health Service and tribal clinics are included as CHIP service providers. Idaho Medicaid and Tribal representatives formally meet on a routine basis. Tribal representatives can request that CHIP information be presented at any of these meetings. Additionally, regional Healthy Connections

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 18 Representatives (primary care case management program coordinators) work with providers and enrollees (both Medicaid and SCHIP) to resolve issues and help ensure assistance is appropriately provided.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 19 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

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

The State of Idaho places equal emphasis on outreach and education activities, which are those administrative procedures and program features that inform and recruit children and their families into potential enrollment. DHW directs outreach and education to the following groups. • Health Care Providers • Schools • HeadStart/Child Care Providers • Child Advocacy Groups

Idaho has developed a multi-dimensional approach to outreach including but not limited to the following. • Support of stakeholder efforts to conduct targeted, grass-roots outreach. • Supporting regional efforts by supplying professionally designed promotional materials. • Provision of technical assistance to regional efforts through central office support staff.

In addition, regional outreach activities are conducted by regional Healthy Connections Representatives (primary care case management program coordinators). Healthy Connections Representatives are part of the Division of Medicaid but are located in regional offices, and coordinate outreach and education for CHIP throughout the state.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 20 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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

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

Idaho is providing Secretary-Approved coverage for the CHIP population, defined in SCHIP Statute as “coverage that provides appropriate coverage for the population of targeted low-income children covered under the program.”

6.1.1.

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

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

6.1.2.

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

6.1.3.

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

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 21 6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe)

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

The State of Idaho will provide one of two benefit packages to children eligible for Title XXI coverage. The Basic Benchmark Benefit Package is attached as Appendix 2. All other provisions of the Basic Benchmark Benefit Package are administered by the Department in accordance with statutory authority granted under Chapter 2 of Title 56, Idaho Code. The Enhanced Benchmark Benefit Package is attached as Appendix 3. All other provisions of the Enhanced Benchmark Benefit Package are administered by the Department in accordance with statutory authority granted under Chapter 2 of Title 56, Idaho Code.

To ensure that children are provided with the benefit package that will lead most directly to desired health outcomes, and to ensure that these benefits represent the most effective and efficient use of scarce health resources, Idaho Medicaid will incorporate a health risk assessment into Idaho's eligibility determination process and primary care case management (PCCM) program, Healthy Connections.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 22 Applicants for medical assistance will complete an accompanying health questionnaire designed to assess general health status and health behaviors. The questionnaire will also serve as a screening tool to determine whether the applicant has special health needs. DHW will also assess whether the applicant requires special education services or is enrolled in Idaho's Children's Special Health Program, Infant and Toddler Program, Children’s Mental Health Program or Adult Mental Health Program.

Eligibility for Idaho’s Children’s Mental Health Program requires a diagnosis of “serious emotional disturbance (SED). SED in children is defined in Idaho Code 16-2403(13).

Children with special health needs will be enrolled in the Enhanced Benchmark Benefit Package. Individuals without such needs will be enrolled in the Basic Benchmark Benefit Package. In addition, the questionnaire will determine whether the applicant is currently under treatment by a physician or has a medical home. If not, the applicant will receive information about Healthy Connections providers and will be asked to select a primary care provider as part of the eligibility determination process.

Failure to complete a health questionnaire will not prohibit an applicant from being determined eligible for medical assistance. However, without a completed health questionnaire, children cannot be immediately provided with the Enhanced Benchmark Benefit Package.

Subsequent to selection of a Healthy Connections provider, the participant will visit a physician for a comprehensive exam and health education. This assessment will comply with federal requirements for EPSDT for children. If the health risk assessment indicates a previously unknown special health need, the participant will be provided with the Enhanced Benchmark Benefit Package. The health risk assessment process will therefore act as both a component of eligibility determination and a safeguard to ensure that benefits address beneficiary health needs by providing access to needed services available under the appropriate benefit package.

6.2.1.

Inpatient services (Section 2110(a)(1)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 23 ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) 6.2.27.

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

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 24 6.2.28.

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

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

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

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

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

N/A

6.4.1.

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

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

6.4.1.2. The cost of such coverage must not be greater, on an

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 25 average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

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

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

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 26 Section 7. Quality and Appropriateness of Care

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

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

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards 7.1.2.

Performance measurement 7.1.3.

Information strategies 7.1.4.

Quality improvement strategies

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

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

Enrollment in Idaho’s primary care case management program (Healthy Connections) is required in most areas of the state, which helps to ensure that enrollees have a usual source of care. Primary care providers are required by contract to provide primary care services to their enrollees. This includes wellness care and immunizations. In addition, Healthy Connections Representatives (primary care case management program coordinators) work with enrollees and providers to help ensure appropriate covered services are provided.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

The State of Idaho will ensure access to covered services, including emergency services as defined in 42 CFR 457.10. Referrals are not required to access emergency services. All provider types necessary to provide covered services are included in the provider panel.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 27 7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The State of Idaho will ensure access to appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition.

Contractually, primary care providers are required to make referrals for most medically necessary specialty services. All provider types necessary to provide covered services are included in the provider panel. In addition, Healthy Connections Representatives (primary care case management program coordinators) work with enrollees and providers to help ensure appropriate covered services are provided.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Decisions related to prior authorization of health services will be completed in accordance with State law and/or Administrative Rule and the medical needs of the patient.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 28 Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

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

8.2.1. Premiums: Enrollees in the Basic Benchmark Benefit Package with family incomes at or above 150% FPL will be subject to a premium in the amount of $10 per member per month for medical services and an additional $5 per member per month for dental services. Premium amounts paid apply first to medical services in determining delinquency. Enrollees in the Basic Benchmark Benefit Package with family incomes above 133% FPL up to 150% FPL will be subject to a premium in the amount of $10 per member per month for medical services and are not subject to the dental premium. Delinquent payments must be paid before re-enrollment (see Section 8.7 for further delinquency and disenrollment protection information). Enrollees in the Enhanced Benchmark Benefit Package are not subject to premiums.

Wellness Preventive Health Assistance (PHA): The state has established a mechanism to assist participants with their premium payment obligations. This mechanism is called Wellness PHA. Each participant who is required to make premium payments can earn 30 points every 3 months by receiving recommended wellness visits from their PCP and demonstrating up-to-date immunizations. These Wellness PHA points can be used to offset premium payments. Each point equals one dollar.

A child with family income below 150% FPG may have all his premium obligations met by utilizing Wellness PHA. Children in families 150-185% FPG may offset up to two-thirds (two out of every three) of their payments.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 29

8.2.2. Deductibles: N/A 8.2.3. Coinsurance or copayments:

• A participant who seeks care at a hospital emergency department for a condition that is not an emergency medical condition may be required to pay a co-payment to the provider. The determination that the participant does not have an emergency medical condition is made by the emergency room physician conducting the medical screening and using the prudent layperson standard. • A participant who accesses emergency transportation services for a condition that is not an emergency medical condition may be required to pay a co-payment to the provider of the service. The determination that the participant did not have an emergency medical condition is made by Idaho Medicaid. • Beginning on February 1, 2007, the nominal fee amount required to be paid by the participant as a co-payment is three dollars ($3.00). This nominal amount will be adjusted annually as determined by the Secretary of Health and Human Services.

8.2.4. Other: N/A

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

Changes to cost-sharing requirements are communicated through the public legislative process. DHW also adheres to a public rules promulgation process in order to communicate cost-sharing and other program changes.

In addition, the public is made aware of cost-sharing requirements through the following communication methods. • Publication on the State’s Medicaid website. • Program information materials including brochures and applications. • Program notices to participants at eligibility determination and redetermination. • Public hearings held in conjunction with Administrative rules promulgation.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 30 8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

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

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

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

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 31 8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

The State of Idaho will ensure that the annual aggregate cost-sharing for a family does not exceed five (5) percent of such family’s income for the length of the child’s eligibility period in the State. Upon enrollment participants are sent a notice advising them of their cost-sharing responsibilities. This includes notice of the five percent maximum.

Cost-sharing in the Idaho plan is set so low that very few families will reach their 5% limit. Additionally, a family that does exceed the limit will do so due to inappropriate use of emergency services.

Through the various information strategies such as the use of eligibility workers and other avenues of information dissemination, participants and their families are informed as to the limits of their financial liability for the coverage. The first direct written communication with families instructs parents that the expenditures on their child(ren)s health care should not exceed 5% of family income.

Benefit booklets are provided to all participants at initial eligibility determination and upon request thereafter. Information is included which directs families to inform the state whenever the 5% maximum is met or exceeded.

The State has adopted the "shoe box" approach to reimburse families who exceed the 5% limit. Families are required to track expenditures based on he calculation of family income provided by the state and to submit receipts for all expenditures in excess of the 5% limit. The family will receive a refund in an amount equal to their excess payments.

Once the maximum out of pocket is met, the family is not required to pay premiums for the remainder of the eligibility period.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 32 The state will ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. Native American and Alaskan Native children will not be charged monthly premiums or co-payments. The family will be required to declare tribal membership so that the cost sharing exemption can be processed.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Renewal: If premium payments are two or more months in arrears at the time of renewal, the child(ren) will lose eligibility for the program and be prohibited from participation until the delinquency is paid. Delinquent accounts will be sent a delinquency notice monthly. The notice includes the amount of the delinquency, their right to be considered for Medicaid eligibility and the consequence of not bringing their account current. The notice also includes a reminder that the family may receive help with their premium payments by participating in Wellness PHA.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8. The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copays,

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 33 coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 34 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

Strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children are listed in Table 9.1.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

Performance goals are listed in Table 9.1.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Performance under the plan will be measured through objective, independently verifiable means, listed in Table 9.1, and will be compared against performance goals. The state also uses the following performance measures.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. • Well child visits for children in the first 15 months of life.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 35 • Well child visits in the 3rd, 4th, 5th, and 6th years of life. • Use of appropriate medications for children with asthma. • Comprehensive diabetes care (hemoglobin A1c tests). • Children’s access to primary care services.

9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well childcare 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: 9.3.8.

Performance measures for special targeted populations.

Table 9.1 (1) Strategic Objectives (2) Performance Goals for each Strategic Objective (3) Performance Measures and Progress (specify data sources, methodology, time period, etc.) Objectives related to Reducing the Number of Uninsured Children To increase the number of children participating in Title XIX and XXI health programs.

The targeted increase in enrollment is 8,000 children annually New/Revised

Continuing X

Data Sources: Enrollment data from the Division of Medicaid AIM system. • Methodology: Annual increase in enrollment of uninsured children in both programs compared to the previous federal fiscal year. • The total number of new uninsured children enrolled in both programs compared to the base number of enrollees as of 9/30/99 • Numerator: Number of enrollees on 9/30/03: 112,678 • Denominator: Number of enrollees on 9/30/99: 54,824 Progress Summary: Idaho achieved its annual target by increasing enrollment an additional 8001 children in FFY03. As of 9/30/03, Idaho has enrolled an additional 57,854 children, more than doubling the number of children covered by Title XIX & Title XXI in the past 4 years. Objectives Related to SCHIP Enrollment To increase the number of children enrolled in the Title XXI. program

The targeted increase in enrollment is 2,000 children annually.

New/Revised

Continuing X

Data Sources: Enrollment data from the Division of Medicaid AIM system • Methodology: Annual increase in enrollment of uninsured children compared to the previous federal fiscal year. • The total number of children enrolled each year. • Numerator: Number of enrollees on 9/30/03: 10,954 • Denominator: Number of enrollees on 9/30/99: 3,735

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 36 (1) Strategic Objectives (2) Performance Goals for each Strategic Objective (3) Performance Measures and Progress (specify data sources, methodology, time period, etc.) Progress Summary: The number of Title XXI children decreased this year for the first time in 4 years. The number decreased by 1,022 in FFY03 resulting in an 8.5% decline. It is believed that with the downturn in the economy, children applying for assistance are qualifying for Title XIX instead of Title XXI. The statistics bear this out. As of 9/30/03, overall Idaho had increased enrollment since 1999 by 7,219 children, a 193% increase. Objectives Related to Increasing Medicaid Enrollment To increase the number of children enrolled in Title XIX health programs The targeted increase in enrollment is 6,000 children annually.

New/Revised

Continuing X Data Sources: Enrollment data from the Division of Medicaid AIM system.

• Methodology: Annual increase in enrollment of uninsured children in Title XIX programs compared to the previous federal fiscal year. • The total number of new uninsured children enrolled in Title XIX programs compared to the base number of enrollees as of 9/30/99 • Numerator: Number of enrollees on 9/30/03: 101,724 • Denominator: Number of enrollees on 9/30/99: 51,089 Progress Summary: The number of children enrolled in Title XIX increased by 9,023 or nearly 10% in FFY03. As of 9/30/03, Idaho had increased enrollment by 50,635 children, an increase of 99%.

Objectives Related to Increasing Access to Care (Usual Source of Care, Unmet Need) To ensure that enrolled children have a medical home. There will be a 10% annual increase in the number of children participating in Healthy Connections and having a primary care provider as a “medical home”. New/Revised

Continuing X

Data Sources: Division of Medicaid, Healthy Connections (PCCM) Program • Methodology: Baseline data on the number of children in the Healthy Connections is known. The data system will track new enrollees in the program • Numerator: Number of children enrolled in HC at the end of the FFY 9/30/03: 88,415 • Denominator: Number of children enrolled in HC at the beginning of the FFY 10/1/00: 25,661 Progress Summary: Healthy Connections enrollment increased by 37,058 children in FFY 03, a 72% increase for the year and a 244% increase over the baseline. Percent of children participating rose from 49% to 80%. Objectives Related to Use of Preventative Care (Immunizations, Well Child Care) To ensure that enrolled children receive appropriate and necessary medical care. 90% of enrolled children will have up- to-date, age- appropriate vaccinations.

80% of enrolled children age 12 months and younger will have received New/Revised

Continuing X

Data Sources: Division of Medicaid information system, Division of Health Immunization Registry • Methodology: Claims data will be reviewed for immunization and preventive care visits. The immunization registry is being used to track immunization levels. • Numerator: Number of children with up-to-date immunizations and preventive care visits. • Denominator: Total number of Title XIX and XXI children.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 37 appropriate preventive care. Progress Summary: No change- At this time, Idaho is examining the data collection criteria to report wellness visits. The FFY02 HCFA416 report indicates that the screening ratio for children <1 year of age has dropped to 25%. However this is believed to be currently underreported. FFY03 data is not available at the time of this report. Medicaid will be addressing the issue of correct coding for wellness visits in FFY04.

Immunizations: No change. For the first three series of shots, Idaho's rate of immunizations is in the low 90s. By the time children are ready to go to school the rate is approximately 95%. Similar to other states, rates reflect a decline in the percentage for the 2 year old age group.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 38 9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

Idaho Medicaid and Tribal representatives formally meet on a quarterly basis. Tribal representatives can request that program information be presented at any of these meetings. The Department requests time for program updates to be presented as

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 39 needed.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d).

Public hearings, advertised through prior public notice, are held in conjunction with Administrative Rules promulgation required to amend eligibility or benefits for the Children’s Health Insurance Program. These hearings allow public comment on the entire program.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 40 9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140) • Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

State match for CHIP participants with family incomes between 150% and 185% FPL is collected through a state-imposed premium tax on insurance policies sold within the State. A portion of these funds is dedicated to CHIP funding via Idaho statute. The premium tax that funds this portion of the program is imposed on all entities that sell insurance (not just health insurance) in Idaho. Less than 85 percent of the premium tax burden falls on health care providers. The premium tax collections from health insurance are treated the same as premium tax collections from other types of insurance. Therefore, this premium tax does not meet the definition of a “health-care related tax” as defined in 42 CFR §433.55.

State match for CHIP participants with family incomes between 133% and 150% FPL is appropriated from the state General Fund.

Benefit Costs FFY06 FFY07 Insurance payments, PCCM (PMPM x # eligibles) $9,176,418 $10,743,319 Insurance payments, Fee for Service (PMPM x # eligibles) $1,619,367 $1,895,880 Total Benefit Costs $10,795,786 $12,639,199 (Offsetting beneficiary cost sharing payments) ($242,715) ($548,770) Net Benefit Costs $10,553,071 $12,090,429

Administration Costs

Personnel $638,000 $650,760 General Administration $223,321 $227,788

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 41 Contractors/Brokers (e.g., enrollment contractors)

Claims Processing

Outreach/Marketing Costs

Healthy Schools (Health Services Initiatives) $100,000 $410,000 Other

Total Administration Costs $961,321 $1,288,548 10% Administrative Cap $1,172,563 $1,343,381 Federal Title XXI Share $9,089,461 $10,507,848 State Share $2,424,931 $2,871,128 TOTAL COSTS OF APPROVED SCHIP PLAN $11,514,392 $13,378,977

Average Monthly Eligibles 7,139 8,021

Average PMPM Cost (Prior to Offsets) $126.02 $131.32

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 42 Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment.

10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3.

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 43 Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1.

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 44 Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

12.1. Eligibility and Enrollment Matters

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120.

12.3. Premium Assistance Programs

If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

1 IDAHO TITLE XXI PROGRAM FACT SHEET

Name of Plan:

Idaho Children’s Health Insurance Plan

Date Plan Submitted:

February 17, 1998 Date Plan Approved:

June 15, 1998 Effective Date of Plan:

October 1, 1997

Date Amendment #1 Submitted: October 13, 1998 Date Amendment #1 Approved: December 4, 1998 Date Amendment #1 Effective:

July 1, 1998

Date Amendment #2 Submitted: March 21, 2000 Date Amendment #2 Approved:

March 1, 2001 Date Amendment #2 Effective: January 1, 2000

Date Amendment #3 Submitted: June 28, 2002 Date Amendment #3 Approved: September 19, 2002 Date Amendment #3 Effective:

July 1, 2002

Date Amendment #4 Submitted: February 25, 2004 Date Amendment #4 Approved: June 10, 2004 Date Amendment #4 Effective:

July 1, 2004

Date Amendment #5 Submitted: August 30, 2004 Date Amendment #5 Approved: January 13, 2005 Date Amendment #5 Effective:

July 1, 2004

Date Amendment #6 Submitted: June 9, 2005 Date Amendment #6 Approved: September 7, 2005 Date Amendment #6 Effective:

June 1, 2005

Date Amendment #7 Submitted: April 28, 2006 Date Amendment #7 Approved:

May 25, 2006 Date Amendment #7 Effective:

July 1, 2006

Date Amendment #8 Submitted: May 5, 2006 Date Amendment #8 Approved: May 25, 2006 Date Amendment #8 Effective:

July 1, 2006

Date Amendment #9 Submitted: January 24, 2007 Date Amendment #9 Approved:

September 28, 2007 Date Amendment #9 Effective:

January 1, 2007 (Wellness PHA) February 1, 2007 (cost sharing)

2 Date Amendment #10 Submitted: March 17, 2009 Date Amendment #9 Approved:

Pending Date Amendment #9 Effective: November 1, 2008 (Substance Abuse &Speech-Language Pathology Services) January 1, 2009 (Mental Health & Developmental Disability Agency)

Background

• On February 17, 1998, Idaho submitted a Title XXI state plan to expand Medicaid coverage to optional targeted low-income children up to age 19 with incomes through 160 percent of the Federal poverty level (FPL).

Amendments

• On October 13, 1998, the State submitted an amendment to its approved Title XXI plan to lower the income eligibility standards from incomes through 160 percent of the FPL to incomes through 150 percent of the FPL, retroactive to July 1, 1998. This change was mandated by the Idaho Legislature, and the State discussed this change in its original Title XXI Plan proposal.

• On March 21, 2000, Idaho submitted an amendment to its Title XXI plan to implement program design changes to increase coordination of efforts across agencies, simplify the application, and improve media and outreach approaches.

