Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 11-007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

FEB 14 2012

Julie Hamos, Director

Illinois Department of Healthcare and Family Services Prescott E. Bloom Building

201 South Grand Avenue East

Springfield, Illinois 62763-0001

ATTN: James Parker and Michelle Maher

Transmittal #11-007 - Approves I/linois’1932(a) State plan amendment to implement mandatory managed care for the adult aged, blind and disabled population in Cook County and the surrounding boarder counties.

--Effective Date: May !, 2011

If you have any questions, please have a member of your staff contact Michelle Baldi at (312) 353-0909 or by email at Michelle. Baldi(@cms.hhs.gov

Verlon Johns: Associate Regional Administrator Division of Medicaid and Children’s Health Operations

|

|

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA). Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTER FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB NO. 0936-0193

TRANSMITTAL AND NOTICE OF APPROVAL

OF STATE PLAN MATERIAL FOR: CENTER FOR MEDICARE AND MEDICAID SERVICES

1. TRANSMITTAL NUMBER 11-07

2. STATE: ILLINOIS

3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act (Medicaid)

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

4, PROPOSED EFFECTIVE DATE: May 1, 2011

5. TYPE OF PLAN MATERIAL (Check One} [ ] NEW STATE PLAN

E ] AMENDMENT TO BE CONSIDERED AS NEW PLAN

[X] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Section 1932(a) Social Security Act

7, FEDERAL BUDGET IMPACT a. FFY 2011— ($1.4) million b. FFY 2012— ($9.2) million

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

an CoA

Attachment 3.1-F pages 1-45 |b”

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Appiicabie):

New Pages

10. SUBJECT OF AMENOMENT:

Integrated Care Program - Mandatory Managed Care for the AABD Population.

11. GOVERNOR'S REVIEW (Check One)

[] GOVERNOR'S OFFICE REPORTED NO COMMENT [ ] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED { ] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[X] OTHER, AS SPECIFIED: Not submitted for review by prior approval.

12. SIGNATURE OF AGENCY OFFI

13. TYPE

AME: Julie Hamos

14, TITLE: Director of Healthcare and Family

Services

16. RETURN TO:

Department of Healthcare and Family Services

Bureau of Program and Reimbursement Analysis Attn: Greg Wilson, Chief

201 South Grand Avenue East

Springfield, iL 62763-0001

18.DATESUBMITTED /y- Sc?- / }

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

| 18. DATE APPROVED:

FEB 1 0202-—____—_-

PLAN APPROVEO—ONE COPY ATTACHED{

19. EFFECTIVE DATE OF APPROVED MATERIAL:

21. PONE Johnson

Administrator

23. REMARKS:

FORM CMS-179 (07/92) °° —

instrucbons on Back

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Citation Condition or Requirement

1932(a)(1)(A) A. Section 1932(a)(1)(A) of the Social Security Act.

The State of Illinois enrolls Medicaid beneficiaries on a mandatory basis into managed care entities (managed care organization (MCOs) through the Integrated Care program, which, unlike the PPCM program, is a full-risk capitated program, in the absence of section 1115 or section 1915(b) waiver authority. This authority is granted under section 1932(a)(1)(A) of the Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance with provisions of section 1902 of the Act on statewideness (42 CFR 431.50), freedom of choice (42 CFR 431.51) or comparability (42 CFR 440.230). This authority may not be used to mandate enrollment in Prepaid Inpatient Health Plans (PIHPs), Prepaid Ambulatory Health Plans (PAHPs), nor can it be used to mandate the enrollment of Medicaid beneficiaries who are Medicare eligible, who are Indians (unless they would be enrolled in certain plans—see D.2.ii. below), or who meet certain categories of “special needs” beneficiaries (see D.2.iii. - vii. below)

B. General Description of the Program and Public Process.

For B.1 and B.2, place a check mark on any or all that apply.

1932(a)(1)(B)(i) 1. The State will contract with an

1932(a)(1)(B)(ii)

42 CFR 438.50(b)(1) _X__i. MCO ——1i. PCCM (including capitated PCCMs that qualify as PAHPs) ___ iii. Both

42 CFR 438.50(b)(2) 2. The payment method to the contracting entity will be:

42 CFR 438.50(b)(3)

i. fee for service;

X_ii. capitation;

iii. a case management fee;

X__iv. a bonus/incentive payment;

v. a supplemental payment, or

——vi. _ other. (Please provide a description below).

Contractors may earn payments based on performance for specified quality metrics. To fund the incentive pool, each month the Department shall withhold a portion of the contractual Capitation rate. The withheld amount will be one percent (1%) in the first measurement year, one and a half percent (1.5%) in the second measurement year and two percent (2%) in the third measurement year.

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Citation Condition or Requirement

Subsequent withheld amounts will be negotiated. The withheld amount will be combined with an additional bonus amount funded by the Department so that total funding of the incentive pool shall be equal to five percent (5%) of the Capitation rate. An equal portion of the incentive pool will be allocated to each P4P Metric. If Contractor reaches the target goal on a P4P Metric, Contractor will earn the percentage of the incentive pool assigned to that P4P Metric. Withholds of Contractor’s Capitation payment will begin with the January 15, 2012. For purposes of measuring P4P Metrics, calendar year 2010 will be considered the initial baseline year and calendar year 2012 will be considered the initial measurement year. AJl measurement years will be calendar years. In subsequent measurement years, the previous year’s performance will be the baseline for that measurement year unless the previous year’s performance was below the initial baseline, in which case the initial baseline remains the baseline. The P4P metrics for the first three years are specified in the contracts with the MCOs. They include metrics such as preventive visits, behavioral health supports, dental utilization, disease specific therapies, ambulatory care follow-up, medication management, and community retention. P4P metrics, baselines and goals for future years will be negotiated.

1905(t) 3. For states that pay a PCCM on a fee-for-service basis, incentive 42 CFR 440.168 payments are permitted as an enhancement to the PCCM’s 42 CFR 438.6(c)(5)(iti)(iv) case management fee, if certain conditions are met.