• Idaho submitted its third amendment on June 28, 2002. This amendment updates and amends the CHIP state plan to indicate the State’s compliance with the final CHIP regulations.

• On February 25, 2004, Idaho submitted an amendment to create a separate child health program (CHIP B), to expand coverage to children with family incomes over 150 percent through 185 percent of the FPL.

• On August 30, 2004, Idaho submitted its fifth Title XXI state plan amendment (SPA), and subsequently revised it on December 1, 2004, to request secretarial approval for a new benefit package for the State's separate child health program, CHIP B. The amendment specifically: removes the 20-day limit on coverage of outpatient mental health services; limits coverage of inpatient mental health services to 30 days per year; eliminates coverage for dental services, except for emergency dental; eliminates coverage for durable medical equipment; and limits coverage of therapy services (i.e., physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders) to only those services provided by a hospital.

• On June 9, 2005, Idaho submitted its sixth amendment. The amendment removes the enrollment cap on the State’s separate child health program (CHIP-B) and changes the consequences for delinquent CHIP-B premium payments from a family losing

3 eligibility for one year, with the debt forgiven, to a family losing eligibility until the debt is paid in-full.

• On April 28, 2006, Idaho submitted its seventh amendment. This amendment implements a school-based health service initiative for low-income children as allowed under the 10 percent administrative cap of CHIP. Grants will be made to school districts to assist with the salary expenses of registered nurses working in schools. Services provided will include health counseling and education, health screenings, prevention services, health coordination, referral to care outside of school, and application assistance leading to enrollment in Title XIX and Title XXI health coverage programs.

• On May 5, 2006, Idaho submitted its eighth amendment. This amendment changes the lower income eligibility level for the separate CHIP program for children from birth through 18 years from 150 percent of the Federal poverty level (FPL) to above 133 percent of the FPL, yielding a revised income eligibility standard of above 133 percent of the FPL through 185 percent of the FPL. This amendment also limits enrollment in the State’s title XXI Medicaid Expansion Program to children ages 6 through 18 years with family income above 100 percent of the FPL through 133 percent of the FPL. The amendment removes the resource limits related to program eligibility and imposes premiums for children with family income above 133 percent of the FPL. Enrollees in the Basic Benchmark Benefit Package with family incomes above 133 percent through 150 percent of the FPL will be subject to a $10 per member per month premium. Enrollees in the Basic Benchmark Benefit Package with family incomes above 150 percent through 185 percent of the FPL will be subject to a $10 per member per month premium for medical services and an additional $5 per month for dental services. Enrollees in the Enhanced Benchmark Benefit Package are not subject to premiums. This amendment also changes the current benefit package to a Secretary-Approved package, entitled the ‘Basic Benchmark Benefit Package’ or, an ‘Enhanced Benchmark Benefit Package,’ for children with special health care needs.

• On January 24, 2007, Idaho submitted its ninth amendment. This amendment established a mechanism to assist participants with their premium payment obligations, called the Wellness Preventative Health Assistance (Wellness PHA). Each enrollee who is required to make premium payments can earn 30 points every 3 months by receiving recommended wellness visits and demonstrating up-to-date immunizations. Each point equals one dollar and can be used to offset premium payments. A child with family income below 150 percent of the Federal Poverty Level (FPL) may have all his premium obligations met by utilizing Wellness PHA. Children in families from 150 percent up to and including 185 percent of the FPL may offset up to two-thirds of their payments. This amendment also adds a nominal co-payment of $3 for participants who seek care at a hospital emergency department or access emergency transportation for a non emergency condition.

4 • On March 17, 2009, Idaho submitted a CHIP SPA, which proposes to add coverage for substance abuse services, reduce limits for partial care, psychosocial rehab, therapy services and developmental disability agency services.

Children Covered Under Program

The State reported that 43,526 children ever enrolled in CHIP during FFY 2008.

Administration

The program is administered by the State Medicaid Agency.

Health Care Delivery System

• The State utilizes its current Medicaid delivery system to provide services to CHIP enrollees. The delivery system is a primary care case management model.

Benefit Package

• CHIP enrollees will receive one of two benefit packages based on health care needs. Most children will be covered under the Basic Benchmark Benefit Package. Children with special health needs will be enrolled in the Enhanced Benchmark Benefit Package.

• These benefit packages are Secretary-approved coverage. The benefit package includes well-baby and well-child services, immunizations, emergency services, inpatient and outpatient care, prescription drugs, diagnostic services, vision services, and inpatient and outpatient mental health services.

Cost Sharing

Premiums are imposed for children with family income above 133 percent of the FPL. Enrollees in the Basic Benchmark Benefit Package with family incomes above 133 percent of the FPL to 150 percent FPL will be subject to a premium in the amount of $10 per member per month for medical services and are not subject to a dental premium. Enrollees in the ‘Basic Benchmark Benefit Package’ with family incomes from 150 percent up to and including 185 percent of the FPL will be subject to a premium in the amount of $10 per member per month for medical services and an additional $5 per member per month for dental services. Enrollees in the Enhanced Benchmark Benefit Package are not subject to premiums. Enrollees have a nominal co-payment of $3 for participants who seek care at a hospital emergency department or access emergency transportation for a non emergency condition.

Coordination Between CHIP and Medicaid Idaho uses a single application, and children are first evaluated for regular Medicaid. Those who are found eligible for regular Medicaid are enrolled in Medicaid. A child who

5 is eligible for Medicaid is ineligible for CHIP.

Crowd-Out Strategy Idaho requires a 6-month period of uninsurance for CHIP. The application requires information on when the child was last covered by health insurance. Exceptions to the period of uninsurance will be made if the applicant lost private insurance through no fault of their own (i.e., employer driven) or due to hardship. In addition, substitution of coverage under CHIP is monitored by tracking the number of eligibility denials due to having creditable insurance.

Outreach

• Idaho has developed a multi-dimensional approach to outreach including but not limited to: - Building on existing regional successes through emphasis on targeted, grass-roots outreach. - State-level coordination across all Department of Health and Welfare divisions. - Establishment of a virtual resource network for CHIP.

Financial Information

Total FFY '09 CHIP Allotment -- $44 million FFY '09 Enhanced Federal Matching Rate – 78.84%

Date Last Updated: CMSO, FCHPG, DSCHI on December 1, 2009

_____________________________________________________________________________

Table of Contents

State/Territory Name: Idaho

State Plan Amendment (SPA) #: ID-13-0013

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

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

Children and Adults Health Programs Group

Matt Wimmer

CHIP Director

Department of Health and Welfare P.O. Box 83720

Boise, ID 83720-0036

Dear Mr. Wimmer:

DEC 1 2 2013

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) ID-13-0013 submitted on September 13, 2013 and related to Modified Adjusted Gross Income (MAGD Eligibility has been approved with an effective date of

January 1, 2014.

Non-Financial Eligibility:

SPA number ID-13-0013 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; substitution of coverage, non-payment of premiums, and continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Idaho’s current state plan as laid out below:

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security Number

Section 4.1.9.1

CS20: Non-Financial Eligibility — Substitution of Coverage

Section 4.4.4

CS21: Non-Payment of Premiums

Section 8.7

C827: General Eligibility - Continuous Eligibility

Section 4.1.8

Page 2 — Mr. Matt Wimmer

Your Title XXI project officer is Victoria Collins. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Collins’ contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2176

Facsimile: (410) 786-5882

E-mail: Victoria.Collins@cms.hhs.gov

If you have questions or wish to discuss this determination further, please contact Ms. Carol

Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 2201 6" Ave, Suite 801

Seattle, WA 98121

Congratulations on the approval of your SPA. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have

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

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

Sincerely,

Eliot Fishman Director

ce: Ms. Carol Peverly, ARA, CMS Region X, Seattle

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility ID.0327.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Idaho State Funds: $ 0.00 Federal Funds: $ 0.00 Submitted By: Rachel Strutton Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ID-13-0013 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact This SPA has a budget impact. Total budget impact: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:22 out of 2000 Title XXI SPA action 5 Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Last Revision Date: Dec 11, 2013 Submit Date: Sep 13, 2013 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CCMsS CHIP Eligibility

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

Separate Child Health Insurance Program csi7 Non-Financial Eligibility - Residency

42 CFR 457.320

Residency

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

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

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

1. Intends to reside in the state, including without a fixed address, or 2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. {@] A non-institutionalized child not described above and a child who is not a ward of the state:

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

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

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

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

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

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [8] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

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

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

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

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

TN: ID-13-0013-CS17 Effective Date: January 1, 2014 Approval Date: December 12, 2013 Page 1 of 2

cemMs CHIP Eligibility

One or more interstate agreement(s). No

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

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

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

TN: ID-13-0013-CS17 Effective Date: January 1, 2014” Approval Date: December 12, 2013 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

Separate Child Health Insurance Program Non-Financial Eligibility - Citizenship

CS18

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

Citizenship

national status or satisfactory immigration status.

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

Who are citizens or nationals of the United States; or Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Recon

prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.

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.

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

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

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

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

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

ciliation

380.

Yes

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

The date benefits are furnished is:

@ The date of application containing the declaration of citizenship or immigration status.

C The date the reasonable opportunity notice is sent.

C Other date, as described: The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing N in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). ° The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state ba also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- ° Income Pregnant Women.

TN: 13-0013-CS18 Effective Date: January 1, 2014 Approval Date: December 12, 2013

Page 1 of 2

CHIP Eligibility

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

TN: 13-0013-CS18 Effective Date: January 1, 2014 Approval Date: December 12, 2013 Page 2 of 2

coms CHIP Eligibility

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

Separate Child Health Insurance Program Cs19 Non-Financial Eligibility - Social Security Number :

42 CFR 457.340(b)

Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as

determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or

Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

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

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

How the state will use the SSN.

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

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

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

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

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

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

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

PRA Disclosure Statement

TN: 13-0013-CS19 Effective Date: January 1, 2014 Approval Date: December 12, 2013

Page 1 of 2

CCMs CHIP Eligibility

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

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

TN: 13-0013-CS19 Effective Date: January 1, 2014 Approval Date: December 12, 2013

Page 2 of 2

cCcCmMsS CHIP Eligibility

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

Separate Child Health Insurance Program cs20 Non-Financial Eligibility - Substitution of Coverage

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

Substitution of Coverage

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

[@] Substitution of coverage prevention strategy:

TN: 13-0013-CS20 Effective Date: January 1, 2014 Approval Date: December 12, 2013

Page 1 of 3

CHIP Eligibility

Name of policy Description Monitoring for Substitution of Insurance provided under CHIP does not substitute for Coverage coverage under group health plans.

Prior to January 1, 2014, the State required that a child not have had creditable health insurance for the 6 months immediately preceding the application or to determine if the family lost insurance through no fault of the insured such as, financial hardship, unaffordable premiums, loss of employment, or the loss of eligibility for employer sponsored insurance. To monitor its substitution of coverage policy, the State requires applicants to list health coverage for all persons in the household who currently have health insurance, and to include the information on the policy for those that do. The application also contains a question on whether anyone has had health insurance end within the six months prior to application, and asks the applicant to provide a reason for the coverage ending. The trigger point for this policy is at initial application or at eligibility redetermination. Historically, very few applicants did not meet the no + fault threshold.

As of January 1, 2014, the Department will not require a 6 month period of un-insurance prior to receipt of CHIP. It has been found that the vast majority of applicants are able to meet the no-fault provisions and were provided coverage as of application date.

The Department will continue to monitor the availability of private insurance through the application and eligibility redetermination process , the monitoring of coverage through our third party liability contractor, enforcement of child medical support orders and evaluating Medical billings that might indicate another party liable for an accident or injury.

Applicants are informed of the requirement to pursue available coverage resources, including ESI, individual coverage, medical support or third party claims through the application process.

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

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

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

TN: 13-0013-CS20 Effective Date: January 1, 2014 Approval Date: December 12, 2013 Page 2 of 3

CCMS CHIP Eligibility

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

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

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

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

V.20130718

TN: 13-0013-CS20 Effective Date: January 1, 2014 Approval Date: December 12, 2013

Page 3 of 3

coms CHIP Eligibility

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

Separate Child Health Insurance Program C821

(Non-Financial Eligibility - Non-Payment of Premiums

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? No

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

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

'V.20130709

TN: 13-0013-CS21 Effective Date: January 1, 2014 Approval Date: December 12, 2013 Page 1 of 1

ccms CHIP Eligibility

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

CS27

Separate Child Health Insurance Program General Eligibility - Continuous Eligibility

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

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

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

@ For children up to age 19

C For children up to age

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

[Mi] Atthe end ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [| The child attains the age specified by the state Agency or age 19. [Bi] The child or child's representative requests voluntary disenrollment.

[Mi] The child is no longer a resident of the state.

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

[i] The child dies.

{| There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

([] Other

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

V.20130717

TN: 13-0013-CS27 Effective Date: January 1, 2014 Approval Date: December 12, 2013 Page 1 of 1

_____________________________________________________________________________

Table of Contents State/Territory Name: Idaho State Plan Amendment (SPA) # ID-13-0015

This file contains the following documents in the order listed:

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

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

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

7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

“CMS

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

OCT 0.8 2013

Richard Armstrong, Director Department of Health and Welfare Towers Building -Tenth Floor P.O. Box 83270

Boise, ID 83270-0036

Dear Mr. Armstrong:

I am pleased to inform you that Idaho’s Children’s Health Insurance Program (CHIP) state plan amendment number ID-13-0015 submitted on September 17, 2013 has been approved with an

effective date of January 1, 2014.

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

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

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

Baltimore, MD 21244-1850 Telephone: (410) 786-0620 Facsimile: (410) 786-5882

E-mail: Angela.Corbin@cms.hhs.gov

If you have questions or wish to discuss this determination further, please contact Carol Peverly, Associate Regional Administrator in our Seattle Regional Office. Ms. Peverly’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations

2201 6" Ave. Mail Stop RX-43 Seattle, WA 98121

Page 2 — Mr. Armstrong

Congratulations on the approval. We look forward to continuing to work with you toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please

contact Linda Nablo, Director, of the Division of Children’s Health Insurance Programs, at 410- 786- 5143.

Sincerely,

Eliot Fishman Director

ce: Denise Chuckovich, Deputy Director Paul Leary, Medicaid Benefits Administrator Carol Peverly, ARA, CMS Region X, Seattle

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility ID.0331.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Idaho State Funds: $ Federal Funds: $ Submitted By: Rachel Strutton Last Revision Date: Sep 17, 2013 Submit Date: Sep 17, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:0 out of 2000 Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/16/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/16/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

coms CHIP Eligibility

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

CS14

Child Health Insu Eligibility - Childr

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

{@) Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

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

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

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

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

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

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

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

(% FPL.

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

OCT 0 8 2013

Idaho - State Plan ID#13-0015 Approval Date? Effective Date: January 1, 2014 Page | of 2

coms CHIP Eligibility

C Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

£102 8.0 130

Idaho - State Plan 1ID#13-0015 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Idaho

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

This file contains the following documents in the order listed:

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

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

eal a we

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

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES Children and Adults Health Programs Group

DEC 1 8 2013 Matt Wimmer CHIP Director

Department of Health and Welfare P.O. Box 83720 Boise, ID 83720-0036

RE: Idaho State Plan Amendment (SPA) Transmittal Number ID-13-0023 Dear Mr. Wimmer:

I am pleased to inform you that Idaho’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) ID-13-0023, has been approved. This SPA incorporates the Modified Adjusted Gross Income (MAGI)-Based eligibility process requirements, including the single streamlined application, into the Medicaid State Plan in accordance with the Affordable Care Act. This SPA is approved effective October 1, 2013.

The approval of SPA ID-13-0023 includes full approval of your state’s alternative application used to apply for multiple human service programs. By January 1, 2014, the state will implement a single streamlined paper application for health coverage only. Until July 31, 2014, the state is using an interim alternative single streamlined online application and will submit a revised alternative single streamlined online application that will address 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 Idaho’s approved CHIP state plan:

o C824 '

o Idaho Department of Health & Welfare Application for Assistance (multi-benefit application) Form HW2000, Rev. 11/26/2013

o Statement of use with respect to the alternative single streamlined paper application.

o Statement of use with respect to the alternative single streamlined online application.

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

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

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your Title XXI project officer is Ms. Victoria Collins. She is available to answer

Page 2—Mr. Matt Wimmer, Director

questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-2176

Facsimile: (410) 786-5882

E-mail: Victoria.Collins@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Ms. Carol Peverly

Office of the Regional Administrator 2201 6th Ave, Suite 801

Seattle, WA 98121

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

We look forward to continuing to work with you and your staff. Sincerely, Eliot Fishman Director

cc: Ms. Carol Peverly, ARA, CMS Region X, Seattle

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12 4q Cc M 4 Baltimore, Maryland 21244-1850 cet acc Ss

Children and Adults Health Programs Group

Division of State Coverage Programs

DEC 1 8 2013

Matt Wimmer

CHIP Director

Department of Health and Welfare P.O. Box 83720

Boise, ID 83720-0036

Dear Mr. Wimmer:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) transmittal ID-13-0023. CMS is granting approval for Form C824 — Eligibility Process ID-13-0023, which was submitted to CMS on October 7, 2013. Our review of this submission included a review of the alternative application used to apply for multiple human service programs developed by the state and a review of the timeline for completion of both the online single streamlined application and the single streamlined paper application for health coverage only.

Until January 31, 2014, the state is using an interim alternative single streamlined paper application and until July 31, 2014, the state is using an interim alternative single streamline online application. Both these applications must be revised to meet the standards as outlined in 42 CFR 435.907 and the guidance on alternative applications released by CMS on June 19", 2013.

Please submit the single streamlined paper application for health coverage only to CMS for review no later than January 1, 2014 to ensure approval by January 31, 2014. Please also submit a revised alternative single streamlined online application to CMS for review no later than July 1, 2014 to ensure approval by July 31, 2014. We continue to be available to provide technical assistance. If you have any questions about this letter, please contact Victoria Collins at

Victoria.Collins@cms.hhs.gov or (410) 786-2176.

incerel

inda Nablo Director, Division of State Coverage Programs

ce: Ms. Carol Peverly, ARA, CMS Region X, Seattle

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility ID.0414.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Idaho State Funds: $ Federal Funds: $ Submitted By: Rachel Strutton Last Revision Date: Jan 23, 2014 Submit Date: Oct 7, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ID-13-0023 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2101(b)(3) & 2107(e)(1)(o) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:47 out of 2000 CHIP Eligibility Process (ACA XXI SPA Action 4) Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/30/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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

— CHIP Eligibility

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

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

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

Application Processing

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

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

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

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

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CFR 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means.

Other electronic means:

Name of method Description Fillable PDF The State will have on line a fillable PDF application as an interim solution. The on line ; application is not yet completed but is in process. xX

The PDF may be completed and printed or scanned or emailed, etc.

In person Applicants may bring application into the office.

Telephonic Applicants may complete an application in the course of a telephone interview and provide a telephonic signature.

SPA# ID-13-0023 Approval Date: DEC j 8 2013 Effective Date: October 1, 2013 Page 1 of 3

CoMS CHIP Eligibility

E-Mail The applicant may completed the fillable PDF and x email to the local office. me

Fax A completed application may be faxed to the local : office.

Postal mail An applicant may mail a completed application to x : the Department. ;

Screen and Enroll Process

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

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

Procedures include:

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

im Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

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

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced Yes premium tax credits in accordance with section 1943(b)(2) of the SSA.

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 457.343:

[i] Once every 12 months.

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

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering & insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of 42

CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

SPA# ID-13-0023 Approval Date:, DEC { 8 2013 Effective Date: October 1, 2013 Page 2 of 3

cms. CHIP Eligibility

Check all types of agencies that apply:

The Exchange

Medicaid

{C] Other agency administering insurance affordability programs

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

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

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

SPA# ID-13-0023 Approval Date: DEC { 8 2013

Effective Date: October 1, 2013 Page 3 of 3

_____________________________________________________________________________ Table of Contents State/Territory Name: Idaho State Plan Amendments (SPA) #: ID-17-0018 This file contains the following documents in the order listed: 1) Approval Letter 2) Final Approved State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-16 Baltimore, MD 21244-1850 tvts cfNTIRS FOI M[DtCÁRt & MrDtC^tD SERVTCES CENTER TON MEDICAID & CH¡P SENVICES Children and Health Proerams Groun APR 1 I 2010 Matt V/immer Administrator Idaho Department of Health and Welfare P.O. Box 83720 Boise, lD 83720-0036 Dear Mr. V/immer: I am pleased to inform you that the Centers for Medicare & Medicaid Senices (CMS) has approved your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) number ID-17-0018, submitted on June 29,2017. Idaho curently provides Secretary-approved coverage under Section 2103(fi@) ofthe Social Security Act for its separate CHIP population. This coverage is modeled after the coverage provided under the state's Medicaid Altemative Benefit Plan (ABP). In addition, Idaho has elected to provide the Early and Periodic Sueening, Diagnostic and Treatment (EPSDT) benefit for children in its separate CHIP. Idaho recently received approval for Medicaid ABP SPAs, ID- l7-0001 , ID- l7-0008, and ID- I 7-0009. In this companion CHIP SPA, the state is making changes to some of its benefits to align with approved changes to the state's Medicaid ABP. In addition, the SPA provides technical clarifications to better explain existing policies. This SPA has a retroactive effective date of January I,2017 for the benefit updates, and July 1, 2017, for clarification of existing policies. Your title XXI project officer is Ms. Janice Adams. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Adams' contact information is as follows: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Mail Stop: RX-200 701 Fifth Avenue, Suite 1600 Seattle, V/A 98104 Telephone: (206) 615-2541 E-mail : Janice.Adamsl¿Dcms. hhs. sov Offrcial communications regarding program matters should be sent simultaneously to Ms. Adams and to Mr. David Meacham, Associate Regional Administrator (ARA) in our Seattle Regional Office. Mr. Meacham's address is:

Page 2 -Mt. Matt V/immer Centers for Medicare &Medicaid Services Division of Medicaid and Children's Health Operations Mail Stop: RX-200 701 Fifth Avenue, Suite 1600 Seattle, WA 98104 If you have additional questions, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (410) 786-072L We look forward to continuing to work with you and your staffon your program. Sincerely Director Mr. David Meacham, ARA, CMS Region X, Seattle / Anne Marie Costello /

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 1

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

Preamble

Section 490 I of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children.,s Health Insurance Program (SCHIP). Title XXl provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any ti.me through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. Ithas been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 2 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

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

State/Territory:________________Idaho___________________________________________ (Name of State/Territory)

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

/S/Matt Wimmer

_____ Medicaid Director

Date Division of Medicaid Idaho Department of Health and Welfare

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

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

Name: Matt Wimmer Position/Title: Medicaid Administrator Name: David Taylor Position/Title: Chief Financial Officer, Idaho Department of Health and Welfare Name: George Gutierrez Position/title: Deputy Administrator, Division of Medicaid Name: Elizabeth Kriete Position/Title: Deputy Administrator, Division of Medicaid

*Disclosure. 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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 3 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

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

1.1.1

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

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

1.1.3.

A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3

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

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

ORIGINAL PLAN Submitted: February 17, 1998 Date Approved: June 15, 1998 Effective Date: October 1, 1997

AMENDMENT#’S

DATES DESCRIPTION

Amendment #1

Change income limit from 160% FPG to 150% FPG Submitted October 13, 1998 Approved December 4, 1998 Effective Date July 1, 1998

Amendment #2

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 4 Submitted March 10, 2000 • Program design changes to- • increase coordination of efforts across agencies • simplify the application process, and • improve media and outreach approaches Approved March 1, 2001 Effective Date January 1, 2000

Amendment #3

• Technical changes to conform to model template • Revise outreach strategies Submitted June 28, 2002 Approved September 19, 2002 Effective Date July 1, 2002

Amendment #4

Establish Separate Program Submitted February 25, 2004 Approved June 10, 2004 Effective Date July 1, 2003

Amendment #5

Revise benefit package of separate program Submitted August 30, 2004 Approved January 13, 2005 Effective Date July 1, 2004

Amendment #6

Removal of enrollment cap Submitted June 9, 2005 Approved September 7, 2005 Effective Date June 1, 2005

Amendment #7

Addition of child health services initiative (Healthy Schools) Submitted April 28, 2006 Approved May 25, 2006 Effective Date July 1, 2006

Amendment #8

• Lower the income limit of separate program from 150% to 133% • Remove resource limit • Incorporate Basic and Enhanced Benchmark Benefit Packages • Changes to premium structure Submitted May 5, 2006 Approved May 25, 2006 Effective Date July 1, 2006

Amendment #9

• Addition of Wellness Preventive Health Assistance • Addition of co-pays Submitted January 24, 2007 Approved September 28, 2007 Effective Date January 1, 2007 Wellness PHA February 1, 2007 co-pays

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 5 Amendment #10

• Addition of Substance Abuse Treatment Services • Addition of Independent Therapists for Speech Language Pathology (SLP) Services • Reduce limits for Psycho-Social Rehabilitation, Partial Care and Developmental Disability Agency Services Submitted March 17, 2009 Approved July 15, 2003 Effective Date November 1, 2008 Substance use treatment & SLP January 1, 2009 Reduction in Mental Health and DDA

Amendment #11

• Contact Lens Coverage Modification • Mental Health Assessment Annual Limitation • Mental Health Treatment Plan Limitation • Collateral Contact & Partial Care Elimination • PSR Limitation • DDA Assessment Annual Limitation • Incorporation of Dental Services Template (Sections 6.2-D & 10.3-D) Submitted February 28, 2011 Approved July 15, 2013 Effective Date January 1, 2011

Amendment #12

Change to Chiropractic Service Limitations Submitted August 29, 2011 Approved July 15, 2013 Effective Date July 1, 2011

Amendment #13

Addition of co-payments (co-pays) for certain services Submitted December 31, 2011 Approved July 2, 2012 Effective Date November 1, 2011 Chiropractor, Optometrist and Podiatrist Svcs. January 1, 2012 Physical Therapy, Occupational Therapy, Speech

Amendment #14

• Addition of Health Homes for Chronically Ill • Implementation of Children’s Redesign Benefit Plan • Implementation of Behavioral Health Managed Care • Developmentally Disabled Children’s Benefit Redesign • Removal of Therapy Prior Authorization Submitted June 15, 2013 Approved August 29, 2013

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 6 Requirements Effective Date January 5, 2012 Removal of Therapy prior authorization requirements January 1, 2013 Health Homes July 1, 2013 Developmentally Disabled children’s benefit redesign September 1, 2013 Behavioral health managed care

MAGI Amendment #13- 0014

Medicaid Expansion Submitted September 17, 2013 Approved December 17, 2013 Effective Date January 1, 2014

MAGI Amendment #13- 0015

Establish 2101(f) Group Submitted September 17, 2013 Approved October 8, 2013 Effective Date January 1, 2014

MAGI Amendment #13- 0016

MAGI Eligibility & Methods Submitted September 19, 2013 Approved December 17, 2013 Effective Date January 1, 2014

MAGI Amendment #13- 0023

Eligibility Process Submitted October 7, 2013 Approved December 18, 2013 Effective Date January 1, 2014

Amendment #15

ACA Changes, Tobacco Cessation, Children’s Hospice Submitted June 27, 2014 Approved October 8, 2014 Effective Date January 1, 2014

Amendment #15-0016

MAGI Eligibility Income Methods Submitted June 25, 2015 Approved August 12, 2015 Effective Date July 1, 2014

Amendment #15-0016-A

Technical Updates

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 7 Submitted June 25, 2015 Approved September 9, 2015 Effective Date July 1, 2014

Amendment #16-0017

Primary Care Case Management Submitted June 1, 2016 Approved August 11, 2016 Effective Date July 1, 2016

Amendment #ID-17-0018

ABP Alignment & Technical Updates Submitted June 29, 2017 Approved April 19, 2018 Effective Date July 1, 2017 Technical Updates

January 1, 2017 ABP Alignment

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

The State used its standard negotiation (with the Tribes of Idaho) process for Tribal Consultation for this SPA. Hard copies of the Tribal notices were sent to Tribal Leaders and e-mailed to a contact list of Tribal Representatives as indicated in the table below. The notices were subsequently posted to the Idaho Medicaid-Tribes website.

SUBJECT DATE OF NOTIFICATION DESCRIPTION Basic ABP Enhanced ABP January 20, 2017 Idaho Medicaid’s Alternative Benefit Plans were aligned with Blue Cross of Idaho’s PPO Plan. The amendments aligned limitations, authorization requirements and/scope limits for certain benefits. Other changes were made to clarify benefits or policy. The State used its standard notification process for our Tribal partners for this SPA. Hard copies of the Tribal notices were sent to Tribal Leaders and e-mailed to a contact list of Tribal Representatives. The notices were subsequently posted to the Idaho Medicaid-Tribes website. This SPA’s were discussed as part of the quarterly meeting with the Tribes in February 2017. No additional requests for discussion or consultation were received.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 8 Superseding Pages of MAGI CHIP State Plan Material State: Idaho

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

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

CS 13

CS15 Eligibility – Targeted Low Income Children

Eligibility – Deemed Newborns

MAGI-Based Income Methodologies Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Incorporate within a separate subsection under 4.3

Incorporate within a separate subsection under section 4.3 ID-13-0014

Effective/Implementation Date: January 1, 2014 Title XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid Expansion section 4.0 ID-13-0015

Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 ID-13-0023

Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 ID 13-0013

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

CS18

CS19 Non-Financial Eligibility – Residency

Non-Financial – Citizenship

Supersedes the current section 4.1.5

Supersedes the current sections

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 9

CS20

CS21

CS27

Non-Financial – Social Security Number

Substitution of Coverage

Non-Payment of Premiums

Continuous Eligibility 4.1.0; 4.1 – L.R.; 4.1.1 – L.R.

Supersedes the current section 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Supersedes the current section 4.1.8 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)- (3)) and (Section 2105)(c)(7)(A)-(B))

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

Idaho is a predominantly rural state. The current population of 1,683,140 resides in its 44 counties. Seventy-five percent of Idaho’s counties have fewer than 25,000 residents, with a disproportionally high number of people residing in frontier counties. The rural nature of Idaho has a significant impact on health care issues, including insurance coverage and access to health care services.

Idaho’s largest ethnic minority is of Hispanic heritage. Southwest, southeast and south-central Idaho in particular have large concentrations of people with Hispanic heritage. Idaho also has five Native American tribes: the Shoshone and Bannock Tribes in eastern Idaho, the Shoshone and Paiute Tribes in Duck Valley, southwestern Idaho, the Nez Perce Tribe in north central Idaho, and the Coeur d’Alene Tribe in northern Idaho.

According to the 2015 American Community Survey, there are 440,000 children under the age of 18 in Idaho. It is estimated that 13,000 are uninsured compared to 30,000 in 2004. This comparison would indicate that the implementation of the Affordable Care Act has had a significant impact on the uninsured rate of Idaho’s children, in addition to a significant increase in the enrollment in CHIP and Medicaid.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR457.80(b))

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 10 2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance): The Idaho Department of Health and Welfare (DHW) strives to increase Idaho children’s enrollment in public health insurance programs by coordinating enrollment efforts across DHW divisions, coordinating with other public agencies, and by coordinating with other stakeholders. These coordination efforts include:

• Idaho Health Plan Coverage Booklet—a brochure outlining the services available throughout DHW to families, including Title XIX and Title XXI child health programs. • Idaho CareLine—an 800 number providing referral assistance to DHW customers throughout Idaho. The Idaho CareLine has a direct link to CHIP assistance. CHIP makes up the largest segment of callers on a regular basis. 888 KIDS NOW connects directly to the Idaho CareLine. • Coordinated outreach and enrollment activities with the Idaho Department of Education and school lunch and child care food programs. • Partnerships with stakeholder organizations that encourage posting of links to the State’s CHIP website (www.chip.idaho.gov) on stakeholder web sites in order to provide current information to Idaho citizens. • YourHealthIdaho – DHW contracts with the Idaho state based marketplace to provide eligibility determination for Medicaid and CHIP, as well as premium tax credits. This allows for streamlined eligibility determination for health coverage.

In addition, DHW provides potential enrollees with several types of application assistance by:

• Providing multiple options such as online submittal, mail-in/fax-in applications—the redesigned application allows potential CHIP enrollees to submit their application by internet, mail or fax. Self- reliance specialists make CHIP eligibility determinations without a face-to-face visit. When information is missing, self-reliance specialists contact potentially eligible families by telephone. • Using a simplified Application for Assistance for all benefit programs in the Self-Reliance Program (advanced premum tax credits, Health Coverage, Cash Assistance, Food Stamps, Child Care, Telephone Service and Nursing Home). • Coordinating with Your Health Idaho, the Idaho health insurance exchange, to facilitate eligibility determination and enrollment of eligible participants in the Medicaid and CHIP programs.

Presumptive eligibility determinations as conducted by trained facilities

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership: • IDHW conducts eligibility in coordination with Your Health Idaho, the Idaho health insurance exchange, to facilitate eligibility determination and enrollment of eligible participants in the Medicaid and CHIP programs.

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

The State of Idaho utilizes routine stakeholder engagement with other entities engaged in providing or

coordinating health benefits coverage for children. Programs such as title V, head start , early intervention

services and public schools are integral to increasing the number of children with creditable health coverage.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 11 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

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

The same method of assuring delivery of insurance products and delivery of health care services is used for Title XXI and Title XIX. Providers are required by contract to assure that services are delivered in accordance with state and federal regulations. CHIP utilizes the same provider network as Idaho Medicaid. Services are primarily reimbursed on a fee-for-service basis under a Primary Care Case Management (PCCM) model of managed care, administered by the State. Behavioral Health and dental services are delivered under separate managed care agreements.

In addition, Idaho Medicaid promotes wellness by financing preventive services for children in schools. Idaho Medicaid awards grants to schools to facilitate delivery of preventive health services to low-income students. These grants are issued as Title XXI non-primary expenditures and as an alternative to School-Based Administrative Claiming.

Existing Idaho and federal law obligates Idaho Medicaid to pay schools for covered rehabilitative and health-related services under the Individual with Disabilities Act (IDEA). These services are listed in Individualized Education Plans (IEPs} for children identified as having special health needs. Idaho Medicaid pays schools on a fee-for- service basis by certifying school funds. In order to provide preventive services through schools Idaho Medicaid proposes to fund services through Title XXI non- primary expenditures rather than developing an administrative claiming mechanism.

Title XXI non-primary expenditures are those program expenditures that are not medical services provided under the benefit package as described in the Title XXI state plan. Non-primary expenditures are reimbursable at the enhanced federal financial participation rate but are capped at 10 percent of the cost of benefits. Per 42 CFR 457.618, there are four categories of non-primary expenditures allowable under Title XXI, which include administrative expenditures outreach, health initiatives and certain other child health assistance. Health Services Initiatives, defined in 42 CFR 457.10, means "activities that protect the public health, protect the health of individuals, improve or promote a State's capacity to deliver public health services, or strengthen the human and material resources necessary to accomplish public health goals relating to improving the health of children (including targeted low-income children and other low-income children)."

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 12 Idaho Medicaid issues grants to 16 school districts to assist schools with the salary expenses of registered nurses (RNs) working in schools or with related resource needs. Idaho Medicaid has partnered with the Idaho Department of Education and the Division of Health, Idaho Department of Health and Welfare, to establish criteria for school nurse programs eligible for Medicaid grant funding and to distribute these grants. Currently, 33 out of 114 Idaho school districts maintain school nurse programs, and Idaho schools' current RN to student ratio in Idaho is 1:2,393 (the national standard is 1:750 for the general,non-special-needs student population.) Increasing the nurse to student ratio will result in increased health counseling and education, health screenings, prevention services, health coordination, referral to care outside of school,and applications to and enrollment in Title XIX and Title XXI health coverage programs.

Grant criteria will include the percentage of low-income students and need for increased access to health services. Idaho Medicaid funds grant amounts proportionate to percentages of low-income students in each grantee district. Idaho Medicaid requires semi-annual reports from grantee schools on provision of preventive health services and achievement of health services objectives as outlined in the grant program scope of work. Grant agreements will stipulate that grantee districts may not expend grant funds on services that may be billed through existing school-based services under a child's Individualized Education Plan.

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

This State Plan uses utilization controls from the Title XIX program, including prior approval controls, peer reviews,claims processing edits, and post-audit and review procedures. Primary care providers are charged with making referrals for medically necessary specialty services. Health services providers are provided a handbook describing the benefit package including limitations. Participants are issued an identification card which is used to determine covered services and service limitations.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 13

Section 4. Eligibility Standards and Methodology. (Section 2102(b)) CS3 SUPERSEDED 4.0 – CURRENT MEDICAID EXPANSION SEE MAGI SECTION) Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5. 4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a)) SUPERSEDED BY CS18 FOR 4.1.0; 4.1-LR & 4.1.1LR (SEE MAGI SECTION) 4.1.1. Geographic area served by the Plan: This State Plan applies to the entire State of Idaho. 4.1.2. Age: Children are eligible from birth through the month of the 19th birthday. 4.1.3. Income: Children with family incomes over 133% through 185% FPL are eligible for Idaho’s stand-alone SCHIP under Title XXI. Children who have family incomes over 100% through 133% FPL are eligible for Idaho’s Medicaid-expansion SCHIP under Idaho’s Title XIX State Plan from the month of their 6th birthday through the month of the 19th birthday. 4.1.1, 4.1.2 & 4.1.3 SUPERSEDED BY CS7 – GEOGRAPHICAL AREA & AGE AND INCOME (SEE MAGI SECTION) 4.1.4. Resources (including any standards relating to spend downs and disposition of resources): 4.1.5. Residency (so long as residency requirement is not based on length of time in state): SUPERSEDED BY CS17 (SEE MAGI SECTION) Children served are residents of the State of Idaho. 4.1.6. Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7. Access to or coverage under other health coverage: A child will be ineligible for coverage under this plan if they have access to or are enrolled in other health coverage, including the following scenarios. • The child is covered by creditable health insurance at the time of application. • The child has been voluntarily dropped from creditable coverage in the six months preceding application with the intention of qualifying for public coverage. • The child is eligible under Idaho’s Title XIX State Plan. • The child is eligible to receive health insurance benefits under Idaho’s state employee benefit plan.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 14

4.1.8. Duration of eligibility: The duration of eligibility is 12 months unless the child is terminated for one of the reasons described below. • The child loses his or her Idaho residency. • The child attains 19 years of age. • The child becomes eligible for and is enrolled in Medicaid. • The child’s parent or adult who is legally responsible for the child’s health care makes a written request to terminate coverage. • The application is found to have inaccurate information which effected an incorrect eligibility determination. • The child dies. SUPERSEDED BY CS27 (SEE MAGI SECTION) 4.1.9. Other standards (identify and describe): • At the time of application, a) the child must not be a patient in an institution for mental diseases, or b) an inmate of a public institution. • The Social Security number, proof of application for a Social Security number or resident alien card number must be provided for applicants who are requesting coverage. Individuals on the application that are not requesting coverage are not required to provide Social Security numbers. • The State does not exclude individuals based on citizenship or nationality, to the extent that the child is a U.S. citizen, U.S. national or qualified alien (as defined at section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, as amended by the BBA of 1997, except to the extent that section 403 of PRWORA precludes them from receiving Federal means- tested public benefits). SUPERSEDED BY CS19 SECTION 4.1.9.1 (SEE MAGI SECTION) ADDING CS14 AS SEPARATE SECTION UNDER 4.1 (SEE MAGI SECTION) 4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

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

State Plan for the Idaho State Children’s Health Insurance Program Effective Date: July 1, 2017

Approval Date: April 19, 2018 15

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350) Methods of establishing eligibility and continuing enrollment include a combined application for all Idaho children’s health insurance programs. The application can be mailed to DHW. Face-to-face interviews are not required. All eligibility determinations will be made within the 45 days following receipt of the application. All applicants are notified in writing regarding the outcome of their eligibility and enrollment status.