If applicable to this state plan, place a check mark to affirm the state has met

all of the following conditions (which are identical to the risk incentive rules

for managed care contracts published in 42 CFR 438.6(c)(5)(iv)).

i. Incentive payments to the PCCM will not exceed 5% of the total

FFS payments for those services provided or authorized by the

PCCM for the period covered.

ii. Incentives will be based upon specific activities and targets.

iii. Incentives will be based upon a fixed period of time.

iv. Incentives will not be renewed automatically.

v. Incentives will be made available to both public and private

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Citation Condition or Requirement

——vi. Incentives will not be conditioned on intergovernmental transfer agreements. —_vii. Not applicable to this 1932 state plan amendment.

CFR 438.50(b)(4) 4. Describe the public process utilized for both the design of the program and its initial implementation. In addition, describe what methods the state will use to ensure ongoing public involvement once the state plan program has been implemented. (Example: public meeting, advisory groups.)

The State researched various integrated care models through literature and

reaching out to other state Medicaid programs. The state held many meetings with clients, client advocates and providers to assist with the development of the program, development of the RFP to solicit the contractors, and to guide the implementation of the program. Invitees and attendees included representatives from:

e other state agencies, such as the Division of Mental Health, Division of Developmental Disabilities and the Department on Aging;

* provider associations, such as the Illinois Hospital Association, Hlinois Association of Rehabilitation Facilities, IL Occupational Therapy Association, Illinois Homecare Council, Illinois Primary Health Care Association;

¢ — individual providers; client advocates, such as Centers for Independent Living, IARF, Area Agencies on Aging, IL Council on Developmental Disabilities, AIDS Foundation of Chicago, The ARC of Illinois, The Hope Institute for Children and Families, Equip for Equality, Campaign for Real Choice in Illinois, Center for Developmental Disabilities Advocacy and Community Supports, National Alliance on Mental IlIness-IL, AARP;

e local health departments;

* private companies, such as pharmaceutical companies;

¢ American Indian Health Services of Chicago and

¢ members of the Illinois General Assembly.

¢ — The State will continue to have meetings with representatives from the above listed entities throughout implementation and on an on-going basis. These meetings will be through ad-hoc requests and regularly scheduled stakeholders meetings.

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Citation Condition or Requirement

¢ — The State’s tribal consultation process included contacting the American Indian Health Services of Chicago (AIHSC) on April 6, 2011, to notify them of the State’s intention to submit this SPA. A copy of the State’s administrative rule was provided, and a meeting was set up on April 7, 2011, to discuss the consultation process, including this proposed amendment. On May 13, 2011, a draft copy of this SPA was provided to the AIHSC for review and comment.

1932(a)(1)(A) 5. The state plan program will___/will not_X_ implement mandatory enrollment into managed care on a statewide basis. If not statewide, mandatory__X__/ voluntary. enrollment will be implemented in the

following county/area(s):

i. county/counties (mandatory) Du Page, Kane, Kankakee, Lake, Will and Suburban Cook (with the exception of the city of Chicago as defined as areas with zip codes that begin with 606”) effective May 1, 2011.

ii. county/counties (voluntary) iii. area/areas (mandatory). iv. area/areas (voluntary)

C. State Assurances and Compliance with the Statute and Regulations.

If applicable to the state plan, place a check mark to affirm that compliance with the following statutes and regulations will be met.

1932(a)(1)(A)()(D 1. _X_The state assures that all of the applicable requirements of

1903(m) section 1903(m) of the Act, for MCOs and MCO contracts will be met.

42 CFR 438.50(c)(1)

1932(a)(1)(A)G)() 2. N/A The state assures that all the applicable requirements of section 1905(t) 1905(t) of the Act for PCCMs and PCCM contracts will be met.

42 CFR 438.50(c)(2)

1902(a)(23)(A)

1932(a)(1)(A) 3. _X_The state assures that all the applicable requirements of section 1932

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Citation Condition or Requirement 42 CFR 438.50(c)(3) (including subpart (a)(1)(A)) of the Act, for the state's option to limit freedom of choice by requiring recipients to receive their benefits through managed care entities will be met. 1932(a)(1)(A 4. _X The state assures that all the applicable requirements of 42 CFR 431.51 42 CFR 431.51 regarding freedom of choice for family planning services and supplies as 1905(a)(4)(C) defined in section 1905(a)(4)(C) will be met. 1932(a)(1)(A) 5. _X_The state assures that all applicable managed care requirements of 42 CFR 438 42 CFR Part 438 for MCOs and PCCMs will be met. 42 CFR 438.50(c)(4) 1903(m) 1932(a)(1)(A) 6. _X_The state assures that all applicable requirements of 42 CFR 438.6(c) 42 CFR 438.6(c) for payments under any risk contracts will be met. 42 CFR 438.50(c)(6) 1932(a)(1)(A) 7. N/A The state assures that all applicable requirements of 42 CFR 447.362 for 42 CFR 447.362 payments under any nonrisk contracts will be met. 42 CFR 438.50(c)(6) 45 CFR 74.40 8. _X_The state assures that all applicable requirements of 45 CFR 92.36 for procurement of contracts will be met. D. Eligible groups 1932(a)(1)(A)(i) 1. List all eligible groups that will be enrolled on a mandatory basis. The following individuals residing in the counties listed in subsection B.5.i.: - Persons age 19 and older who are aged, blind or disabled and meet more restrictive eligibility criteria than those under SSI and as described in 42 CER sections 435.121, 435.122, 435.130, 435.133, 435.134, - Certain institutionalized individuals who were eligible in December 1973 as described in 42 CFR 435.131. - _ Persons age 19 or older who would be eligible if institutionalized except they receive home and community based services under a waiver as described in 42 CFR 435.217. - Qualified Severely Impaired Blind and Disabled Individuals older than age 19 and under age 65 as described in 1902(a)(10)(A)()(II) and 1905(q) of the Social Security Act. - Disabled widows and widowers as described in section 1634 of the Act. TN No. 11-07 ; Supersedes Approval Date__FEB 30 2012 Effective Date____ 05/01/2011