CS24 SUPERSEDES 4.3 SINGLE STREAMLINED APPLICATION SCREEN & ENROLL (SEE MAGI SECTION

An annualized gross income figure is used to determine eligibility. There are no earned income disregards. There is no resource limit. The number of persons in the family determines the applicable income standard.

The eligibility redetermination process entails checking all available interfaces and databases for current pertinent information prior to contacting the participant by phone. If the renewal is not completed at this point, a renewal form is sent to the family at least 45 days before their health coverage will end. The form instructs the family to review the information on the form, provide any updated information, sign and return the form or call and report that there are no changes.

ADDING CS13 TO 4.3 (SEE MAGI SECTION) ADDING CS15 TO 4.3 (SEE MAGI SECTION)

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

Check here if this section does not apply to your state. 4.4. Describe the procedures that assure that:

CS24 SUPERSEDES 4.4 RENEWALS SCREENING BY OTHER INSURANCE AFFORDABILITY PROGRAMS (SEE MAGI SECTION)

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

The State of Idaho will ensure that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. The application for assistance requires information on when the child was last covered by health insurance. Creditable insurance determinations are made if the applicant indicates current health insurance coverage. Place of employment is also required on the application which is used to determine if the applicant is a dependent of a State employee with access to coverage.

State Plan for the Idaho State Children’s Health Insurance Program Effective Date: July 1, 2017

Approval Date: April 19, 2018 16

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

The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX.

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

Through the single application process, all children are first reviewed for Title XIX eligibility. Those that are found eligible are enrolled in Title XIX. Those who are ineligible for Title XIX and meet the income standards for Title XXI are considered for Title XXI enrollment. Eligibility determinations for both Medicaid and SCHIP are handled by State employees.

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

SUPERSEDED BY CS20 (SEE MAGI SECTION)

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. The insurance provided under the state child health plan does not substitute for coverage under group health plans. A six month period of uninsurance is incorporated as an eligibility requirement for CHIP. The application requires information on when the child was last covered by health insurance. Exceptions to the period of uninsurance will be made if the applicant lost private insurance through no fault of their own (i.e., due to employer decisions) or due to hardship. The State monitors the number of eligibility denials of children that have creditable insurance who subsequently become eligible within six months.

4.4.4.2. Coverage provided to children in families over 200% and

up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

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

State Plan for the Idaho State Children’s Health Insurance Program Effective Date: July 1, 2017

Approval Date: April 19, 2018 17 4.4.4.4. If the state provides coverage under a premium assistance program, describe:

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

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

Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. Indian Health Service and tribal clinics are included as CHIP service providers. Idaho Medicaid and Tribal representatives formally meet on a routine basis. Tribal representatives can request that CHIP information be presented at any of these meetings. Additionally, regional Healthy Connections Representatives (primary care case management program coordinators) work with providers and enrollees (both Medicaid and SCHIP) to resolve issues and help ensure assistance is appropriately provided..

State Plan for the Idaho State Children’s Health Insurance Program Effective Date: July 1, 2017

Approval Date: April 19, 2018 18

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them ofthe availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(l)) (42CFR 457 .90)

The State of Idaho places equal emphasis on outreach and education activities, which are those administrative procedures and program features that inform and recruit children and their families into potential enrollment. DHW directs outreach and education to the following groups.

• Health Care Providers • Schools • HeadStart/Child Care Providers • Child Advocacy Groups • Health insurance exchange

Idaho has developed a multi-dimensional approach to outreach including but not limited to the following.

• Support of stakeholder efforts to conduct targeted, grass-roots outreach. • Supporting regional efforts by supplying professionally designed promotional materials. • Provision of technical assistance to regional efforts through central office support staff.

In addition, regional outreach activities are conducted by regional Healthy Connections Representatives (primary care case management program coordinators). Healthy Connections Representatives are part of the Division of Medicaid but are located in regional offices, and coordinate outreach and education for CHIP throughout the state.

State Plan for the Idaho State Children’s Health Insurance Program Effective Date: July 1, 2017

Approval Date: April 19, 2018 19 Section 6. Coverage Requirements for Children’s Health Insurance

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

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

6.1.1.

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

6.1.1.1.

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

6.1.1.2.

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

6.1.1.3.

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

6.1.2.

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

6.1.3.

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

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1.

Coverage the same as Medicaid State plan 6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver 6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the State has extended to the entire Medicaid population

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.

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

State Plan for the Idaho State Children’s Health Insurance Program Effective Date: July 1, 2017

Approval Date: April 19, 2018 20 6.1.4.6.

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

6.1.4.7.

Other (Describe)

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

6.2.1.

Inpatient services (Section 2110(a)(1)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

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

6.2.14.

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

6.2.15.

Nursing care services (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

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

State Plan for the Idaho State Children’s Health Insurance Program Effective Date: July 1, 2017

Approval Date: April 19, 2018 21 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) 6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28.

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

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

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000- D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule:

State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

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

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

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

State Plan for the Idaho State Children’s Health Insurance Program Effective Date: July 1, 2017

Approval Date: April 19, 2018 22 6.2.2.2-DC State employee coverage; (Section 2103(c)(S)(C)(i i)) {If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

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

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option. 6.2.-D The State will provide dental coverage to children through one of the following. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

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

6.2.1.2-D Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

6.2.2-D

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

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 23

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

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

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 24 Inpatient Hospital Services

Inpatient Hospital Services include semi-private room, intensive and coronary care units, general nursing, drugs, oxygen, blood transfusions, laboratory, imaging service, physical, speech, occupational, heat, radiation and inhalation therapy; operating, recovery, birthing, and delivery rooms, routine and intensive care for newborns and other medically necessary benefits and prescribed supplies for treatment of injury or illness are covered.

Procedures generally accepted by the medical community and which are medically necessary may not require prior approval and may be eligible for payment.

Inpatient hospital services do not include those services provided in an institution for mental diseases.

Inpatient services that are being furnished to infants and children described in 42 CFR 457.310 (targeted low income child) on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

Limitations. Payment is limited to semi-private room accommodations unless private accommodations are medically necessary and ordered by the physician. No limitation is placed on the number of inpatient hospital days. However, these services are reviewed for medical necessity by the Department or its agent after three (3) days, or in four (4) days if the participant has had a cesarean section. Selected services require prior authorization

Excluded Services. Elective medical and surgical treatments, except family planning services and non-medically necessary cosmetic surgery, are excluded from payment unless prior approved by the Department or its authorized agent. New procedures of unproven value and established procedures of questionable current usefulness as identified by the Public Health Service and that are excluded by the Medicare program are excluded from payment.

Acupuncture, bio-feedback therapy, and laetrile therapy are excluded from Medicaid payment.

Procedures, counseling, and testing for the inducement of fertility are excluded from Medicaid payment.

Surgical procedures for the treatment of morbid obesity and panniculectomies are excluded unless prior approved by the Department or its authorized agent.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT, may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 25 Outpatient Hospital Services

Outpatient Hospital Services include all benefits described in the inpatient hospital section which are provided on an outpatient basis in a hospital (including, but not limited to, observation beds and partial hospitalization benefits) or ambulatory surgical center; chemotherapy; emergency room benefits for surgery, injury or medical emergency; and other services for diagnostic or outpatient treatment of a medical condition, injury or illness.

Procedures generally accepted by the medical community and which are medically necessary may not require prior approval and may be eligible for payment .

Limitations. Physical Therapy, Speech-Language Services & Occupational Therapy service limitations are described in the Outpatient Rehabilitation Services and Outpatient Habilitative Services section of this table.

Community based behavioral health services will be provided under the Idaho Behavioral Health Plans' PAHP contract.

Psychological evaluation, speech and hearing evaluations, physical therapy evaluation and, occupational therapy evaluation, and diagnostic services are limited to twelve (12) hours for each eligible recipient per calendar year.

Diabetic education and training services are limited to twenty-four (24) hours of group counseling and twelve (12) hours of individual counseling through a diabetic education program or by a certified diabetic educator recognized by the American Diabetes Association.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Emergency Services

Emergency Room Services are covered when necessary to prevent death or serious impairment of health and when conditions dictate use of the most accessible hospital available, even if the hospital does not currently meet the conditions for participation under Medicare or the definitions of inpatient or outpatient hospital services included elsewhere in this State plan.

Ambulance services will be covered in emergency situations or when retroactively authorized by the Department or its authorized agent.

Limitations. There is no limit on medically necessary emergency room services.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 26 Individuals from birth through the month of their 21st birthday, pursuant to EPSDT, may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Ambulatory Surgical Centers Services (ASC)

Ambulatory surgical center services are outlined in applicable Department rules and must be provided in a facility certified by Medicare as an ASC,and are restricted to those procedures identified by the Medicare program in accordance with 42 CFR 416.65,or identified by the Department as meeting such requirements.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Physician Services

Medical Services: These services include office, clinic, outpatient surgery center and hospital treatment by a physician for a medical condition, injury or illness. Physician services are covered whether furnished in the office, the patient's home, a hospital, or elsewhere.

Covered Services include treatment of medical and surgical conditions by doctors of medicine or osteopathy subject to the limitations of practice imposed by state law, and in accordance to the restrictions and exclusions of coverage contained in applicable Department rules. Medically appropriate second opinions are covered.

Limitations. Selected services may require prior authorization and/or a referral from the participant’s primary care physician.

Surgical Services: Covered services include professional services rendered by a physician, surgeon or doctor of dental surgery.

Abortions Services: A legal abortion is only covered to save the life of the mother or in cases of rape or incest as determined by the courts.

When a pregnancy is life threatening and abortion is provided to save the life of the mother, one licensed physician or osteopath must certify in writing that the woman may die if the fetus is carried to term.

Cases of rape or incest must be determined by a court or documented by a report to law enforcement, except that if the rape or incest was not reported to law enforcement, a licensed physician or osteopath must certify in writing that, in his/her professional opinion, the women was unable to report the rape or incest to law enforcement for reasons related to her health.

Excluded Services. Hysterectomies that are not medically necessary and sterilization procedures are excluded from payment.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 27

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Other Practitioner Services

Other Practitioner Services include medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law.

Certified Pediatric or Family Nurse Practitioners' Services are those services provided by certified pediatric or family nurse practitioners as defined by state and federal law. This coverage has the same exclusions as Physician Services. This coverage specifically includes services by certified pediatric and family nurse practitioners .Services provided by nurse practitioners are limited to Section 54-1402(d) of Idaho Code.

Physician Assistant Services include those services provided by a physician assistant as defined by state and federal law. This coverage has the same exclusions as Physician Services.

Services provided by physician assistants are limited to Section 54-1803(11) of the Idaho Code.

Chiropractor Services are limited to a total of six (6) office visits during any calendar year. The remedial treatment must involve the manipulation of the spine to correct a subluxation condition. Additional visits will be reviewed for medical necessity and are subject to a prior authorization.

Podiatrist Services are services to diagnose and treat medical conditions affecting the foot, ankle and related structures. Routine foot care is not covered.

Optometrist Services are limited to providing eye examination and eyeglasses unless the optometrist has been issued and maintains certification under the provisions of Idaho Code to diagnose and treat injury or diseases of the eye. In these circumstances, payment will be made for diagnosis and treatment services.

Nurse-Midwife Services are provided to the extent that nurse-midwives are authorized to practice under State law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid/CHIP agency without regard to whether the nurse-midwife is under the supervision of,or associated with, a physician or other health care provider.

Certified nurse-midwife services are those services provided by certified nurse midwives as defined by state and federal law. This coverage has the same exclusions as Physician Services.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 28 Individuals from birth through the month of their 21st birthday, pursuant to EPSDT, may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

Primary Care Case Management (PCCM)

Primary Care Case Management Services are provided by a primary care case manager (PCCM) consistent with a program authorized under section 1932 of the Social Security Act. Most participants must enroll with a PCCM.

The PCCM structure pays primary care providers monthly case management payments based on a tier structure .The tiers are defined relative to patient complexity and the patient centered medical home capabilities of the primary care provider:

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT, may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Prevention Services

Prevention Services include a Health Risk Assessment which consists of:

• An initial health questionnaire, and • A well child screen.

The health questionnaire is designed to assess the general health status and health behaviors of a recipient. This information will be used to provide customized health education. The health questionnaire will be administered at initial program entry and periodic intervals thereafter.

A well child screen conducted at periodic or interperiodic intervals which constitutes a health risk assessment will consist of a comprehensive physical examination and health education

Well Child Screens. Periodic medical screens completed at intervals recommended by the American Academy of Pediatrics (AAP) and immunizations recommended by the Advisory Committee for Immunization Practices (ACIP) and preventive care and screening for infants and children recommended by HRSA’s Bright Futures guidelines.

Periodic screens and lnterperiodic screens should constitute a health risk assessment as specified in applicable Department rules. lnterperiodic medical screens are screens that are done at intervals other than those identified in the AAP periodicity schedule referenced above and must be performed by physician or physician extender. lnterperiodic screens will be performed when there are indications that it is medically necessary to determine whether a child has a physical or mental illness or condition that may require further assessment, diagnosis,or treatment . lnterperiodic screening examinations may occur in children who have already been diagnosed with an illness or condition,and there is

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 29 indication that the illness or condition may have become more severe or changed sufficiently, so that the further examination is medically necessary.

Developmental screening is considered part of every routine initial and periodic examination. If the screening identifies a developmental problem then a developmental assessment will be ordered by the physician and conducted by qualified professionals.

Diagnostic Screening Clinics. Services provided in a diagnostic screening clinic are outlined in applicable Department rules.

Limitations. Service limitations for Diagnostic Screening Clinics are as follows : five (5) hours of medical social services per eligible recipient per state fiscal year is the maximum allowable.

Prevention and Health Assistance (PHA) Benefits Targets overweight individuals for enhanced Prevention and Health Assistance (PHA) benefits in accordance with applicable Department rules.

PHA benefits are individualized benefits targeted to address weight management. Authorizations will be managed by the state Medicaid agency.

PHA benefits will be available when individuals complete specified activities in preparation for addressing their weight. These activities include discussing the condition with their primary care provider,participating in an applicable support group,and completing basic educational material related to managing their weight.

PHA benefits may be used to purchase services related to weight reduction/management in accordance with applicable Department rules.These services may include weight-loss programs, and other health related benefits.

Nutrition Services Include intensive nutritional education, counseling and monitoring by a registered dietician or an individual who has a baccalaureate degree granted by a U.S. regionally accredited college or university and has met the academic/professional requirements in dietetics as approved by the American Dietetics Association to assure the patient's proper nutrition is allowed. Nutrition services must be discovered by the screening services and ordered by the physician.

Limitations. Services are limited to (2) visits per year. Additional visits may be prior authorized in accordance with EPSDT. Nutrition services related to obesity, including dietary assessment and individualized nutrition education, shall not be subject to the (2) visit limitation when provided as PHA benefits.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 30 Diabetes Education and Training Clinics Provide diabetic education and training services as outlined in applicable Department rules. Outpatient diabetes education and training services will be covered under the following conditions.

The education and training services are provided through a diabetic management program recognized as meeting the program standards of the American Diabetes Association.

The education and training services are provided through a formal program conducted through a hospital outpatient department or a physician's office by a Certified Diabetic Educator certified by the American Diabetes Association.

Only training and education services which are reasonable and necessary for treatment of a current injury or illness will be covered . Covered professional and educational services will address each client's medical needs through scheduled outpatient group or individual training or counseling concerning diet and nutrition, medications, home glucose monitoring,insulin administration, foot care, or the effects of other current illnesses and complications.

To receive diabetic counseling the patient must have a written order by his or her primary care physician or physician extender referring the patient to the program

Limitations. Diabetes education and training services will be limited to twenty-four (24) hours of group sessions and twelve (12) hours of individual counseling every five (5) calendar years. Diabetes education related to obesity shall not be subject to the above limitations when provided as PHA benefits.

Tobacco Cessation Counseling Services are covered in accordance with USPSTF Recommendations.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Diagnostic Test (X-ray and Lab Work) Services

Diagnostic Test and Lab Work Services include imaging and laboratory services for diagnostic and therapeutic purposes due to accident, illness or medical condition, as well as X-ray, CT/PET Scans, MRI’s, Nuclear Cardiology, radium or radioactive isotope therapy. Diagnostic testing and lab work services are provided upon and under the direction of a physician or other licensed practitioner. Excluded Services. Diagnostic tests and lab work which are associated with excluded Hospital Services and Physician Services are excluded from payment.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 31 Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Prescription Drugs

Prescribed Drugs are those prescribed by a practitioner acting within the scope of his practice, chemotherapy drugs approved for use in humans by the U.S. Food and Drug Administration, vaccines and prenatal vitamins.

Additional Covered Drug Products. will be covered as follows: Therapeutic Vitamins Injectable Vitamin B12 (cyanocobalamin and analogues); Vitamin K and analogues; Prescription drugs, including: Prescription cough and cold agents Legend folic acid Permethrin

The Department covers at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class.

Federal legend medications that change to non-legend status, as well as their therapeutic equivalents. The Director determines that non-legend drug products are covered based on appropriate criteria including safety, effectiveness, clinical outcomes, and the recommendation of the Pharmacy and Therapeutics’ Committee.

Other non-legend drug products approved for coverage by the Director of the Department of Health and Welfare based on the determination of the Pharmacy and Therapeutics Committee that the non-legend product is therapeutically interchangeable with legend drugs in the same pharmacological class based on evidence comparison of efficacy, effectiveness, and safety and determined by the Department to be a cost- effective alternative. Information regarding the P&T Committee and covered drug products is posted at http://healthandwelfare.idaho.gov/Medical/PrescriptionDrugs/tabid/119/Default.aspx

The Department will cover either generic or brand if medically necessary. Excluded Drug Products. • Legend drugs for which Federal Financial Participation is not available • Ovulation stimulants and fertility enhancing drugs. • Medications used for cosmetic purposes • Prescription vitamins except injectable B12, vitamin K, legend vitamin D, legend pediatric vitamin and fluoride preparations, legend prenatal vitamins for pregnant or lactating individuals, and legend folic acid. Limitations: Prior authorization criteria is developed by the Department’s clinical pharmacists with input from the Medical Director, the Pharmacy and Therapeutics Committee, and the Drug Utilization Review Board. The criteria used to place drugs on prior authorization is based upon safety, efficacy and clinical outcomes as provided by the product labeling of the drug,

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 32 and quality evidence provided by established drug compendia, and the Drug Effectiveness Review Program.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT, may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Family Planning Services

Family Planning Services include pre-pregnancy family planning services and prescribed supplies including birth control contraceptives.

Family planning services and supplies for individuals of child-bearing age include counseling and medical services prescribed by a licensed physician, qualified certified nurse practitioner, or physician’s assistant. The Department will cover diagnosis, treatment, contraceptive supplies, and related counseling.

The requirements of 42 CFR 441.20 are met regarding freedom from coercion or pressure of mind and conscience, and freedom of choice of method to be used for family planning.

All requirements of 42 CFR Part 441, Subpart F are met.

Limitations. Contraceptive supplies include condoms, foams, creams and jellies, prescription diaphragms, intrauterine devices, or oral contraceptives, which are limited to purchase of a three-month supply.

Hysterectomies performed solely for sterilization are ineligible for payment.

Individuals under twenty-one (21) years of age pursuant to EPSDT, may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Mental Health and and Substance Use Services

Inpatient Psychiatric Services Includes services in Institutions for Mental Diseases (IMD).

Inpatient psychiatric facility services include services provided which meet medical necessity criteria determined by the Department or its authorized agent and provided in an IMD or a psychiatric unit of a general hospital. Limitations. Does not include services in a psychiatric residential treatment facility.

Inpatient Substance Use Disorder Services Includes services provided which meet medical necessity criteria determined by the Department or its authorized agent and provided in a general hospital

Limitations. Services are not provided in an IMD.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 33 Community-Based Outpatient Mental Health and Substance Use Services Mental health services and Substance Use Services are medically necessary rehabilitation services that evaluate the need for and provide therapeutic and rehabilitative treatment to minimize symptoms of mental illness and substance use disorders and restore independent functioning. These services include: • Case Management • Community-based Rehabilitation Services • Crisis Intervention • Drug Screening • ECT Therapy • Partial Care • Pharmacological management • Psychological and neuropsychological testing • Psychotherapy (group, family and individual) • Screening, Evaluation & Diagnostic Assessment • Treatment Planning

All community based mental health and substance use disorder treatment services will be provided through a Pre-paid Ambulatory Health Plan known as the Idaho Behavioral Health Plan.

Limitations. All community based outpatient mental health and substance use services are subject to limitations of practice imposed by state law, federal regulations and according to applicable Department rules, the PAHP contract as awarded or amended and approved by the Department or its authorized agent based upon medical necessity.

Excluded Services. Experimental or Non-medically necessary services as determined by the Department or its authorized agent will be excluded.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Home Health Care

Home Health Care Services include intermittent or part-time nursing services or Home Health Aide services provided through a home health agency or by a registered nurse when no home health agency exists in the area.

Services also include home health aide, Occupational Therapy, Physical Therapy and Speech Language Pathology services provided by a home health agency.

Home health services are provided in accordance with the requirements of 42 CFR 441.15.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 34 Limitations. Services by a licensed nurse, when no home health agency exists in the area, must be prior approved by the Department as defined in 42 CFR 440.70(b)(l).

Home health visits are limited to one hundred (100) per recipient per calendar year provided by any combination of home health agency licensed nurse, home health aide, home health physical therapist, home health occupational therapist, licensed nurse.

This benefit does not include Skilled Nursing services and is in addition to PT/OT/SLP services provided under the rehabilitative and habilitative services section. Private Duty Nursing (PDN) are nursing services provided by a registered nurse or licensed practical nurse to a non-institutionalized child under the age of 21 requiring care for conditions of such medical severity or complexity that skilled nursing care is necessary.

PDN Services must: Be ordered by a physician, provided under a written plan of care. and include: The medical severity and complexity of the child’s condition must require more individual and continuous care than is available from a visiting nurse and the needed services cannot safely be delegated to Unlicensed Assistive Personnel (UAP). The nursing needs of the participant must be of such a nature that Idaho Code, Idaho Nursing Practice Act or IDAPA rules or policies require the service to be provided by an Idaho Licensed Registered Nurse (RN) or by an Idaho Licensed Practical Nurse (LPN) and require more individual and continuous care than is available from Health Health nursing services.

Limitations. PDN services must be prior authorized by the Department or its authorized agent.

PDN Services may be provided only in the child's personal residence or when normal life activities take the child outside of this setting. However, if service is requested only to attend school or other activities outside of the home, and the child does not need such services in the home, private duty nursing will not be authorized. The following are specifically excluded as personal residences: •Licensed Nursing Facilities (NF); •Licensed Intermediate Care Facilities for Individuals with Intellectual Disabilities •Licensed Residential Care Facilities; •Licensed hospitals; and •Public or private school

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 35 Outpatient Rehabilitation Services

Rehabilitation Services include physical therapy, occupational therapy, or speech- language pathology services provided by a home health agency or medical rehabilitation facility for the purpose of restoring certain functional losses due to disease, illness, or injury.

Therapy services by an independent provider may be furnished by the following providers:

Physical therapist who in accordance with 42 CFR 440.110(a) is licensed by the PT Licensing Board within the Board of Occupational Licensing.

Occupational Therapist who in accordance with 42 CFR 440.110(b) is licensed by the Board of Occupational Licensing.

Speech-Language Pathologist who in accordance with 42 CFR 440.110(c), is licensed by the Speech and Hearing Services Licensure Board within the Board of Occupational Licensing.

All therapy services are provided according to a written physician order as a part of a plan of care, and must be provided either in the patient's home or in the therapist's office. An office in a nursing home or hospital is not considered an independent therapist's office.

Respiratory care services may be furnished to individuals qualifying under EPSDT.

Limitations. To comply with 45 CFR 156.115(a)(5)(iii), Idaho Medicaid provides separate, equal 20-visit limits each for rehabilitation and habilitation. Services are not provided through a Home Health Agency.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Outpatient Habilitation Services

Habilitation Services include physical therapy, occupational therapy and speech- language services related to developing skills and functional abilities necessary for daily living and skills related to communication of persons who have never acquired them.

Therapy services by an independent provider may be furnished by the following providers:

Physical therapist who in accordance with 42 CFR 440.110(a) is licensed by the PT Licensing Board within the Board of Occupational Licensing.

Occupational Therapist who in accordance with 42 CFR 440.110(b) is licensed by the Board of Occupational Licensing.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 36 Speech-Language Pathologist who in accordance with 42 CFR 440.110(c), is licensed by the Speech and Hearing Services Licensure Board within the Board of Occupational Licensing.

All therapy services are provided according to a written physician order as a part of a plan of care, and be provided either in the patient's home or in the therapist's office. An office in a nursing home or hospital is not considered an independent therapist's office.

Limitations To comply with 45 CFR 156.115(a)(5)(iii), Idaho Medicaid provides separate, equal 20-visit limits each for rehabilitation and habilitation. Services are not provided through a Home Health Agency.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Audiology Services

Audiologist services are covered for individuals with hearing disorders when provided by an audiologist who is licensed by the Speech and Hearing Services Board of the Idaho Board of Occupational Licenses. Participants under the age of 21 are eligible to receive necessary audiometric services and supplies. Hearing Aids. Hearing aids and related services will be covered by the Department.

Augmentative Communication Devices. Augmentative communication devices are covered as specified in applicable Department rules.

Limitations. The Department will prior authorize audiometric examination and testing if needed more frequently than once per year. Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Medical Equipment, Supplies and Devices

Medical Equipment and Supplies Includes durable medical equipment and other medically-related or remedial devices. These also include medical supplies, equipment, and appliances suitable for use in the home.

Medical equipment and medical supplies must be ordered in writing by a physician. Medical equipment and supplies are provided only on a written order from a physician that includes the medical necessity documentation listed in the Medicare DMERC Supplier manual.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 37 Limitations. Items not specifically listed in applicable Department rules will require prior authorization by the Department or its authorized agent.

Specialized Medical Equipment and Supplies

Oxygen and related equipment is covered for individuals qualifying under EPSDT when the medical need is discovered during a screening service and is physician ordered. PRN oxygen, or oxygen as needed on less than a continual basis, will be authorized for six (6) months following receipt if medical documentation from the attending physician as to an acute or chronic medical condition which requires oxygen support to maintain respiratory status. Medical documentation will include a diagnosis, oxygen flow rate and concentration, and an estimate of the frequency and duration of use. Portable oxygen systems may be ordered to compliment a stationary system if the recipient is respirator dependent, or the attending physician documents the need for a portable oxygen system for use in transportation. Laboratory evidence for hypoxemia is not required under the age of six (6) months.

Prosthetic Devices These services include prosthetic and orthotic devices and related services prescribed by a physician and fitted by an individual who is certified or registered by the American Board for Certification in orthotics and/or prosthetics.

The Department will purchase and/or repair medically necessary prosthetic and orthotic devices and related services which artificially replace a missing portion of the body or support a weak or deformed portion of the body.

Limitations. Prosthetic and orthotic devices and services will be purchased only if pre-authorized by the Department or its authorized agent. Limit of one refitting, repair or additional parts in a calendar year.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Vision Services

Vision Services include eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

The Department will pay for vision services and supplies. One eye exam by physicians and/or optometrists is allowed during any twelve (12) month period. The Department will cover vision-screening services according to the recommended guidelines of the AAP. The screen administered will be an age-appropriate vision screen. The guidelines coincide with certain scheduled medical screens; the vision is considered part of the medical screening service, (i.e. eye chart). The Department will pay for one (1) eye examination by an ophthalmologist or optometrist during any twelve (12) month period for each eligible recipient to determine the need for glasses to correct or treat refractive error.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 38 Eyeglasses. Each recipient, following a diagnosis of visual defects and a recommendation that eyeglasses are needed for correction of a refractive error, can receive one (1) pair of eyeglasses per year, except in the following circumstances: In the case of a major visual change, the Department can authorize purchase of a second pair of eyeglasses and can authorize a second eye examination to determine that visual change; or the Department may pay for replacement of lost glasses or replacement of broken frames or lenses. New frames will not be purchased if the broken frame can be repaired for less than the cost of new frames if the provider indicates one of these reasons on his claim. If repair costs are greater than the cost of new frames, new frames may be authorized. Lenses will be provided when there is documentation that the correction needed is equal to or greater than plus or minus one-half (.50) diopters of correction. Limitations. Polycarbonate lenses will be purchased only when it is documented that the prescription is above plus or minus two (2.00) diopters of correction. Payment for tinted lenses will only be made when there is a diagnosis of albinism or in the case of extreme medical conditions as determined by the Department. Contact lenses will be covered only when documentation of an extreme myopic condition requiring a correction equal or greater than minus four (-4) ten diopters, cataract surgery, keratoconus, or other extreme medical condition preclude the use of conventional lenses. Replacement lenses will be purchased only when there is documentation of a major visual change of at least one-half (.50) diopter plus or minus. Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Essential Providers

Clinic Services and Rehabilitative Services are preventative, diagnostic, therapeutic, rehabilitative, or palliative items or services furnished by or under the direction of a physician and which may include those services provided by community health centers.

Rural Health Clinic services and other ambulatory services furnished by a rural health clinic, which are otherwise included in the State plan. Federally Qualified Health Center (FQHC) services and other ambulatory services that are furnished by an FQHC in accordance with section 4231 of the State Medicaid Manual (HCFA-Pub. 45-4).

Indian Health Service Facility services are provided in accordance with 42 CFR 431.110(b), on the same basis as other qualified providers.

Independent School Districts which have entered into a provider agreement with the Department may bill for the following services when the service(s) and the amount needed are identified by the interdisciplinary team and listed on the student’s Individual Education Plan (IEP).All provider qualification and prior authorization requirements as specified in IDAPA 16.03.09 for these services apply.

• Audiology Services Diagnostic, screening, preventive or corrective services provided by an audiologist licensed by the Speech and Hearing Services Board in the Idaho Board of Occupational Licensing.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 39 • Behavioral Consultation Consultation with the IEP team during the assessment process, performing advanced assessment, coordinating the implementation of the behavior implementation plan and providing ongoing training to the behavioral interventionist and other team members.

• Behavioral Intervention Continuous intervention method focused on promoting the student’s ability to participate in educational services through a consistent, assertive intervention process. It includes the development of replacement behaviors with the purpose to prevent or treat behavioral conditions of students who exhibit maladaptive behaviors.

• Evaluation and Diagnostic Services Evaluation and diagnostic services are reimbursable if they are to determine eligibility or need for health related services. Evaluations must meet the criteria in IDAPA rule, section 852 School Based Services. Evaluations completed for education services only are not reimbursable.

• Medical Equipment and Supplies Medical equipment and supplies that are covered by Medicaid and are needed for use at school but are too large or unsanitary to transport from home to school. They must be for the student’s exclusive use and transfer with the student if the student changes schools.

• Nursing Services Skilled nursing services that must be provided by a licensed nurse. Emergency, first aide or assistance with non- routine medications not identified on the IEP as health related services are not reimbursable.

• Occupational Therapy, Physical Therapy or Speech Language Pathology Rehabilitation Services Services for the purpose of restoring certain functional losses due to disease, illness or injury. Services for vocational assessment, training or vocational rehabilitation are not covered.

• Personal Care Services School based personal care services include medically oriented tasks having to do with the student’s physical or functional requirements while at school.

• Psychological Evaluation Evaluations of cognitive abilities, mental health issues and issues related to brain injury.

• Psychotherapy Rehabilitative therapeutic interventions to address alcohol or drug abuse and/or emotional, behavioral or cognitive problems.

• Community Based Rehabilitation Services Services to assist the student in gaining and utilizing skills necessary to participate in school such as training in behavior control, social skills, and coping skills.

• Social History and Evaluation Assessment of home and family environment, to determine suitability to meet the participant’s medical needs.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 40 • Transportation Student must require special transportation that is ordered by a physician and included on the IEP, and receive another Medicaid reimbursable service on the same day.

• Interpretive Services May only be billed when the student needs the services of an interpreter to receive a Medicaid reimbursable service. Not covered if the person providing the service is able to communicate in the student’s primary language.

Limitations. Audiology Services do not include equipment. Equipment is included under the DME benefit. Behavioral Consultation is limited to thirty-six (36) hours per student per year.

Excluded Services. Vocational, Educational and Recreational services are not reimbursable.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department. Medical Transportation Services

Medical Transportation Services include transportation services and assistance for eligible persons to medical facilities. Payment for meals and lodging may be authorized where appropriate.

Ambulance services will be covered in emergency situations or when prior authorized by the Department or its authorized agent.

Limitations. Requests for transportation services will be reviewed and authorized by the Department or its authorized agent. Authorization is required prior to the use of transportation services except when the service is emergent in nature. Payment for transportation services will be made, for the least expensive mode available, which is most appropriate to the recipient's medical needs.

Excluded Services. Transportation to medical facilities for the performance of medical services or procedures which are excluded from payment are also excluded.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

Long Term Care Services

Personal Care Services are services furnished to a participant who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for people with intellectual disabilities, or institution for mental diseased that are:

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 41 Authorized by a physician • provided in accordance with a plan of care; • provided by an individual who is qualified to provide such services and who is not a member of the individual's family; and • provided in the participant’s place of residence.

Limitations. Services are limited to sixteen (16) hours per calendar week, per eligible client.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

Hospice Care

Hospice Care is provided only to terminally ill recipients. Services must be provided by a Medicare certified hospice and in accordance with Section 2302 of the Affordable Care Act, which requires hospice services to be provided to children concurrently with curative treatment.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

Special Services for Children/EPSDT

EPSDT Services include diagnosis and treatment involving medical care as well as such other necessary health care described in Section 1905(a) of the Social Security Act, and not included in this State Plan as required to correct or ameliorate defects and physical and mental illness discovered by the screening service. The Department will set amount, duration and scope for services provided under EPSDT. Needs for services discovered during a screening which are outside the coverage provided by applicable Department rules must be medically necessary and prior authorized in accordance with Department rules.

Case Management Services

Case Management Services are provided to targeted children who meet the requirements set forth in Department rules. A Service Plan must be completed and authorized prior to delivery of case management services. The case manager must review and update the approved service plan for service coordination at least annually. The Department or its authorized agent must approve the Service Plan for continued authorization.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 42 Specific Pregnancy-Related Services

Risk Reduction Follow-up. Services to assist the client in obtaining medical, educational, social and other services necessary to assure a positive pregnancy outcome. Payment is available to licensed social workers, registered nurses and physician extenders either in independent practice or as employees of entities which have current provider agreements with the Department.

Individual and Family Medical Social Services. Services directed at helping a patient to overcome social or behavioral problems which may adversely affect the outcome. Payment is available for two (2) visits during the covered period to a licensed social worker qualified to provide individual counseling according to the provisions of the Idaho Code and the regulations of the Board of Social Work Examiners.

Nutrition Services. Intensive nutritional education, counseling and monitoring by a registered dietician or an individual who has a baccalaureate degree granted by a U.S. regionally accredited college or university and has met the academic/profession requirements in dietetics as approved by the American Dietetic Association to assure the patient's proper nutrition. Payment for two (2) visits per pregnancy is available.

Nursing Services. Home visits by a registered nurse to assess the client's living situation and provide appropriate education and referral during the covered period. A maximum of two (2) visits per pregnancy is provided.

Maternity Nursing Visit. Office visits by a registered nurse, acting within the limits of the Nurses Practices Art, for the purpose of checking the progress of the pregnancy. These services must be prior authorized by the Department's care coordinator and can be paid only for women unable to obtain a physician to provide prenatal care. This service is to end immediately when a primary physician is found. A maximum of nine (9) visits can be authorized.

Qualified Provider Risk Assessment and Plan of Care. When prior authorized by the Department care coordinator, payment is made for qualified provider services in completion of a standard risk assessment and plan of care for women unable to obtain a primary care physician, nurse practitioner, or nurse midwife for the provision of antepartum care.

Individuals from birth through the month of their 21st birthday, pursuant to EPSDT,may receive additional services under this section if determined to be medically necessary and prior authorized by the Department.

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

6.3.1. The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2. The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 43 family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4. Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010) 6.4.1. Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

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

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

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

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

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 44 6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002 issued February, 2, 2010)A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)). Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low- income children?

Yes

No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan. 6.4.3.2.1-PA If the State is providing premium assistance for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low- income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 45 6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits. 6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance 6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)).

6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA: Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 46 6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)).

6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 47 Section 7. Quality and Appropriateness of Care Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

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

Claims data are collected and analyzed to assess performance using National Performance Measurements (see section 9.3.6). An annual participant survey monitors and assesses quality and appropriateness of care.

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

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

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

Enrollment in Idaho’s primary care case management program (Healthy Connections) is required in most areas of the state, which helps to ensure that enrollees have a usual source of care. Primary care providers are required by contract to provide primary care services to their enrollees. This includes wellness care and immunizations. In addition, Healthy Connections Representatives (primary care case management program coordinators) work with enrollees and providers to help ensure appropriate covered services are provided.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

The State of Idaho will ensure access to covered services, including emergency services as defined in 42 CFR 457.10. Referrals are not required to access emergency services. All provider types necessary to provide covered services are included in the provider panel.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 48

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The State of Idaho will ensure access to appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of- network providers when the network is not adequate for the enrollee’s medical condition.

Contractually, primary care providers are required to make referrals for most medically necessary specialty services. All provider types necessary to provide covered services are included in the provider panel. In addition, Healthy Connections Representatives (primary care case management program coordinators) work with enrollees and providers to help ensure appropriate covered services are provided.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Decisions related to prior authorization of health services will be completed in accordance with State law and/or Administrative Rule and the medical needs of the patient.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 49 Section 8. Cost-Sharing and Payment

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505) Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09-006, issued May 11, 2009)

8.1.1. Yes 8.1.2. No, skip to question 8.8.

8.1.1-PW Yes 8.1.2-PW No, skip to question 8.8.

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

8.2.1. Premiums: Enrollees with family incomes at or above 150% FPL will be subject to a premium in the amount of $10 per member per month for medical services and an additional $5 per member per month for dental services. Premium amounts paid apply first to medical services in determining delinquency. Enrollees with family incomes above 142% FPL up to 150% FPL will be subject to a premium in the amount of $10 per member per month for medical services and are not subject to the dental premium.