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Citation Condition or Requirement - Persons age 19 and older who qualify for the AABD expansion as described in 42 CFR sections 435.320, 435.322 and 435.324. - Persons age 19 and older who qualify for Health Benefits for Workers with Disabilities under the Ticket to Work-Work Improvement Act (TWWIIA) as described in 1902(a)(10)(A)(ID. 2. Mandatory exempt groups identified in 1932(a)(1)(A)(i) and 42 CFR 438.50. Use a check mark to affirm if there is voluntary enrollment any of the following mandatory exempt groups. 1932(a)(2)(B) i. Recipients who are also eligible for Medicare. 42 CFR 438(d)(1) If enrollment is voluntary, describe the circumstances of enrollment. (Example: Recipients who become Medicare eligible during mid- enrollment, remain eligible for managed care and are not disenrolled into fee-for-service.) 1932(a)(2)(C) ii. X_Indians who are members of Federally recognized Tribes except when 42 CFR 438(d)(2) the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Acct. 1932(a)(2)(A)(i) iii. Children under the age of 19 years, who are eligible for Supplemental 42 CFR 438.50(d)(3)(i) Security Income (SSI) under title XVI. 1932(a)(2)(A)(iii) iv. Children under the age of 19 years who are eligible under 42 CFR 438.50(d)(3)(ii) 1902(e)(3) of the Act. 1932(a)(2)(A)(v) v. Children under the age of 19 years who are in foster care or other out-of- 42 CFR 438.50(3)(iii) the-home placement. 1932(a)(2)(A)(iv) vi. Children under the age of 19 years who are receiving foster care or 42 CFR 438.50(3)(iv) adoption assistance under title IV-E. 1932(a)(2)(A)(ii) vii. Children under the age of 19 years who are receiving services througha TN No. 11-07 Supersedes Approval Date__ FEB.10 2012 Effective Date. 5/01/2011

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Citation

Condition or Requirement

42 CFR 438.50(3)(v)

family-centered, community based, coordinated care system that receives grant funds under section 501(a)(1)(D) of title V, and is defined by the state in terms of either program participation or special health care needs.

E. Identification of Mandatory Exempt Groups

1932(a)(2) 1. 42 CFR 438.50(d)

1932(a)(2) 2. 42 CFR 438.50(d)

1932(a)(2) 3. 42 CFR 438.50(d)

1932(a)(2) 4. 42 CFR 438.50 (d)

Describe how the state defines children who receive services that are funded under section 501(a)(1)(D) of title V. (Examples: children receiving services at a specific clinic or enrolled in a particular program.)

Children identified as either receiving services from, or participating in, a particular program will be identified through the use of paid claims data.

Place a check mark to affirm if the state’s definition of title V children is determined by:

X_ i. program participation, ji. special health care needs, or

iii. both Place a check mark to affirm if the scope of these title V services is received through a family-centered, community-based, coordinated care system. Xi. yes

ii, no

Describe how the state identifies the following groups of children who are exempt from mandatory enrollment: (Examples: eligibility database, self- identification)

i. Children under 19 years of age who are eligible for SSI under title XVI; Recipient database and self-identification.

ii. Children under 19 years of age who are eligible under section 1902 (e)(3) of the Act;

Recipient database and self-identification.

iii. Children under 19 years of age who are in foster care or other out- of-home placement; Recipient database and self-identification.

iv. Children under 19 years of age who are receiving foster care or adoption assistance.

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Citation Condition or Requirement

Recipient database and self-identification.

1932(a)(2) 5. Describe the state’s process for allowing children to request an exemption from

42 CFR 438.50(d) mandatory enrollment based on the special needs criteria as defined in the state plan if they are not initially identified as exempt. (Example: self-identification) Not applicable

1932(a)(2) 6. Describe how the state identifies the following groups who are exempt from

42 CFR 438.50(d) mandatory enrollment into managed care: (Examples: usage of aid codes in the

eligibility system, self- identification)

i. Recipients who are also eligible for Medicare.

Recipient database and self-identification.

ii, Indians who are members of Federally recognized Tribes except when the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act.

Recipient database and self-identification.

42 CFR 438.50 F. List other eligible groups (not previously mentioned) who will be exempt from

mandatory enrollment

- Children under 19 years of age;

- Individuals eligible for Medicare Part A or enrolled in Medicare Part B; and - Participants with spend-down; and

- _ Participants who are presumptively eligible; and

- Participants in the Illinois Breast and Cervical Cancer program; and

- _ Participants with comprehensive third party insurance;

- _ Participants eligible through Illinois Healthy Women; and

- Participants eligible through Asylees and Torture Victims.

42 CFR 438.50 G. _ List all other eligible groups who will be permitted to enroll on a voluntary basis

Indians who are members of Federally recognized Tribes except when the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating

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Citation

Condition or Requirement

1932(a)(4) 42 CFR 438.50

1932(a)(4) 42 CFR 438.50

under a contract, grant or Cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act.

H. Enrollment _ process.

1. Definitions

i, An existing provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous year. This may be established through state records of previous managed care enrollment or fee-for-service experience, or through contact with the recipient.

ii, A provider is considered to have "traditionally served" Medicaid recipients if it has experience in serving the Medicaid population.

2. — State process for enrollment by default. Describe how the state’s default enrollment process will preserve: i, the existing provider-recipient relationship (as defined in H.1.i).

Existing provider-recipient relationships will be considered based on historical claims data and requests by the recipient.

ii. the relationship with providers that have traditionally served Medicaid recipients (as defined in H.2.ii).

The Integrated Care Program contractors have targeted all Medicaid enrolled providers to join their plans, with specific emphasis on enrollment of primary care providers enrolled in the Department’s Primary Care Case Management program, in which most of the beneficiaries are participating.

iii. the equitable distribution of Medicaid recipients among qualified MCOs and PCCMs available to enroll them, (excluding those that are subject to intermediate sanction described in 42 CFR 438.702(a)(4)); and disenrollment for cause in accordance with 42 CFR 438.56 (d)(2). (Example: No auto-assignments will be made if MCO meets a certain percentage of capacity.)

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Citation

Condition or Requirement

1932(a)(4) 3. 42 CFR 438.50

A Potential Enrollee who does not select an MCO will be auto-assigned to an MCO by the ICEB. During the first twelve (12) month period of the contract, the auto-assignment will equalize enrollment in the participating MCOs so that each MCO has approximately the same number of enrollees. The ICEB will equalize the auto-assignment by distributing the enrollment of those that do not make an active choice between the two plans, taking into considerations existing provider patient relationships, provider capacity and geographical access. During the second year, auto-assignment will occur systematically and randomly by algorithm with the same considerations, but each MCO will receive approximately fifty percent (50%) of all auto-assignments, as capacity allows. During the second year there will not be an effort to equalize enrollment between the plans. The Department will re-evaluate and modify, as necessary, the auto- assignment algorithm and may provide that auto-assignment will also be based on Contractor’s performance on quality measures. The Department shall provide written notice of any modification of the auto-assignment algorithm at least sixty (60) days before the implementation of the modification.

As part of the state’s discussion on the default enrollment process, include the following information:

i, The state will __X_/ will not, use a lock-in for managed care.

ii. The time frame for recipients to choose a health plan before being auto- assigned will be 60 days.

iii. Describe the state's process for notifying Medicaid tecipients of their

auto-assignment. (Example: state generated correspondence.)

During the enrollment process, potential enrollees will be sent an initial enrollment packet, reminder letters and a second enrollment letter. The second enrollment letter will specify the provider to whom the potential enrollee will be assigned if no choice is made. If no choice is made and a client is enrolled through auto-assignment, within five days after enrollment the MCO will senda welcome packet to the enrollee that includes all basic information, including a summary of important topics, such as how to get needed care, a benefits summary, and information about the complaint, grievance and appeal processes

iv. Describe the state's process for notifying the Medicaid recipients who are auto-assigned of their right to disenroll without cause during the

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Citation Condition or Requirement first 90 days of their enrollment. (Examples: state generated correspondence, HMO enrollment packets etc. )

During the enrollment process, potential enrollees will receive an information

guide from the Illinois Client Enrollment Broker. This information guide will

provide information regarding disenrollment rights, including without cause during the first 90 days of enrollment.

Vv. Describe the default assignment algorithm used for auto-assignment. (Examples: ratio of plans in a geographic service area to potential enrollees, usage of quality indicators.)

The default assignment algorithm will take into consideration: ¢ Current assignment to a PCP in the Primary Care Case Management Program ¢ Existing provider-client relationship based on claims data. ¢ The geographic location of the client and PCP. © Special needs of the client, if known. ¢ Capacity limits set by HFS or the provider. ¢ Provider panel status.

vi. Describe how the state will monitor any changes in the rate of default assignment. (Example: usage of the Medical Management Information System (MMIS), monthly reports generated by the enrollment broker)

On a weekly basis, the Illinois Client Enrollment Broker will report to the

Department Potential Enrollees who have voluntarily chosen a health care

delivery system and PCP, Potential Enrollees who are enrolled by auto-

assignment, and Enrollees who request to change from one HMO to another

HMO during enrollment change periods. Summary reports of such information

will be provided by the Illinois Client Enrollment Broker to the Department ona

monthly basis, and the Department will produce ad-hoc reports as necessary. 1932(a)(4) I. State assurances on the enrollment process

42 CFR 438.50

Place a check mark to affirm the state has met all of the applicable requirements of choice, enrollment, and re-enrollment.

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Citation

Condition or Requirement

1932(a)(4) 42 CFR 438.50

—X_ The state assures it has an enrollment system that allows recipients who are already enrolled to be given priority to continue that enrollment if the MCO or PCCM does not have capacity to accept all who are seeking enrollment under the program.

-X_ The state assures that, per the choice requirements in 42 CFR 438.52, Medicaid recipients enrolled in either an MCO or PCCM model will have a choice of at least two entities unless the area is considered rural as defined in 42 CFR 438.52(b)(3).

N/A The state plan program applies the rural exception to choice requirements of 42 CFR 438.52(a) for MCOs and PCCMs.

-X_ This provision is not applicable to this 1932 State Plan Amendment.

N/A The state limits enrollment into a single Health Insuring Organization

(HIO), if and only if the HIO is one of the entities described in section

1932(a)(3)(C) of the Act; and the recipient has a choice of at least two primary care providers within the entity. (California only.)

—X_ This provision is not applicable to this 1932 State Plan Amendment. ~X_ The state applies the automatic reenrollment provision in accordance with 42 CFR 438.56(g) if the recipient is disenrolled solely because he or she loses Medicaid eligibility for a period of 2 months or less.

_—This provision is not applicable to this 1932 State Plan Amendment.

J. _Disenrollment

1. The state will_X_ /will not___ use lock-in for managed care. 2. The lock-in will apply for 12 months (up to 12 months). 3. Place a check mark to affirm state compliance. —X_ The state assures that beneficiary requests for disenrollment (with and without cause) will be permitted in accordance with 42 CFR 438.56(c). 4. Describe any additional circumstances of “cause” for disenrollment (if any). Supersedes 7 Approval Date. FEB ] 9 2012 Effective Date. 05/01/2011

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Citation Condition or Requirement

An Enrollee may request, orally or in writing, to disenroll from Contractor at any time for any of the following reasons: (i) the Enrollee moves out of the Contracting Area; (ii) Contractor, due to its exercise of Right of Conscience, does not provide the Covered Service that the Enrollee seeks; (iii) the Enrollee needs related Covered Services to be performed at the same time, not all of the related services are available through Contractor, and the Enrollee’s PCP or other Provider determines that receiving the services separately would subject the Enrollee to unnecessary risk; or (iv) other reasons, including, but not limited to, poor quality of care, lack of access to Covered Services, lack of access to Providers experienced in dealing with the Enrollee’s health care needs, or, if automatically re-enrolled and such loss of coverage causes the Enrollee to miss the Open Enrollment period.

K. Information requirements for beneficiaries

Place a check mark to affirm state compliance.

1932(a)(5) —X_ The state assures that its state plan program is in compliance with 42 CFR 42 CFR 438.50 438.10(i) for information requirements specific to MCOs and PCCM programs 42 CFR 438.10 operated under section 1932(a)(1)(A)(i) state plan amendments. (Place a check

mark to affirm state compliance.)

1932(a)(5)(D) L. List all services that are excluded for each model (MCO & PCCM)

1905(t) The covered services in the Integrated Care Program are being phased in through three service packages. Service package I will include all non-long term care services, including pharmacy, alcohol and substance abuse services and all medical services for nursing facility residents and all HCBS waiver participants. Service package II will include all nursing facility services and HCBS waiver services except those designed for individuals with developmental disabilities. Service package III will include the HCBS waiver services for individuals with developmental disabilities and ICF/DD services. The only excluded services in all three service packages are services provided in a State operated psychiatric hospital as a result of a forensic commitment and services provided through local education agencies.

1932 (a)(1)(A)(ii) M. Selective contracting under a 1932 state plan option

To respond to items #1 and #2, place a check mark. The third item requires a brief narrative.