Wellness Preventive Health Assistance (PHA): The state has established a mechanism to assist participants with their premium payment obligations. This mechanism is called Wellness PHA. Each participant who is required to make premium payments can earn 30 points every 3 months by receiving recommended wellness visits from their PCP and demonstrating up-to-date immunizations. These Wellness PHA points can be used to offset premium payments. Each point equals one dollar.

A child with family income below 150% FPG may have all his premium obligations met by utilizing Wellness PHA. Children in families 150-185% FPG may offset up to two- thirds (two out of every three) of their payments.

8.2.2. Deductibles: Not applicable. 8.2.3. Coinsurance or copayments:

Co-payment amount: Beginning on November 1, 2011, the nominal fee amount required to be paid by the participant as a co-payment is three dollars and 65 cents ($3.65). The reimbursable amount of the services rendered during a visit must be at least ten times the amount of the co-pay. Visits where the provider is reimbursed $36.50 or less for their services are not subject to co-pay and

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 50 providers are directed not to assess co-pays for services where reimbursement is less than or equal to $36.50. Well-baby and well-child care as defined in 42 CFR 457.520 are not subject to co-pay.

The State will submit a State Plan Amendment for any future changes to the co- pay amount.

Co-pays for use of emergency services for a non-emergent medical condition • A participant who seeks care at a hospital emergency department for a condition that is not an emergency medical condition may be required to pay a co-payment to the provider. The determination that the participant does not have an emergency medical condition is made by the emergency room physician conducting the medical screening and using the prudent layperson standard. • A participant who accesses emergency transportation services for a condition that is not an emergency medical condition may be required to pay a co- payment to the provider of the service. The determination that the participant did not have an emergency medical condition is made by Idaho Medicaid.

Co-pays for other services • Chiropractic services • Occupational Therapy • Optometric Services • Physical Therapy • Physician Office Visits unless the visit is for preventive care or family planning • Speech Therapy

The reimbursable amount of the services rendered during a visit must be at least ten times the amount of the co-pay. Otherwise, the visit is exempt from co-pay. The provider may provide the service and decline to collect the co-pay at the time of service, if the participant can’t pay. The provider may also choose not to bill the participant for the co-pay.

Population: All children 142% - 185% of the federal poverty guidelines.

8.2.4. Other: Not applicable

8.2-DS

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

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 51 8.2.1-DS Premiums: 8.2.2-DS Deductibles: 8.2.3-DS Coinsurance or copayments: 8.2.4-DS Other:

8.3 Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(A)) (42CFR 457.505(b))

8.4 The State assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

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

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

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

8.5 Describe how the State will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the State for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

The State of Idaho will ensure that the annual aggregate cost-sharing for a family does not exceed five (5) percent of such family’s income for the length of the child’s eligibility period in the State. Upon enrollment participants are sent a notice advising them of their cost-sharing responsibilities. This includes notice of the five percent maximum.

Cost-sharing in the Idaho plan is set so low that very few families will reach their 5% limit.

The State informs families of the co-payment requirement and limitations in writing at the time of eligibility determination or re-determination. Idaho monitors co-payments and premiums on at least a monthly basis based on information from its systems that show the amount paid compared with family income. When the State identifies that co-pays and premiums assessed have reached 95% or more of the maximum amount for the eligibility period, a letter is sent to the family informing them that they are approaching their limit and that they will be exempted for the remainder of the eligibility period. The status of the beneficiary is changed to co-pay exempt in the information system at that point for the remainder of the eligibility period.

Providers are instructed to check each participant’s eligibility prior to rendering services. The co-pay field of the eligibility response indicates whether the participant is subject to co-pay or is exempt.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 52 8.6 Describe the procedures the State will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

The state will ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. Native American and Alaskan Native children will not be charged monthly premiums or co- payments. The family will be asked to declare Native American/Alaskan Native status so that the cost sharing exemption can be processed.

8.7 Provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Premiums Renewal: If premium payments are two or more months in arrears at the time of renewal, the child(ren) will lose eligibility for the program and be prohibited from participation until the delinquency is paid. Delinquent accounts will be sent a delinquency notice monthly. The notice includes the amount of the delinquency, their right to be considered for Medicaid eligibility and the consequence of not bringing their account current. The notice also includes a reminder that the family may receive help with their premium payments by participating in Wellness PHA.

Co-pays If a participant is unable to make a co-pay the provider can bill the patient, waive the co-pay or refuse to provide services. SUPERSEDED BY CS21 (SEE MAGI SECTION) 8.7.1 Provide an assurance that the following disenrollment protections are being applied:

Guidance: Provide a description below of the State’s premium grace period process and how the State notifies families of their rights and responsibilities with respect to payment of premiums. (42CFR 457.570(a))

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment.

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non- payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the State will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The State provides the enrollee with an opportunity for an impartial review

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 53 to address disenrollment from the program. (42CFR 457.570(c))

8.8. The State assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward State matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copayments, coinsurance and all other types) will be used toward State matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 54

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

The state of Idaho has developed a set of strategic objectives, performance goals, and performance measures to assess the success of implementing its Children’s Health Insurance Program. Idaho will track enrollment, retention, access, comprehensiveness, and quality of care. All performance measures will be linked to performance standards and strategic objectives. These measures are designed to measure the effectiveness of both Title XIX and Title XXI Programs. The objectives, goals, and measures focus on standard indicators of success in enrollment and retention and in basic health outcomes. The measures have been developed based upon data that is readily available to the Department of Health and Welfare.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 55 9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

Table 9.1

(1) Strategic Objectives (2) Performanc e Goals for each Strategic Objective (3) Performance Measures and Progress (specify data sources, methodology, time period, etc.) Objectives related to Reducing the Number of Uninsured Children To increase the number of children participating in Title XIX and XXI health programs The targeted increase in enrollment is 8,000 children New/Revised Continuing Data Sources: Enrollment data from the Division of Medicaid claims payment system. X annually The total number of new uninsured children in both programs compared to the previous federal fiscal year. • The total number of new uninsured children enrolled in both programs compared to the base number of enrollees as of 9/30/99: 54,824 • Numerator: Number of enrollees on 9/30/16: (218,408) • Denominator: Number of enrollees on 10/1/15 (205,407) • Progress summary: Idaho achieved its annual target by increasing enrollment an additional 14,073 children, as reported in its FFY2015 Annual Report.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 56

Table 9.1

(1) Strategic Objectives (2) Performanc e Goals for each Strategic Objective (3) Performance Measures and Progress (specify data sources, methodology, time period, etc.)

Progress Summary: Idaho achieved its annual target by increasing enrollment an additional 14,073 children in FFY16. As of 9/30/16, Idaho has enrolled an additional 164,656 children, more than quadrupaling the number of children covered by Title XIX & Title XXI in the past 18 years. Objectives Related to SCHIP Enrollment To increase the number of children enrolled in the Title XXI. program The targeted increase in enrollment is 2,000 children annually. New/Revised Continuing X

Data Sources: Enrollment data from the Division of Medicaid claims payment system • The total number of children enrolled in XXI program compared to the previous federal fiscal year. • Numerator: Number of enrollees on 9/30/16 (23,304) • Denominator: Number of enrollees on 10/1/15 (18,345) Progress Summary: increased this year B y 4 , 9 5 9 c h i l d r e n . Idaho exceeded its goal by 2,959 as reported in its FFY2015 Annual report. Objectives Related to Increasing Medicaid Enrollment To increase the number of children enrolled in Title XIX health The targeted increase in enrollment is 6,000 children annually. New/Revised Continuing X

Data Sources: Enrollment data from the Division of Medicaid claims payment system.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 57

Table 9.1

(1) Strategic Objectives (2) Performanc e Goals for each Strategic Objective (3) Performance Measures and Progress (specify data sources, methodology, time period, etc.) programs • Uninsured children in XIX program compared to the previous federal fiscal year. • The total number of new uninsured children enrolled in Title XIX programs compared to the base number of enrollees as of 9/30/99, 3,735 • Numerator: Number of enrollees on 9/30/16 (196,176) • Denominator: Number of enrollees on 10/1/15 (187,062) Progress Summary: An increase of 9,114 as reported on our FFY15 Annual Report. This exceeded our goal by 3,114 children.

Objectives Related to Increasing Access to Care (Usual Source of Care, Unmet Need) To ensure that enrolled children have a medical home. There will be a 10% annual increase in the number of children participating in Healthy Connections and having a primary care provider as a “medical home”. New/Revised Continuing X Data Sources: Division of Medicaid, Healthy Connections (PCCM) Program Methodology: The total number of XIX children enrolled compared to the base number of enrollees as of 9/30/99 Number of enrollees on 9/30/99: 3,735 • Numerator: Number of children enrolled in HC on 9/30/16 (208,506)Denominator: Number of children enrolled in HC on 10/01/15 (219,480) Progress Summary: Idaho reported an improvement of 1%, and reached its goal of 95% as reported on its FFY2016 Annual report. Objectives Related to Use of Preventative Care (Immunizations, Well Child Care) To ensure that enrolled children receive 90% of enrolled 2 year olds will have up-to-date appropriate New/Revised X Continuing

Data Sources:

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 58

appropriate and necessary medical care. vaccinations.

•

Progress Summary Idaho Medicaid has reported on this measure as part of the core set of CHIP measures during FFY14, FFY15 and FFY16. Combo 2, Combo 3 and Combo 4 have all had an increase of 9% since the baseline year (FFY14). FFY16 = Combo 2 rate was 40%; Combo 3 rate was 38% and Combo 4 rate was 37.8%.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

Performance goals are listed in Table 9.1.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1. The increase in the percentage of Medicaid-eligible children enrolled in Medicaid.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 59 9.3.2. The reduction in the percentage of uninsured children. 9.3.3. The increase in the percentage of children with a usual source of care. 9.3.4. The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6. Other child appropriate measurement set. List or describe the set used.

The State of Idaho uses a modified set of National Performance measures. • Well child visits for children in the first 15 months of life. • Well child visits in the 3rd, 4th, 5th, and 6th years of life. • Well child visits for Adolescents • Medication Management for children with asthma. • Childhood Immunization Status • Immunization Status for Adolescents • Children’s access to primary care services. • Chlamydia Screening for female adolescents • Ambulatory Care – Emergency Department Visits • CAHPS 5.0 Survey • HPV for Female Adolescents

9.3.7. If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well childcare 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: 9.3.8. Performance measures for special targeted populations.

9.4. The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720) 9.5. The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

The assessments will be built upon the data obtained to monitor the achievement of the strategic objectives listed in Table 9.1.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 60 The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720) 9.7. The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1. Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3. Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the State to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

9.9.1 Describe the process used by the State to ensure interaction with Indian Tribes and organizations in the State on the development and implementation of the procedures required in 42 CFR 457.125. States should provide notice and consultation with Tribes on proposed pregnant women expansions. (Section 2107(c)) (42CFR 457.120(c))

When the State determines the need to submit a SPA, a Tribal Solicitation notice is sent to Tribal contacts. The notice is mailed hard copy to Tribal Leaders, e- mailed to a distribution list of Tribal contacts and posted to the Idaho Medicaid- Tribes Teamsite (web-based). The State also meets quarterly with the Tribes. A standing agenda item for these meetings is discussion of SPAs.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), describe how and when prior public notice was provided as required in 42 CFR457.65(b) through (d).

Public hearings, advertised through prior public notice, are held in conjunction with Administrative Rules promulgation required to amend eligibility or benefits for the Children’s Health Insurance Program. These hearings allow public comment on the entire program. Public notification of proposed changes to Administrative Rules is published the first Wednesday of each month in the Administrative Bulletin and also posted to the state’s website.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 61 9.9.3 Describe the State’s interaction, consultation, and coordination with any Indian tribes and organizations in the State regarding implementation of the Express Lane eligibility option. N/A

9.10 Provide a 1-year projected budget. A suggested financial form for the budget is below. The budget must describe: (Section 2107(d)) (42CFR 457.140)

• Planned use of funds, including: • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected expenditures for the separate child health plan, including but not limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, dental services, etc. All cost sharing, benefit, payment, eligibility need to be reflected in the budget.

• Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Include a separate budget line to indicate the cost of providing coverage to pregnant women. • States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. • Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. • Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. • Provide a 1-year projected budget for all targeted low-income children covered under the state plan using the attached form. Additionally, provide the following: a. Total 1-year cost of adding prenatal coverage b. Estimate of unborn children covered in year 1

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 62 COST OF APPROVED CHIP PLAN

2016 2017 Benefit Costs

Insurance payments

Managed Care $23,853,567 $ 24,569,174 Fee for Service $55,658,324 $ 57,328,074 Total Benefit Costs $79,511,891 $ 81,897,248 (Offsetting beneficiary cost sharing payments) $ (859,716) $ (915,855) Net Benefit Costs $78,652,175 $ 80,981,393 Administration Costs

Personnel

General Administration $ 869,960 $ 974,065 Contractors/Brokers (e.g., enrollment contractors) $ - $ - Claims Processing $ 33,081 $ 37,040 Outreach/Marketing costs $ - $ - Other (e.g., indirect costs) $ - $ - Health Services Initiatives $ 1,918,591 $ 2,148,183 Total Administration Costs $ 2,821,632 $ 3,159,288 10% Administrative Cap (net benefit costs ¸ 9) $ 8,739,131 $ 8,997,933

Federal Title XXI Share $81,473,807 $ 84,140,681 State Share $ - $ -

TOTAL COSTS OF APPROVED CHIP PLAN $81,473,807 $ 84,140.681

Per Member Per Month

2017

2018

# of eligibles $ PMPM # of eligibles $ PMPM Managed Care 22,044 $89.20 23,934 $87.52 Fee for Service 22,044 $208.13 23,934 $204.21 Total 22,044 $297.33 23,934 $291.73

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 63

Per Member Per Month

State match for CHIP participants with family incomes between 150% and 185% FPL is currently collected through a state-imposed premium tax on insurance policies sold within the State. A portion of these funds is dedicated to CHIP funding via Idaho statute. The premium tax that funds this portion of the program is imposed on all entities that sell insurance (not just health insurance) in Idaho. Less than 85 percent of the premium tax burden falls on health care providers. The premium tax collections from health insurance are treated the same as premium tax collections from other types of insurance. Therefore, this premium tax does not meet the definition of a “health-care related tax” as defined in 42 CFR §433.55. The current state match for CHIP participants is 100% federal funding in accordance with the Medicare Access and CHIP Reauthorization Act of 2015. This authority extends federal funding through 2017. Re-authorization of funding by Congress may impact the State’s contribution and require changes for FFY2018.

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2017

Approval Date: April 19, 2018 64 Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1. The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2. The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e)) 10.3. The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Section 10.3-D Specify that the State agrees to submit yearly the approved dental benefit package and to submit quarterly the required information on dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Website. Expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1. The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1. 42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2. Section 1124 (relating to disclosure of ownership and related information) 11.2.3. Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4. Section 1128A (relating to civil monetary penalties) 11.2.5. Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6. Section 1128E (relating to the National health care fraud and abuse data collection program) expanded eligibility under the state’s Medicaid plan.

Effective Date: July 1, 2017

Approval Date: April 19, 2018 65 State Plan for the Idaho State Children’s Health Insurance Program

12.1. Eligibility and Enrollment Matters

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

The State of Idaho uses a review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. Idaho CHIP will use the same Fair Hearing rights and process for CHIP as for Idaho Medicaid. Families are informed of their rights and responsibilities upon application for coverage and via the “Notice of Decision” sent upon eligibility determination. A Fair Hearing can be requested to review any adverse decision made in determining eligibility or enrollment.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120.

The State of Idaho uses a review process for health services matters that complies with 42 CFR 457.1120. Upon enrollment, participants are provided instruction and contact information regarding how to file a grievance or make a complaint regarding service delivery. Idaho CHIP uses the same Fair Hearing rights and process for CHIP as for Idaho Medicaid.

12.3. Premium Assistance Programs

If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

Not applicable.

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014

Approval Date: October 1, 2014

State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938-1148 Expiration date: 10/31/2014 Eligibility for Medicaid Expansion Program CS3

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

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

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

+ 6 19 107 133 x

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

Page 1 of 1

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938-1148 Expiration date: 10/31/2014 Separate Child Health Insurance Program Eligibility - Targeted Low-Income Children CS7

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

Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the ■ state. ✔ The CHIP Agency operates this covered group in accordance with the following provisions:

Age

Must be under age 19.

Income Standards

Income standards are applied statewide. Yes

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

Begin with lowest age range first.

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

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

+ 0 6 142 185 x + 6 19 133 185 x Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards. Age ranges do not overlap.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities? No

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program 1 of 2 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938-1148 Expiration date: 10/31/2014 Separate Child Health Insurance Program Eligibility - Deemed Newborns CS13

Section 2112(e) of the SSA and 42 CFR 457.360 Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CHIP ■ or Medicaid until the child turns one. ✔ The state operates this covered group in accordance with the following provisions: ■ The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

The child is deemed to have applied for and been found eligible for CHIP or Medicaid, as appropriate, as of the date of the ■ child's birth, and remains eligible without regard to changes in circumstances until the child's first birthday. The state elects the following option(s):

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

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

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

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

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 Child Health Insurance Program Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards CS14

Section 2101(f) of the ACA and 42 CFR 457.310(d) ■ Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows: The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

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

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

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

% FPL

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

Other.

Describe the benefits provided to this population:

This population will be provided the same benefits as are provided to children in the state’s Medicaid program. This population will be provided the same benefits as are provided to children in the state's separate CHIP. Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D). Describe premiums and cost sharing required of this population: Cost sharing is the same as for children in the Medicaid program.

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2015 Approval Date: August 12, 2015 State Plan Amendment #13-0016 for the Idaho State Children’s Health Insurance Program Separate Child Health Insurance Program OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 MAGI-Based Income Methodologies CS15 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315 The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described ✔ below, and consistent with 42 CFR 457.315 and 435.603(b) through (i). In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later. If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: The pregnant woman is counted just as herself. The pregnant woman is counted just as herself, plus one. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: Current monthly household income and family size. Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of the reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group ✔ income standards to MAGI-equivalent standards. An attachment is submitted. Page 1 of 2 SPA ID-15-0016 x

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: July 1, 2015 Approval Date: August 12, 2015 State Plan Amendment #13-0016 for the Idaho State Children’s Health Insurance Program According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Page 2 of 2 PRA Disclosure Statement SPA# ID-15-0016

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 Separate Child Health Insurance Program Non-Financial Eligibility - Residency CS17

42 CFR 457.320 Residency

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

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

A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the ■ state and: 1. Intends to reside in the state, including without a fixed address, or

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

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

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

An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or ■ caretaker at the time of placement, or ■ A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of ■ residence. If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: ■ A non-institutionalized pregnant woman who is living in the state and:

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

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

An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster ■ care homes, by an agency of the state, or An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the ■ individual established residency in the state prior to entering the institution, or A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's ■ actual state of residence. The state has in place related to the residency of children and pregnant women (if covered by the state):

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

One or more interstate agreement(s). No

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

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

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 Separate Child Health Insurance Program Non-Financial Eligibility - Citizenship CS18

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

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, ✔ including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status. ■ The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals: Who are citizens or nationals of the United States; or Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

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

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

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

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

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). No The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- No Income Pregnant Women.

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program Page 1 of 2 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 Separate Child Health Insurance Program Non-Financial Eligibility - Social Security Number CS19

42 CFR 457.340(b) Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number. The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following ✔ exceptions:

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

The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social ■ Security Administration if the individual does not have or forgot their SSN. ■ The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the ✔ individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below. The state requests non-applicant household members to voluntarily provide their SSN. Yes ✔ When requesting an SSN for non-applicant household members, the state assures that:

At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and ■ provides information regarding how the SSN will be used; and The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or ■ for a purpose directly connected with the administration of the state plan.