TN No. 11-07 . , Supersedes Approval Date. FEB. 10 2012 Effective Date. 05/01/2011 TN No._New Page

CMS-PM-10120 ATTACHMENT 3.1-F Date: January 31, 2008 Page 29

OMB No.:0938-0933 State: Illinois

Citation Condition or Requirement

1. The state will _X_ /willnot intentionally limit the number of entities it contracts under a 1932 state plan option.

2. X_ The state assures that if it limits the number of contracting entities, this limitation will not substantially impair beneficiary access to services.

3. Describe the criteria the state uses to limit the number of. entities it contracts under a 1932 state plan option. (Example: a limited number of providers and/or enrollees.)

Through its research the State determined that the correct number of MCOs to make the program sustainable with the limited number of potential enrollees was two.

4. The selective contracting provision is not applicable to this state plan.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 0933. The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

CMS-10120 (exp. 2/11/2011)

TNNo. 11-07 FEB 102012

Supersedes Approval Date Effective Date. 05/01/2011 TN No._New Page

Table of Contents

State/Territory Name: IL State Plan Amendment (SPA) #: 12-011

This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

June 16, 2014 Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building

201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN 12-011

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #12-011 - Approves Illinois’ request to revise the fee schedule for the cost of drugs provided by a non-pharmacy provider beginning July 21, 2012.

--Effective Date: April 1, 2012

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

cc: Mary Doran, HFS

Teresa Hursey, HFS

06/29/12 06/16/14 04/01/12 /s/ Verlon Johnson Associate Regional Administrator

Attachment 4.19-B

Page 33C

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES— OTHER TYPE OF CARE—BASIS FOR REIMBURSEMENT

TN # 12-11 Approval date: 06/16/2014 Effective date: 04/01/2012 Supersedes TN # New Page

#7. Physician Services, continued: 04/12 Effective April 1, 2012, the reimbursement for the cost of drugs provided by a non-pharmacy provider shall be at a rate equal to the lowest of the provider’s usual and customary charge to the public, or:

 The Average Sales Price (ASP) plus 6 percent; or

 Beginning July 21, 2012, the state upper limit.

 In cases in which ASP is not available, and beginning July 21, 2012, no state upper limit has been developed, the Department’s lowest maximum allowable price for all covered NDC’s assigned to the HCPCS billing code determined in accordance with Section 4(a) of this attachment.

All rates are published on the Department’s website in the Practitioner Fee Schedule located at www.hfs.illinois.gov/feeschedule/

Table of Contents

State/Territory Name: IL State Plan Amendment (SPA) #: 12-019 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

May 30, 2014

Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN 12-019

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #12-019 - Approves Illinois’ request to change limitations for inpatient, chiropractic, podiatric, home health, dental, and physical/occupational/speech therapy services.

--Effective Date: July 1, 2012

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/ Alan Freund, Acting ARA

Verlon Johnson

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Mary Doran, HFS

Beth Green, HFS

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

May 30, 2014

Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN 12-019 Companion

Dear Ms. Hamos:

This letter is being sent as a companion to our approval of State plan amendment (SPA) 12-019 submitted September 4, 2012 by the Illinois Department of Healthcare and Family Services. This SPA proposes to change limitations for inpatient, chiropractic, podiatric, home health, dental, and physical/occupational/speech therapy services effective July 1, 2012. We are requesting that the state submit a response to this letter to resolve our corresponding inpatient page issues found on page 1 of the Appendix to Attachment 3.1-A.

Since a portion of this SPA proposes to limit coverage for inpatient hospital services for “clients under 21 years of age and older who present at a hospital for alcohol or drug-induced detoxification if that client was discharged from a hospital within 60 days of treatment of such services”, we request that the state provide an assurance that no related changes are needed in the state plan for inpatient hospital reimbursement.

The State has 90 days from the date of this letter, to provide the assurance described above. During the 90 days, CMS will provide any required technical assistance.

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/ Alan Freund, Acting ARA

Verlon Johnson

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Mary Doran, HFS

Beth Green, HFS

5/30/14 8/24/12 Alan Freund

Acting Associate Regional Administrator /s/ 7/1/12

5/30/14

5 30 14

5 30 14

5 3014

5 3014

5 3014

5 3014

5 30 14

5 30 14

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 12-023 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 233 N. Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

Regional Operations Group

November 5, 2019

Theresa Eagleson, Director Illinois Department of Healthcare and Family Services 201 South Grand Avenue East, 3rd Floor Springfield, IL 62763-0001

Attn: Douglas Elwell

Dear Ms. Eagleson:

Enclosed for your records is an approved copy of the following State Plan Amendment.

Transmittal #12-023 -Changes Co-Payments -Effective Date: July 1, 2012 -Approval Date: November 1, 2019 If you have any questions, please have a member of your staff contact Courtenay Savage at 312-353-3721 or via email at Courtenay.Savage@cms.hhs.gov.

Sincerely,

/s/ Ruth A. Hughes Deputy Director Center for Medicaid and CHIP Services Regional Operations Group

Enclosure

cc: Sara Barger, HFS

Mary Doran, HFS Jane Eckert, HFS

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 233 N. Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

Regional Operations Group

November 5, 2019

Theresa Eagleson, Director Illinois Department of Healthcare and Family Services 201 South Grand Avenue East, 3rd Floor Springfield, IL 62763-0001

Attn: Douglas Elwell

Dear Ms. Eagleson:

This letter is being sent as a companion to the Centers for Medicare and Medicaid Services’ (CMS) approval of State Plan Amendment (SPA) TN #12-023, which the state submitted on September 28, 2012 to increase cost sharing in the state plan.

During the review of this SPA, CMS concluded that the state was not in compliance with the requirements of sections 1916A(a)(2)(B), (b)(1)(B)(ii) and (b)(2)(A) of the Social Security Act (the Act), as implemented at 42 CFR §447.56(f). These statutory and regulatory requirements limit the total amount of premiums and cost sharing to a five percent aggregate cap. The aggregate cap is based on the beneficiary’s family income used to determine eligibility (or, in the case of a family with multiple beneficiaries, all beneficiaries in the household).

During the review of the SPA, the state was unable to describe and implement a tracking mechanism that met the regulatory requirements. Therefore, the state elected to submit SPA TN #19-0015 to eliminate all cost sharing effective September 1, 2019 and is being approved concurrently with SPA TN #12-023.