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

PRA Disclosure Statement

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

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 Separate Child Health Insurance Program Non-Financial Eligibility - Substitution of Coverage CS20 457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA Substitution of Coverage

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

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

Name of policy Description

Monitoring for Substitution of Coverage Insurance provided under CHIP does not substituted for coverage under group health plans.

Prior to January 1, 2014, the State required that a child not have had creditable health insurance for the 6 months immediately preceding the application or to determine if the family lost insurance through no fault of the insured such as, financial hardship, unaffordable premiums, loss of employment, or the loss of eligibility for employer sponsored insurance. To monitor its substitution of coverage policy, the State requires applicants to list health coverage for all persons in the household who currently have health insurance, and to include the information on the policy for those that do. The application also contains a question on whether anyone has had health insurance end within the six months prior to application, and asks the applicant to provide a reason for the coverage ending. The trigger point for this policy is at initial application or at eligibility redetermination. Historically, very few applicants did not meet the no + fault threshold. x As of January 1, 2014, the Department will not require a 6 month period of un-insurance prior to receipt of CHIP. It has been found that the vast majority of applicants are able to meet the no-fault provisions and were provided coverage as of application date.

The Department will continue to monitor the availability of private insurance through the application and eligibility redetermination process , the monitoring of coverage through our third party liability contractor, enforcement of child medical support orders and evaluating Medical billings that might indicate another party liable for an accident or injury.

Applicants are informed of the requirement to pursue available coverage resources, including ESI, individual coverage, medical support or third party claims through the application process.

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

If the state covers pregnant women, the waiting period does not apply to pregnant women. If the state elects to offer dental only supplemental coverage, the following assurances apply:

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

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

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130718

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 Separate Child Health Insurance Program Non-Financial Eligibility - Non-Payment of Premiums CS21 42 CFR 457.570 Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes

Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130709

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program

Separate Child Health Insurance Program OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 General Eligibility - Eligibility Processing CS24

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

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

Application Processing

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

The single, streamlined application 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 and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

An attachment is submitted.

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

An attachment is submitted.

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

The agency accepts applications in the following other electronic means.

Other electronic means:

Name of method Description

Fillable PDF The State will have on line a fillable PDF application as an interim solution. The on line + application is not yet completed but is in process. x The PDF may be completed and printed or scanned or emailed, etc. + In person Applicants may bring application into the office. x Telephonic Applicants may complete an application in the + course of a telephone interview and provide a x telephonic signature.

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014 State Plan for the Idaho State Children’s Health Insurance Program + + + x x x

E-Mail The applicant may completed the fillable PDF and email to the local office. Fax A completed application may be faxed to the local office. Postal mail An applicant may mail a completed application to the Department. Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low- ✔ income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

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

Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as ■ potentially eligible for Medicaid or other insurance affordability programs based on household income; and

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

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced premium tax credits in accordance with section 1943(b)(2) of the SSA. Yes Redetermination Processing

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 457.343:

■ Once every 12 months.

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.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 ✔ CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014

State Plan for the Idaho State Children’s Health Insurance Program

Check all types of agencies that apply:

The Exchange

Medicaid

Other agency administering insurance affordability programs

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

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

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014

State Plan for the Idaho State Children’s Health Insurance Program

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

 Paper Application  Online Application

TRANSMITTAL NUMBER:

ID-13-0023

STATE:

Idaho

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

CHIP Eligibility State Plan Amendment #14 for the Idaho State Children’s Health Insurance Program

Effective Date: January 1, 2014 Approval Date: October 8, 2014

State Plan for the Idaho State Children’s Health Insurance Program

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

Paper Application Online Application

TRANSMITTAL NUMBER:

ID-13-0023

STATE:

Idaho

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

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24

Application for Assistance

Food Assistance The Idaho Food Stamp Program is a supplemental nutrition assistance program that helps families buy food for good health. Eligible families get a debit like card to buy food items. You may be required to participate in work programs, and cooperate with Child Support Services.

Cash Assistance The Temporary Assistance for Families in Idaho Program provides cash assistance for: emergency situations, families with children, and the elderly, blind, or disabled. Eligible families receive a one- time or on-going payment, depending on the needs of the household. Health Coverage Assistance The Idaho Medicaid Program provides health coverage assistance according to individual needs. Eligible families may qualify for 1) free or low-cost coverage from Medicaid, 2) tax credits to help pay health coverage premiums, or 3) affordable private health insurance plans.

Child Care Assistance The Idaho Child Care Program helps parents and caretakers pay for a part of their child care costs while working, going to school, or participating in approved training activities. Eligible families receive a portion of child care costs paid to the provider.

Who can use this application Anyone may use this application to: ▪ Apply for assistance for themselves and their household members ▪ Apply for just one type of assistance or for multiple types of assistance

What you may need to apply Sending or bringing proof of the items below will help speed up your application: ▪ Identity ▪ Income ▪ Household expenses ▪ Resources

Why we ask for this information We keep all information private and secure, as required by law. We ask for this information for a few reasons: ▪ To figure out what types of assistance you qualify for ▪ To figure out how much assistance you qualify for ▪ To make sure you get the right amount of assistance based on your situation. Equal opportunity for applicants - In accordance with federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, the Idaho Department of Health and Welfare is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited on the basis of religion or political beliefs. To file a complaint of discrimination, contact USDA or HHS at:

▪ USDA, Director, Office of Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 (800) 795.3272 (voice) (202)720.6382 (TTY)

▪ U.S. Department of Health & Human Services Room 506F, 200 Independence Avenue, SW Washington, D.C. 20201 ocrcomplain@hhs.gov (202) 619.0403 (Voice) (202) 619.3257 (TTY)

What happens next Send your complete, signed application to the address below. We will tell you if you're eligible or not, or give you further instructions for completing your application. Self Reliance Programs - Statewide Application Team PO Box 83720 Boise, ID 83720-0026 Fax: 1-866-434-8278 E-mail: MyBenefits@dhw.idaho.gov

Get help with this application ▪ Online: healthandwelfare.idaho.gov ▪ Phone: 1-877-456-4233 ▪ E-mail: MyBenefits@dhw.idaho.gov ▪ In person: Visit our website or call 1-877-456-1233 to find a local office.

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 1. First Name Middle Name Last Name Suffix 2. Date of birth 3. Former Names,if any 12. Do you want an interpreter if you are interviewed (one will be provided at no cost to you)? No Yes 13. ¿Usted necesita a intérprete si usted tiene una entrevista (uno estará disponible en ningún costo para usted)? No Yes Tell us about yourself (or another adult in the household who will be the primary contact for this application)

4. Physical Address City State Zip Code County 5. Mailing Address (if different) City State Zip code County

6. Daytime Phone 7. Phone type (choose one) Home Work Cell 8. If none, where can we leave a message? Phone: 9. Email 10. Preferred language spoken (if not English): 11. Preferred language written/read (if not English):

14. Would you like to name someone as your authorized representative? No Yes. Complete Appendix A. You may give a trusted friend, partner, or third party caseworker permission as an "authorized representative" to talk to the Department, see your information, and act on your behalf for all matters relating to your case. 15. Are you applying for Food Stamps? No. Skip this section. Yes. Complete this section. If you are applying for Food Assistance only, you may start the application process immediately by filling out this page, signing it, and turning it in. You must complete the rest of the application and turn it in as soon as possible. If you qualify, emergency Food Stamp benefits can begin within 7 days. a. Are any members of your household migrant or seasonal farm workers? b. Is your income before taxes this month less than $150? c. Are your monthly housing and utility costs more than your total monthly income and resources? d. Are your resources (cash, checking, savings) less than $100?

No Yes No Yes No Yes No Yes

Signature of applicant/authorized representative to request Food Stamps Date

16. Do you want telephone assistance for your household? No. Go to the next section. Yes. Complete the questions below. The Idaho Telecommunications Service Assistance Program (ITSAP) helps pay monthly telephone service costs.

a. Name of phone company b. Phone number c. Name on bill Tell us who lives in your household Who you need to include on this application ▪ We need information about everyone who lives at the physical address you wrote down in the "Tell Us About Yourself" section above. ▪ If applying for health coverage for anyone under 65 and not disabled, tell us about everyone included on your federal tax return (if you file taxes), even if they don't live at the same address. You don't need to file taxes to get health coverage.

Information that is optional or not required Most fields in this section are required, but some are optional for certain household members. ▪ Social Security Number - optional for people not applying, and for people applying for emergency health coverage or child care assistance ▪ U.S. citizenship, and immigration status (questions 12 & 13) - not required for people not applying for assistance ▪ Race - optional for all types of assistance ▪ Hispanic or Latino - optional for all types of assistance

Tell us more about you (the primary contact person for this application) You/Primary Contact Person 1. Type(s) of assistance requested for this person: Food Health Cash Child Care None 5. Social Security Number 7. Sex M F 8. Marital Status Married Not Married 9. Pregnant? No Yes If yes, due date How many due? 10. Race White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Island 11. Hispanic or Latino? (Optional) No Yes 12. U.S. citizen or national? (Skip #12 & 13 if not applying for assistance) No Yes 13. If not a U.S. citizen or national, does this person have eligible immigration status? Yes. Complete questions a through d.

a. Immigration document type: b. Document ID number: c. Lived in the U.S. since 1996? No Yes d. A veteran or active-duty member of the U.S. military? No Yes 14. Does this person plan to file a federal tax return for the CURRENT YEAR? No. Skip to question c. Yes. Complete questions a, b, c. a. Filing jointly with a spouse? No Yes If yes, name of spouse:

b. Claiming dependents? No Yes If yes, names of dependents:

c. Claimed as a dependent on someone's tax return who does not live at the address listed on page 1 of this application?

No Yes Attach another sheet if you need to provide more information than space allows. Page 1 of 9

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 Tell us about everyone else in your household Tell us about each person who lives with you at the address you wrote down in the "Tell Us About Yourself" section on page 1. If applying for health coverage for anyone under 65 and not disabled, tell us about everyone included on your federal tax return. See page 1 for details. Copy this page or attach another sheet if you need to provide more information than space allows.

Person 1 1. Type(s) of assistance requested for this person: Food Health Cash Child Care None 2. First Name Middle Name Last Name Suffix 3. Former Names, if any 4. Relationship to you 5. Social Security Number 6. Date of birth 7. Sex M F 8. Marital Status Married Not Married 9. Pregnant? If yes, due date How many due? No Yes 10. Race White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Island 11. Hispanic or Latino? (Optional) No Yes 12. U.S. citizen or national? (Skip #12 & 13 if not applying for assistance) No Yes 13. If not a U.S. citizen or national, does this person have eligible immigration status? Yes. Complete questions a through d. a. Immigration document type: b. Document ID number: c. Lived in the U.S. since 1996? No Yes d. A veteran or active-duty member of the U.S. military? No Yes

14. Does this person plan to file a federal tax return for the CURRENT YEAR?

No. Skip to question c.

Yes. Complete questions a, b, c. a. Filing jointly with a spouse? No Yes If yes, name of spouse:

b. Claiming dependents? No Yes If yes, names of dependents:

c. Claimed as a dependent on someone's tax return who does not live at the address listed on page 1 of this application?

No Yes

Person 2 1. Type(s) of assistance requested for this person: Food Health Cash Child Care None 2. First Name Middle Name Last Name Suffix 3. Former Names, if any 4. Relationship to you 5. Social Security Number 6. Date of birth 7. Sex M F 8. Marital Status Married Not Married 9. Pregnant? If yes, due date How many due? No Yes 10. Race White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Island 11. Hispanic or Latino? (Optional) No Yes 12. U.S. citizen or national? (Skip #12 & 13 if not applying for assistance) No Yes 13. If not a U.S. citizen or national, does this person have eligible immigration status? Yes. Complete questions a through d. a. Immigration document type: b. Document ID number: c. Lived in the U.S. since 1996? No Yes d. A veteran or active-duty member of the U.S. military? No Yes

14. Does this person plan to file a federal tax return for the CURRENT YEAR?

No. Skip to question c.

Yes. Complete questions a, b, c. a. Filing jointly with a spouse? No Yes If yes, name of spouse:

b. Claiming dependents? No Yes If yes, names of dependents:

c. Claimed as a dependent on someone's tax return who does not live at the address listed on page 1 of this application?

No Yes

Person 3 1. Type(s) of assistance requested for this person: Food Health Cash Child Care None 2. First Name Middle Name Last Name Suffix 3. Former Names, if any 4. Relationship to you 5. Social Security Number 6. Date of birth 7. Sex M F 8. Marital Status Married Not Married 9. Pregnant? If yes, due date How many due? No Yes 10. Race White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Island 11. Hispanic or Latino? (Optional) No Yes 12. U.S. citizen or national? (Skip #12 & 13 if not applying for assistance) No Yes 13. If not a U.S. citizen or national, does this person have eligible immigration status? Yes. Complete questions a through d. a. Immigration document type: b. Document ID number: c. Lived in the U.S. since 1996? No Yes d. A veteran or active-duty member of the U.S. military? No Yes

14. Does this person plan to file a federal tax return for the CURRENT YEAR?

No. Skip to question c.

Yes. Complete questions a, b, c. a. Filing jointly with a spouse? No Yes If yes, name of spouse:

b. Claiming dependents? No Yes If yes, names of dependents:

c. Claimed as a dependent on someone's tax return who does not live at the address listed on page 1 of this application?

No Yes

Copy this page or attach another sheet if you need to provide more information than space allows. Page 2 of 9

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24

Continue telling us about each person who lives with you. See page 1 for details. Person 4 1. Type(s) of assistance requested for this person: Food Health Cash Child Care None 2. First Name Middle Name Last Name Suffix 3. Former Names, if any 4. Relationship to you 5. Social Security Number 6. Date of birth 7. Sex M F 8. Marital Status Married Not Married 9. Pregnant? If yes, due date How many due? No Yes 10. Race White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Island 11. Hispanic or Latino? (Optional) No Yes 12. U.S. citizen or national? (Skip #12 & 13 if not applying for assistance) No Yes 13. If not a U.S. citizen or national, does this person have eligible immigration status? Yes. Complete questions a through d. a. Immigration document type: b. Document ID number: c. Lived in the U.S. since 1996? No Yes d. A veteran or active-duty member of the U.S. military? No Yes

14. Does this person plan to file a federal tax return for the CURRENT YEAR?

No. Skip to question c.

Yes. Complete questions a, b, c. a. Filing jointly with a spouse? No Yes If yes, name of spouse:

b. Claiming dependents? No Yes If yes, names of dependents:

c. Claimed as a dependent on someone's tax return who does not live at the address listed on page 1 of this application?

No Yes

Person 5 1. Type(s) of assistance requested for this person: Food Health Cash Child Care None 2. First Name Middle Name Last Name Suffix 3. Former Names, if any 4. Relationship to you 5. Social Security Number 6. Date of birth 7. Sex M F 8. Marital Status Married Not Married 9. Pregnant? If yes, due date How many due? No Yes 10. Race White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Island 11. Hispanic or Latino? (Optional) No Yes 12. U.S. citizen or national? (Skip #12 & 13 if not applying for assistance) No Yes 13. If not a U.S. citizen or national, does this person have eligible immigration status? Yes. Complete questions a through d. a. Immigration document type: b. Document ID number: c. Lived in the U.S. since 1996? No Yes d. A veteran or active-duty member of the U.S. military? No Yes

14. Does this person plan to file a federal tax return for the CURRENT YEAR?

No. Skip to question c.

Yes. Complete questions a, b, c. a. Filing jointly with a spouse? No Yes If yes, name of spouse:

b. Claiming dependents? No Yes If yes, names of dependents:

c. Claimed as a dependent on someone's tax return who does not live at the address listed on page 1 of this application?

No Yes

Tell us about your household situation 1. Is anyone in your household American Indian or Alaska Native? No Yes. If yes, complete Appendix B with the application. 2. Is anyone in your household applying for or already receiving Tribal Commodities? No Yes 3. Is anyone in your household applying for or already receiving Foster Care or Adoption Assistance? No Yes

4. Was anyone in foster care when they turned 18? No Yes a. If yes, who?

5. Is anyone in your home currently receiving assistance from another State? No Yes. If yes, tell us when, where, and the type. a. Date b. City State County

c. Type of assistance received

6. Is anyone who is applying for assistance disabled? No Yes a. If yes, who: 7. Does anyone who is applying have a pending application for Social Security disability? No Yes

a. If yes, tell us who: 8. Does anyone who is applying need medical services provided in the home? No Yes

a. If yes, who:

9. Does anyone who is applying live in a medical care facility? No Yes a. If yes, who b. Name of the facility c. Phone

10. Is anyone listed on this application incarcerated? No Yes a. If yes, who:

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 Attach another sheet if you need to provide more information than space allows. Page 3 of 9

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 Tell us about your household situation Are you applying for health coverage only (no other assistance) for someone under 65 and not disabled? No. Complete all questions on this page. Yes. Skip to page 5.

If you are applying for health coverage for someone under 65 and not disabled along with other types of assistance, or you are applying for other types of assistance besides health coverage, complete the questions below. If you are over 65 or disabled, complete the questions below.

1. Has anyone in your household been disqualified from public assistance due to an intentional program violation? No Yes

a. If yes, who: b. When: c. State: 2. Has anyone in your household been convicted of a felony involving drugs? No Yes

a. If yes, who: b. When: 3. Is anyone fleeing to avoid felony prosecution or jail time? No Yes a. If yes, who: 4. Is anyone currently violating conditions of probation or parole? No Yes

a. If yes, who:

5. Is anyone applying for assistance age 16 to 19 and going to high school? No Yes. If yes, use the table below to tell us who. Name of student Name of high school Expected graduation date

6. Is anyone applying for assistance age 18 to 49 and going to college? No Yes. If yes, use the table below to tell us who. Name of student Name of college Student status Work study

Full time Part time No Yes

Full time Part time No Yes

Full time Part time No Yes

7. If you have children in the home, are they immunized? No Yes 8. If you have children in your home, do any of them have a parent NOT living with them? No Yes. If yes, tell us who they are.

If you answered Yes, you will be required to give information about the absent parent(s) to Child Support Services and open a Child Support case unless you fear harm to yourself or your children. Child name Absent parent name Absent parent Social Security Number Absent parent Date of birth

Attach another sheet if you need to provide more information than space allows. Page 4 of 9

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 Tell us about your household income (required for all types of assistance) Tell us about all income your household receives. We want to know about the last 30 days, as well as any money received quarterly or annually. Income is money earned (wages or salary) from a job or self-employment, or unearned from sources such as Social Security, child support, unemployment benefits, gifts, rental income, retirement income, etc. Copy this page or attach another sheet if you need to provide more information than space allows.

Income Source 1 1. Name of person with income: Income from a job - Tell us about any income this person gets from working a job. 2. Employer name 3. Employer phone 4. Average hours worked each week 5. Wages/tips $ (before taxes) paid Hourly Weekly Every Twice 2 weeks a month Monthly Yearly 6. Income expected to change (raise, hours changed, etc.) No Yes Why? Income from your own business - Tell us about any income this person gets from a business they own. 7. Name of business a. Type of work b. Years in business c. Estimated net income this month Income from other sources - Tell us about any other income sources for this person, such as Social Security, child support, etc. 8. Source of income b. Amount c. How often paid

Weekly Every 2 weeks Twice a month Monthly Yearly Weekly Every 2 weeks Twice a month Monthly Yearly Weekly Every 2 weeks Twice a month Monthly Yearly

Income Source 2 1. Name of person with income: Income from a job - Tell us about any income this person gets from working a job. 2. Employer name 3. Employer phone 4. Average hours worked each week 5. Wages/tips $ (before taxes) paid Hourly Weekly Every Twice 2 weeks a month Monthly Yearly 6. Income expected to change (raise, hours changed, etc.) No Yes Why? Income from your own business - Tell us about any income this person gets from a business they own. 7. Name of business a. Type of work b. Years in business c. Estimated net income this month Income from other sources - Tell us about any other income sources for this person, such as Social Security, child support, etc. 8. Source of income b. Amount c. How often paid

Weekly Every 2 weeks Twice a month Monthly Yearly Weekly Every 2 weeks Twice a month Monthly Yearly Weekly Every 2 weeks Twice a month Monthly Yearly

Income Source 3 1. Name of person with income: Income from a job - Tell us about any income this person gets from working a job. 2. Employer name 3. Employer phone 4. Average hours worked each week 5. Wages/tips $ (before taxes) paid Hourly Weekly Every Twice 2 weeks a month Monthly Yearly 6. Income expected to change (raise, hours changed, etc.) No Yes Why? Income from your own business - Tell us about any income this person gets from a business they own. 7. Name of business a. Type of work b. Years in business c. Estimated net income this month Income from other sources - Tell us about any other income sources for this person, such as Social Security, child support, etc. 8. Source of income b. Amount c. How often paid

Weekly Every 2 weeks Twice a month Monthly Yearly Weekly Every 2 weeks Twice a month Monthly Yearly Weekly Every 2 weeks Twice a month Monthly Yearly

Copy this page or attach another sheet if you need to provide more information than space allows. Page 5 of 9

Are you applying for health coverage only (no other assistance) for someone under 65 and not disabled? No. Complete all questions on this page. Yes. Skip to page 8. If you are applying for health coverage for someone under 65 and not disabled along with other types of assistance, or you are applying for other types of assistance besides health coverage, complete the questions below. If you are over 65 or disabled, complete the questions below.

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24

Tell us about your vehicles, resources, and property 1. Motor Vehicles - Tell us about all vehicles, including cars, trucks, motorcycles, trailers, boats, snowmobiles, and other recreational vehicles that your household owns.

Owner Year, make, and model Current value Primary use for this vehicle (choose one)

Business Get to work Medical Recreational Income producing Work search Residence Personal (other)

Business Get to work Medical Recreational Income producing Work search Residence Personal (other)

Business Get to work Medical Recreational Income producing Work search Residence Personal (other)

2. Resources - Tell us about all resources your household owns, including cash on-hand, checking and savings accounts, stocks, bonds, mutual funds, 401Ks, IRAs, trusts, CDs, life insurance policies, burial funds, etc.

Name/owner of resource Resource type Name of financial institution Account number Current value

3. Property - Tell us about all other property (including your home) owned by anyone living in your home.

Name/owner of property Property type Property Address Value Primary use for this property (choose one)

Home Rental income Business/Self-employment Other:

Home Rental income Business/Self-employment Other:

Home Rental income Business/Self-employment Other:

4. Sale or transfer of resources and property - Tell us about everyone in your home who has sold, transferred or given away cash, property, or other assets within the last five years.

Name Date of Transaction What Assets Amount Received Fair Market Value

Are you applying for health coverage only (no other assistance) for someone under 65 and not disabled? No. Complete all questions on this page. Yes. Skip to page 8. If you are applying for health coverage for someone under 65 and not disabled along with other types of assistance, or you are applying for other types of assistance besides health coverage, complete the questions below. If you are over 65 or disabled, complete the questions below.

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 Attach another sheet if you need to provide more information than space allows. Page 6 of 9

Are you applying for health coverage only (no other assistance) for someone under 65 and not disabled? No. Complete all questions on this page. Yes. Skip to page 8. If you are applying for health coverage for someone under 65 and not disabled along with other types of assistance, or you are applying for other types of assistance besides health coverage, complete the questions below. If you are over 65 or disabled, complete the questions below.

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24

Tell us about your household expenses

1. Shelter Expenses - Tell us about your recurring expenses. When telling us the amount of each expense, include only the amount you pay. If your mortgage payments include other payments such as irrigation, property taxes, HOA fees, etc., break them out and record them separately below.

Rent per month $ Mortgage per month $ 2nd Mortgage per month $ Space rent per month $ Irrigation $ per Property t $ ax per HOA fees $ per Homeowners Insurance $ per Check the boxes below for each utility you pay that is NOT included in your rent or mortgage: Heating Cooling Water Sewer Trash Telephone Landlord's name Landlord's contact number 2. Dependent Care Expenses - Use the space below to tell us about any child care, adult disabled care, or elderly care.

Dependent name Total charge for care Amount you pay How often you pay Provider name Provider address Provider phone

Dependent name Total charge for care Amount you pay How often you pay Provider name Provider address Provider phone

Dependent name Total charge for care Amount you pay How often you pay Provider name Provider address Provider phone

3. Individual Expenses - Use the space below to tell us about any individual expenses. Allowable expenses include child support paid and some medical expenses for household members who are disabled or over the age of 60. When telling us the amount of each expense, include only the amount you pay.

Name of person with expense Expense type Amount How often paid?

$

$

$

$

$

Attach another sheet if you need to provide more information than space allows. Page 7 of 9

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 What services are covered? Check all that apply. Inpatient/outpatient hospital services Lab services Physicians medical/surgical services X-ray services What services are covered? Check all that apply. Inpatient/outpatient hospital services Lab services Physicians medical/surgical services X-ray services Tell us about your health coverage situation 1. Does anyone who is applying for health coverage want help paying for medical costs from the last 3 months? No. Skip to #2. Yes. Complete questions the two questions below. a. If yes, tell us who

b. If yes, tell us your gross household income (income before taxes) received by your family in each of the last three months:

Last month Two months ago Three months ago 2. Is anyone on this application insured by any of the following?

Medicaid No Yes Who?

CHIP No Yes Who?

Medicare No Yes Who?

TRICARE No Yes Who?

VA Health Care Peace Corps No No Yes Yes Who?

Who?

Employer Insurance No Yes Who?

Name of insurance:

Policy number: Is this COBRA coverage? No Yes Is this a retiree health plan? No Yes

Other Insurance No Yes Who?

Name of insurance: Policy number: Monthly premium: Is this a limited-benefit plan? No Yes

3. If not currently receiving coverage, does anyone have access to health insurance from a job? Check "yes" even if the coverage is from someone else's job such as a parent or a spouse.

No Yes. Complete Appendix C.

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 Rights and Responsibilities I understand that...

My signature certifies that the information on this application is true and accurate. I could be sanctioned and required to If I am determined eligible for Medicaid, I choose the plan that is based on my health needs, unless I tell the return any benefit I receive if my information is not true.

Self Reliance worker otherwise. Sanctions may include administrative, civil or criminal

actions against me, including prosecution. If I am determined eligible for Medicaid, I may be responsible for paying part of the cost of my child's health I consent to the gathering, use and disclosure of my

coverage, and I will be notified of my co-pay amount. information by the Idaho Department of Health and Welfare or its designees. I understand the information is needed for the purpose of providing benefits or services, obtaining My signature or the signature of my representative authorizes State offices to communicate with insurance payment for my benefits or services, and for normal

companies related to my/my child's medical assistance.

business operations of the Department.

I consent to the gathering and use of income data, including information from tax returns for determining eligibility for help paying for health coverage in future years (up to 5 years). I will receive notice when this occurs, be able to

make changes, and may opt out at any time.

I have the right to revoke this consent, in writing, at any time except to the extent the Department has already used and disclosed my information in reliance on this consent. If I revoke this consent, the Department may not provide

further benefits or services.

I will be notified of the right to appeal Department decisions and I can contact the Department for information on the

appeal process.

My signature indicates I have received a copy of the

Department Privacy Practices.

By applying for benefits for a minor child, a medical support case must be opened, when applicable. If I am receiving benefits for myself, failure to cooperate with Child Support

Services may result in a loss or decrease of my benefits.

If I receive a Child Support payment in error, Child Support Services will withhold future payments to recover the

amount unless I submit written instructions to the contrary.

By applying for heating and energy assistance, I authorize the Department to request information from and/or disclose necessary information to my utility companies for the purpose of determining my eligibility and providing benefits or services until I become ineligible or I request to end the

benefits or services. I have the right to choose a Healthy Connections Primary Care Doctor, to request referrals for services, and to change the doctor/clinic if my circumstances change.

If I receive Medicaid after age 55, my estate may be subject to recovery of medical expenses paid on my behalf, and that any transfer of assets may be set aside by a court if I do not receive adequate value.

If a third party is responsible for my child's disease or injury, I give to Medicaid any rights I may have, or may acquire in the future, to be compensated by the responsible party for any medical benefits I receive for myself/my children.

If I receive Medicaid/Cash Assistance, I am required to report changes in my circumstance, including income, assets, and living situation within ten (10) days of the

change.

I may be required to cooperate with state or federal reviewers who are making sure my benefits are correct. I may not be eligible to receive benefits if I do not cooperate.

To receive Food Assistance, I may be required to participate in work programs. Failure to do so may result in a loss or decrease in benefits.

It is illegal to give my Quest EBT card away or to trade the benefits on my card for cash, firearms, drugs, or other goods and services. Penalties include fines, imprisonment, and disqualification from future benefits.

If I receive cash assistance (TAFI), I may not withdraw cash benefits, or use cash benefit funds to purchase products and services, in gambling establishments, liquor and tobacco stores, adult entertainment venues, other establishments prohibiting persons under the age of 18, or tattoo, body

piercing, or other branding parlors.

Signature (must be completed) Under penalty of perjury, I swear or affirm the information I have provided is true and complete. My signature confirms that I have read and understand the Rights and Responsibilities listed on this page.

Signature of applicant/authorized representative Date

Signature of applicant/authorized representative Date

Page 9 of 9

Appendix A

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24

You can name someone as an authorized representative. You may give a trusted person, such as a friend, partner, or third party caseworker permission to talk about this application with us, see your information, and act for you on all matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.”

If you ever need to change your authorized representative, contact the Department to complete a new Authorized Representative Form. If you’re a legally appointed representative for someone on this application, submit proof with the application.

Tell us who you want to name as your authorized representative First Name Middle Name Last Name

Address Apartment or suite number City State Zip Code County Phone Phone type (choose one) Home Work Cell Email Organization Name (if third party caseworker) Organization ID (if applicable) By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with the Department.

Signature of Authorized Representative Date

Appendix B

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24

Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Assistance.

Tell us about your American Indian or Alaska Native family member(s). American Indians (AI) and Alaska Natives (AN) 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 special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. NOTE: If you have more than three people to include, make a copy of this page and attach with your Application for Assistance.

Person 1 1. First Name Middle Name Last Name

2. Is this person a member of a federally recognized tribe? No Yes b. If yes, name of tribe:

3. Has this person ever received services from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs?

No Yes

b. If no, is this person eligible to receive these services?

No Yes

4. List any income (amount and how often) reported on the application that includes money from: ▪ Per capita payments from a tribe that come from natural resources, usage rights, or royalties ▪ Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) ▪ Money from selling things that have cultural significance

Amount: $

Frequency:

Person 2 1. First Name Middle Name Last Name

2. Is this person a member of a federally recognized tribe? No Yes b. If yes, name of tribe:

3. Has this person ever received services from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs?

No Yes

b. If no, is this person eligible to receive these services?

No Yes

4. List any income (amount and how often) reported on the application that includes money from: ▪ Per capita payments from a tribe that come from natural resources, usage rights, or royalties ▪ Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) ▪ Money from selling things that have cultural significance

Amount: $

Frequency:

Person 3 1. First Name Middle Name Last Name

2. Is this person a member of a federally recognized tribe? No Yes b. If yes, name of tribe:

3. Has this person ever received services from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs?

No Yes

b. If no, is this person eligible to receive these services?

No Yes

4. List any income (amount and how often) reported on the application that includes money from: ▪ Per capita payments from a tribe that come from natural resources, usage rights, or royalties ▪ Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) ▪ Money from selling things that have cultural significance

Appendix B

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24

Amount: $

Frequency:

Appendix C

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24

Complete this appendix if someone in the household is eligible for health 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. First Name Middle Name Last Name

2. Social Security Number

Employer Information 3. Name 4. Identification Number (EIN) 5. Address 6. Phone 7. City 8. State 9. Zip Code 10. Who can we contact about employee health coverage at this job?

11. Phone 12. Email

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?

No. Stop here and submit this form with your application.

Yes. Complete the rest of this form.

a. If you're in a waiting or probationary period, when can you enroll in coverage?

b. List everyone who is eligible for coverage from this job:

Tell us about the health plan offered by this employer.

14. Does the employer offer a health plan that meets the minimum value standard?*

Yes No 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 discount for any tobacco cessation programs, and did not 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?

Weekly

Every 2 weeks

Twice a month Quarterly Yearly

16. What change will the employer make for the new plan year (if known)?

Employer won't offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. Seequestion 15.)

a. How much would the employee have to pay in premiums for that plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month Quarterly Yearly

c. Date of change:

*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

Appendix C

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

Effective Date: January 1, 2014 Approval Date: October 8, 2014 Attachment to CS24 State Plan Amendment or the Idaho State Children’s Health Insurance Program CHIP Eligibility

OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 Separate Child Health Insurance Program General Eligibility - Continuous Eligibility CS27

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926 The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. Yes For children up to age 19 For children up to age

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

■ At the end of the 12 months continuous eligibility period. Exceptions to the continuous eligibility period: ■ The child attains the age specified by the state Agency or age 19.

■ The child or child's representative requests voluntary disenrollment.

■ The child is no longer a resident of the state.

The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility ■ because of Agency error or fraud, abuse, or perjury attributed to child or child's representative. ■ The child dies. ■ There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan. Other

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130717

Page 1 of 1

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Idaho ID-19-0019

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-1,6 Baltin'rore, MD 2'l2M-1,850 Children ¿nd Adulfs Í{ealth Proørams Groun lvrs ctNftRs fclR MrDrcARr & MtDtc¡tD srRvtcts CENIEN TON MEDICAID & CHIP SERV¡CES AUG 0I 2019 Matt Wimmer Administrator Idaho Department of Health and Welfare P.O. Box 83720 Boise, ID 83720-0036 Dear Mr. V/immer: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA),ID-19-0019, has been approved. ID-19-0019 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L for utilization of a managed care delivery system. The SPA also makes changes to the state's benefits to align with changes to its Medicaid Altemative Benefit Plans, as recently approved in Medicaid SPAs ID-I8-0006 and ID- l9-0007. SPA ID-l9-0019 has an efïective date of July 1, 2018. Sections 2101(a),2103(Ð(3), 2107(b),and2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Idaho has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan as of July 1, 2018. This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on or after July I , 2018 must comply with the CHIP managed care regulations and be submitted for CMS review. Your title XXI project offrcer is Ms. Janice Adams. She is available to answer questions concerning this amendment and other CHlP-related issues. Her contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 701 Fifth Avenue, Suite 1600, Mail Stop: RX-200 Seattle, V/A 98104 Telephone : (206) 61 5 -25 41 E-mail : Janice.Adams@crns.hhs. gov

Page 2 - Mr. Matt Wimmer Official communications regarding program matters should be sent simultaneously to Ms. Adams and to Mr. David Meacham, Deputy Director in our Division of Medicaid Field Operations West. Mr. Meacham's address is: Centers for Medicare & Medicaid Services Division of Medicaid Field Operations West 70i Fifth Avenue, Suite 1600, Mail Stop: RX-200 Seattle, WA 98104 If you have additional questions, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs at (410) 786-0721. We look forward to continuing to work with you and your staff. Di¡ector cc: Mr. David Meacham, Deputy Director, Division of Medicaid Field Operations West /Signed by Anne Marie Costello/

State Plan for the Idaho State Children’s Health Insurance Program

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

ORIGINAL PLAN

Submitted: February 17, 1998 Date Approved: June 15, 1998 Effective Date: October 1, 1997 AMENDMENT#’S

DATES DESCRIPTION

Amendment #1

Change income limit from 160% FPG to 150% FPG Submitted October 13, 1998 Approved December 4, 1998 Effective Date July 1, 1998

Amendment #2

• Program design changes to- • increase coordination of efforts across agencies • simplify the application process, and • improve media and outreach approaches Submitted March 10, 2000 Approved March 1, 2001 Effective Date January 1, 2000

Amendment #3

• Technical changes to conform to model template • Revise outreach strategies Submitted June 28, 2002 Approved September 19, 2002 Effective Date July 1, 2002

Amendment #4

Establish Separate Program Submitted February 25, 2004 Approved June 10, 2004 Effective Date July 1, 2003

Amendment #5

Revise benefit package of separate program Submitted August 30, 2004 Approved January 13, 2005 Effective Date July 1, 2004

Amendment #6

Removal of enrollment cap Submitted June 9, 2005 Approved September 7, 2005 Effective Date June 1, 2005

Amendment #7

Addition of child health services initiative (Healthy Schools)

Submitted April 28, 2006 Approved May 25, 2006

State Plan for the Idaho State Children’s Health Insurance Program

Effective Date July 1, 2006

Amendment #8

• Lower the income limit of separate program from 150% to 133% • Remove resource limit • Incorporate Basic and Enhanced Benchmark Benefit Packages • Changes to premium structure Submitted May 5, 2006 Approved May 25, 2006 Effective Date July 1, 2006

Amendment #9

• Addition of Wellness Preventive Health Assistance • Addition of co-pays Submitted January 24, 2007 Approved September 28, 2007 Effective Date January 1, 2007 Wellness PHA February 1, 2007 co-pays

Amendment #10

• Addition of Substance Abuse Treatment Services • Addition of Independent Therapists for Speech Language Pathology (SLP) Services • Reduce limits for Psycho-Social Rehabilitation, Partial Care and Developmental Disability Agency Services Submitted March 17, 2009 Approved July 15, 2013 Effective Date November 1, 2008 Substance use treatment & SLP January 1, 2009 Reduction in Mental Health and DDA

Amendment #11

• Contact Lens Coverage Modification • Mental Health Assessment Annual Limitation • Mental Health Treatment Plan Limitation • Collateral Contact & Partial Care Elimination • PSR Limitation • DDA Assessment Annual Limitation • Incorporation of Dental Services Template (Sections 6.2-D & 10.3-D) Submitted February 28, 2011 Approved July 15, 2013 Effective Date January 1, 2011

Amendment #12

Change to Chiropractic Service Limitations

Submitted August 29, 2011 Approved July 15, 2013 Effective Date July 1, 2011

State Plan for the Idaho State Children’s Health Insurance Program

Amendment #13

Addition of co-payments (co-pays) for certain services Submitted December 31, 2011 Approved July 2, 2012 Effective Date November 1, 2011 Chiropractor, Optometrist and Podiatrist Svcs. January 1, 2012 Physical Therapy, Occupational Therapy, Speech

Amendment #14

• Addition of Health Homes for Chronically Ill • Implementation of Children’s Redesign Benefit Plan • Implementation of Behavioral Health Managed Care • Developmentally Disabled Children’s Benefit Redesign • Removal of Therapy Prior Authorization Requirements Submitted June 15, 2013 Approved August 29, 2013 Effective Date January 5, 2012 Removal of Therapy prior authorization requirements January 1, 2013 Health Homes July 1, 2013 Developmentally Disabled children’s benefit redesign September 1, 2013 Behavioral health managed care

MAGI Amendment #13- 0014

Medicaid Expansion Submitted September 17, 2013 Approved December 17, 2013 Effective Date January 1, 2014

MAGI Amendment #13- 0015

Establish 2101(f) Group Submitted September 17, 2013 Approved October 8, 2013 Effective Date January 1, 2014

MAGI Amendment #13- 0016

MAGI Eligibility & Methods Submitted September 19, 2013 Approved December 17, 2013 Effective Date January 1, 2014

MAGI Amendment #13- 0023

Eligibility Process