If you have any questions, please have a member of your staff contact Courtenay Savage at 312-353-3721 or via email at Courtenay.Savage@cms.hhs.gov.

Sincerely,

/s/

Ruth A. Hughes Deputy Director Center for Medicaid and CHIP Services Regional Operations Group

Enclosure

cc: Sara Barger, HFS

Mary Doran, HFS Jane Eckert, HFS

September 28, 2012

November 1, 2019 July 1, 2012 /s/ Ruth A. Hughes

Deputy Director

Attachment 4.18-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois CO-PAYMENTS TN # 12-023 Approval date: Effective date: 07/01/2012 Supersedes TN # 03-11 A. Hospitals 07/12 1. Effective for dates of service July 1, 2012, a co-payment is required for all inpatient days with the exception of those classes of individuals identified in Section B.3. of this attachment.days of care provided children (individuals through age 17), long-term care facility residents and pregnant women, including those post-partum women who have given birth within the last sixty days. 2. The co-payment is a deduction from the hospital per diem. 07/12 3. The co-payment amount is determined as follows: $325 per day or more $3.00 per day Above $275 but less than $325 per day $2.00 per day $275 per day or less No co-payment Inpatient hospital services: a daily copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the copayment amount is $3.90. Copayments for hospital admissions will not exceed a total amount of $75.00. Non-emergency services rendered in an emergency room: a copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the copayment amount is $3.90. 4. The co-payment amounts are automatically deducted from the Department’s per diem payment to the hospital. 5. No provider may deny care or services on account of an individual’s inability to pay a co- payment. (This requirement, however, does not extinguish the liability for payment of the co-payment.) 07/03 6. The exclusions for children and long-term care residents are enforced by MMIS edits using patient age and resident’s information. Those exclusions are enforced based upon indicators entered into the Department’s computer system. Indicators exist for pregnancy, hospice selection and long term care residency upon admission to the Long Term Care facility. Family planning services are uniquely identified by procedure code and drug therapeutic class code. 7. The hospital is required to identify days of care for pregnant women in coding the UB 92. 07/12 8. A nominal co-payment amount as described in Section A.3. of this attachment may be imposed for non-emergency services provided in an emergency room. B. Non-institutional providers 1. The provider is responsible for collecting the co-payment from the patient. The co- payment amount owed by the patient is automatically deducted from the department’s payment, regardless of the provider’s ability to collect from the patient. 11/1/19

Attachment 4.18-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois CO-PAYMENTS TN # 12-023 Approval date: Effective date: 07/01/2012 Supersedes TN # 03-11 07/12 2. Effective for dates of service July 1, 2012, a co-payment will be assessed to participants for each fee-for-service visit based on the following rate: a. A $2.00 co-payment for each over the counter and generic drug billed to the Department. fee-for-service office visit to a chiropractor, podiatrist, optometrist, or physician. b. For dates of service beginning July 1, 2012 through March 31, 2013, a $3.65 $3.00 co-payment for each brand name drug billed to the Department. Beginning April 1, 2013, the copayment amount is $3.90. c. For dates of service beginning July 1, 2012 through March 31, 2013, a $3.65 a $3.65 co-payment for each office visit and encounter visit billed to the Department. Beginning April 1, 2013, the copayment amount is $3.90.No co- payment for generic legend drugs. Except, no co-payment will be assessed for emergency services, as defined in 42 CFR 447.53(b)(4), or for pharmacy products that are so identified in the Department’s point of sale system for pharmacies and listed in notices to providers, available to the public on the Department’s Internet website. 07/12 3. Co-payments will not apply to: a. persons residing in hospitals, nursing facilities, intermediate care facilities for the mentally retarded;, b. pregnant women (including a postpartum period of 60 days) ;, c. children under 19 years of age;, d. all non institutionalized individuals whose care is subsidized by the Department of Children and Family Services or the Department of Corrections;,, and e. hospice patients; and. f. In addition, co-payments will not apply to residents of a State-certified, State- licensed, or State-contracted residential care program where residents, as a condition of receiving care in that program, are required to pay all of their income, except an authorized protected amount for personal use, to the cost of their residential care program. For the purpose of this subsection, the protected amount shall be no greater than the protected amount authorized for personal use by the Department. 07/12 4. Co-payments will not be assessed for services paid by Medicare, family planning services, certain medications, cancer chemotherapy, radiation therapy and, renal dialysis treatment and over the counter drugs. 5. Except for those services and drugs excluded, the Department will automatically deduct the appropriate co-payment from the provider. 6. No provider may deny services to an eligible individual due to the individual’s inability to pay the co- payment. However, this does not remove the individual’s liability for the co-payment. The patient will self-declare inability to pay at the time of service. 11/1/19

Attachment 4.18-C Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois CO-PAYMENTS TN # 12-023 Approval date: Effective date: 07/01/2012 Supersedes TN # 03-11 A. Hospitals 07/12 1. Effective for dates of service July 1, 2012, a co-payment is required for all inpatient days with the exception of those classes of individuals identified in Section B.3. of this attachment.days of care provided children (individuals through age 17), long-term care facility residents and pregnant women, including those post-partum women who have given birth within the last sixty days. 2. The co-payment is a deduction from the hospital per diem. 07/12 3. The co-payment amount is as follows: $325 per day or more $3.00 per day Above $275 but less than $325 per day $2.00 per day $275 per day or less No co-payment Inpatient hospital services: a daily copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the copayment amount is $3.90. Copayments for hospital admissions will not exceed a total amount of $75.00. Non-emergency services rendered in an emergency room: a copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the copayment amount is $3.90. 4. The co-payment amounts are automatically deducted from the Department’s per diem payment to the hospital. 5. No provider may deny care or services on account of an individual’s inability to pay a co- payment. (This requirement, however, does not extinguish the liability for payment of the co-payment.) 07/03 6. The exclusions for children and long-term care residents are enforced by MMIS edits using patient age and resident’s information. Those exclusions are enforced based upon indicators entered into the Department’s computer system. Indicators exist for pregnancy, hospice selection and long term care residency upon admission to the Long Term Care facility. Family planning services are uniquely identified by procedure code and drug therapeutic class code. 7. The hospital is required to identify days of care for pregnant women in coding the UB 92. 07/12 8. A nominal co-payment amount as described in Section A.3. of this attachment may be imposed for non-emergency services provided in an emergency room. B. Non-institutional providers 1. The provider is responsible for collecting the co-payment from the patient. The co- payment amount owed by the patient is automatically deducted from the department’s payment, regardless of the provider’s ability to collect from the patient. 11/1/19

Attachment 4.18-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois CO-PAYMENTS TN # 12-023 Approval date: Effective date: 07/01/2012 Supersedes TN # 03-11 07/12 2. Effective for dates of service July 1, 2012 through August 31, 2019, a co-payment will be assessed to participants for each fee-for-service visit based on the following rate: a. A $2.00 co-payment for each over the counter and generic drug billed to the Department. fee-for-service office visit to a chiropractor, podiatrist, optometrist, or physician. b. For dates of service beginning July 1, 2012 through March 31, 2013, a $3.65 $3.00 co-payment for each brand name drug billed to the Department. Beginning April 1, 2013, the copayment amount is $3.90. c. For dates of service beginning July 1, 2012 through March 31, 2013, a $3.65 co- payment for each office visit and encounter visit billed to the Department. Beginning April 1, 2013, the copayment amount is $3.90.No co-payment for generic legend drugs. Except, no co-payment will be assessed for emergency services, as defined in 42 CFR 447.53(b)(4), or for pharmacy products that are so identified in the Department’s point of sale system for pharmacies and listed in notices to providers, available to the public on the Department’s Internet website. 07/12 3. Co-payments will not apply to: a. persons residing in hospitals, nursing facilities, intermediate care facilities for the mentally retarded;, b. pregnant women (including a postpartum period of 60 days) ;, c. children under 19 years of age;, d. all non institutionalized individuals whose care is subsidized by the Department of Children and Family Services or the Department of Corrections;,, and e. hospice patients; and. f. In addition, co-payments will not apply to residents of a State-certified, State- licensed, or State-contracted residential care program where residents, as a condition of receiving care in that program, are required to pay all of their income, except an authorized protected amount for personal use, to the cost of their residential care program. For the purpose of this subsection, the protected amount shall be no greater than the protected amount authorized for personal use by the Department. 07/12 4. Co-payments will not be assessed for services paid by Medicare, family planning services, certain medications, cancer chemotherapy, radiation therapy and, renal dialysis treatment and over the counter drugs. 5. Except for those services and drugs excluded, the Department will automatically deduct the appropriate co-payment from the provider. 6. No provider may deny services to an eligible individual due to the individual’s inability to pay the co- payment. However, this does not remove the individual’s liability for the co-payment. The patient will self-declare inability to pay at the time of service. 11/1/19

Table of Contents

State/Territory Name: IL State Plan Amendment (SPA) #: 13-007

This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

June 16, 2104

Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building

201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN 13-007

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #13-007 - Approves Illinois’ request to increase, by $60, the rate paid to hospitals and clinics for outpatient renal services or home dialysis treatment.

--Effective Date: July 1, 2013

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Mary Doran, HFS

Teresa Hursey, HFS

09/27/13 06/16/14 07/1/13 /s/ Verlon Johnson Associate Regional Administrator

06/16/2014

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 13-0016-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

August 12, 2014

Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN IL-13-0016-MM3

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #IL-13-0016-MM3-MAGI-based Income Methodology

-Effective Date: October 1, 2013

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Alan Freund

Acting Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Mary Doran, HFS

Beth Green, HFS

Pat Curtis, HFS

Jacquetta Ellinger, HFS

State/Territory name: Illinois Submitted By: Jamie Ursch Last Revision Date: Jun 30, 2014 Submit Date: Dec 30, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IL-13-0016 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(e)(14), 42 CFR 435.603 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment MAGI-Based Income Methodologies Governor's Office Review       Governor's office reported no comment       Comments of Governor's office received Describe:           No reply received within 45 days of submittal       Other, as specified Describe: The Governor has authorized the director of Healthcare and Family Services to act as his designee to review, approve and submit State Plan amendments under Title XIX of the Social Security Act. The director has reviewed this submission and has no comments. Signature of State Agency Official DATE RECEIVED 12/30/2013 EFFECTIVE DATE OF APPROVED MATERIAL: 1/1/2014 TYPED NAME Alan Freund

PLAN APPROVED - ONE COPY ATTACHED DATE APPROVED: SIGNATURE OF REGIONAL OFFICIAL: TITLE: Acting Associate Regional Administrator 8/12/2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

IL-13-0016-MM3 STATE: Illinois

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

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

Notwithstanding any other provisions of the Illinois Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment IL-13-0016-MM3 will apply to all MAGI- based eligibility groups covered under the Illinois Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. ■ In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: The pregnant woman is counted just as herself. The pregnant woman is counted as herself, plus one. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: Current monthly household income and family size Projected annual household income and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Yes No TN No: IL-13-0016-MM3 Illinois Approval Date: Effective Date: January 1, 2014 8/12/14

Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: ■ Age 19 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: IL-13-0016-MM3 Illinois Approval Date: Effective Date: January 1, 2014 8/12/14

Table of Contents State/Territory Name: Illinois State Plan Amendment (SPA) #:13-0017-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the state plan

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

March 19, 2015

Felicia F. Norwood, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: James Parker

RE: TN IL-13-0017-MM2

Dear Ms. Norwood:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #IL-13-0017-MM2 - Eligibility Process

-Effective Date: October 1, 2013

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Alan Freund

Acting Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosures

cc: Jamie Ursch, HFS

Kim Pearce, HFS

Pat Curtis, HFS

Jacquetta Ellinger, HFS

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Chicago Regional Office 233 North Michigan Avenue, Suite 600 Chicago, IL 60601-5519

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 19, 2015 Felicia F. Norwood, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: James Parker

Dear Ms. Norwood:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) transmittal IL#13-0017-MM2. CMS is granting approval for Form S94 – Eligibility Process IL#13-0017-MM2, which was submitted to CMS on December 30, 2013. Our review of this submission included the review of the multiple program application and streamlined application developed by the state.

Until October 31, 2015, the state is using an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following changes. MAGI-based Online Application Necessary Changes

Completion Date

The request for child-support income will be removed for applicants applying on the basis of MAGI March 31, 2015 The question about past health coverage will ask only about the last 90 days, and will only be asked of applicants under age 19. March 31, 2015 The state agrees to add logic to ask questions about access to employer sponsored coverage only for applicants who appear ineligible for Medicaid and CHIP. December 31, 2015

Please submit the revised alternative single streamline online application to CMS for review no later than December 1, 2015 to ensure approval by December 31, 2015. We continue to be available to provide technical assistance.

Page 2 Ms. Felicia Norwood

If you have any questions about this letter, please contact Cathy Song at (312) 353-5184 or catherine.song1@cms.hhs.gov.

Sincerely,

/s/

Alan Freund

Acting Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

State/Territory name: Illinois Submitted By: Jamie Ursch Last Revision Date: Mar 13, 2015 Submit Date: Dec 30, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IL-13-0017 Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment IL 13-0017 General Eligibility Requirements- Eligibility Process Governor's Office Review       Governor's office reported no comment       Comments of Governor's office received Describe:           No reply received within 45 days of submittal       Other, as specified Describe: The Governor has authorized the director of Healthcare and Family Services to act as his designee to review, approve and submit State Plan amendments under Title XIX of the Social Security Act. The director has reviewed this submission and has no comments. Signature of State Agency Official g , 03/19/2015 htt // dl d d /MMDL/f / t t d/ / 01/ i t/P i tS l t j DATE RECEIVED 12/30/2013 EFFECTIVE DATE OF APPROVED MATERIAL: 10/1/2013 TYPED NAME Alan Freund

PLAN APPROVED - ONE COPY ATTACHED DATE APPROVED: 03/19/2015 SIGNATURE OF REGIONAL OFFICIAL: /s/ TITLE: Associate Regional Administrator

FORM HCFA-179 (07-92)

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0017-MM2 STATE:

Illinois

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 - Eligibility Process, page S94-1, S94-2 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2, Page 10, section 2.1(a), TN # 91-29; Approval Date: 2/14/92; Eff. Date: 10/1/01; Section 2, Page 11a, section 2.1(d), TN # 99-3, Approval Date: 06/08/01; Eff. Date: 04/01/99

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

Page 2 of 2 Medicaid Eligibility The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ 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. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) Maiden Name: MI: First Name: Last Name: County: Best time to call you: Zip Code: State: City: Apartment Number: Present Address: County: Zip Code: State: City: Date: Mailing Address (if different from above): 8. If you want to register to vote, fill out the enclosed Illinois Voter Registration Application (SBE R-19) and give it to your DHS office or your local election official. For help filling it out or for translation services, contact your DHS Family Community Resource Center. You may also call the Helpline at 1-800-843-6154, or 1-800-447-6404 (for TTY). For information online, see www.dhs.state.il.us or www.elections.il.gov/.

Filling out the Voter Registration Application as part of this application is optional. Registering to vote is your choice and will not affect the amount of benefits you get from this agency. 7. You may complete this form at home and mail or bring it to a Department of Human Services (DHS) office. Another member of the household or an adult who knows you may complete and return the form to us also. If someone else completes this form for the household, they are to answer the questions for the person(s) they are applying for, not himself or herself. You have the right to choose the office where you apply. Once you submit your application to an office it will be processed by that office. 6. You may be entitled to receive SNAP benefits right away if:

* your gross nonexempt income and liquid assets are less than your monthly rent or mortgage payment and the

appropriate utility standard: or,

* you have assets of $100 or less and

- your gross monthly income for the month of application is less than $150; or

- at least one person applying is a migrant who is "out of funds." 5. If applying for SNAP benefits, a decision on your eligibility will be made within 30 days. If determined eligible, SNAP

benefits will be issued from the date the application is filed. 4. Before you can get any benefits, you must sign page 18. 3. Read pages 14 & 15 to know your rights and responsibilities for SNAP benefits.

Read pages 16, 17 and 18 to know your rights and responsibilities for Cash and Medical benefits. 2. You have the right to immediately file the application as long as the top of this page (Page 1) is completed with your name, address and signature. The filing of this signed page (Page 1) starts the application processing timetable. 1. Please print all of your answers on the application form so that we can read and understand your answers. Instructions to person(s) applying for Cash, Medical, and/or SNAP benefits Signing here will start your application. You must sign Page 18 before we approve you for any benefits. Telephone number(s) Are you homeless? Yes No Home: Daytime phone: Work: Other: Approved Representative ID # if applicable: Address: When you sign to have an approved representative it means you give permission for this person (1) to sign your application for you, (2) to receive official information about this application, and (3) to act for you on all matters with this agency. Yes No Name of approved representative: Signature of applicant: Organization Name: Phone Number: Do you want to name an approved representative? If yes, complete the following: Signature: Cash - Medical - SNAP - Page 1 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Citizenship/Immigration Status If you or any other persons are not applying because you do not wish to provide information about your immigration status, you do not have to give us that information. The failure to provide immigration information will not affect processing the application for the remaining persons. However, any person who is applying for benefits for himself or herself has to provide information on their immigration status. If there are persons who are not applying for SNAP and/or cash benefits because they do not wish to provide proof of their immigration status, please list them below. We will only ask questions about their income & assets. Name (Last) (First) (MI) Name (Last) (First) (MI) 1. 3. 2. 4. Page 2 of 18 Language Preference Does the adult member of your household who will usually receive mail or written information from DHS read English fluently? Yes No Yes No Does the adult member of your household who will discuss your case with DHS speak English fluently? General Household Questions Disabled? If yes, who: If yes, who: If yes, who: Name of facility: What is their SSN or RRB claim number? 1. Are you or is anyone who lives with you blind? Yes No Yes No 2. Does anyone in the household receive Social Security Disability or Railroad Retirement benefits? 3. Does anyone have a physical, mental or emotional health condition that limits common activities (like bathing, dressing, daily chores, etc)? 5. Does anyone in your household want help paying for medical bills from the last 3 months? Yes No Yes No 6. Has anyone in your household been in foster care at age 18 or older? Yes No If yes, name of person: If yes, name of person: 7. Is anyone in your household age 18 or older a full time student? (college, or trade school) Yes No Yes No Yes No Complete the following for any non-citizens who are applying for benefits. If you need more room, attach another sheet of paper. Name Age Arrival Date in the United States Registration document/number 1. 2. 3. 4. 4. Does anyone applying live in a nursing home facility, supportive living facility, or other facility or institution? If no, please list your preferred spoken language: If no, please list your preferred written language: Are all persons U.S. Citizens? Yes No TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) State of Illinois Department of Human Services IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Page 3 of 18 How many people live with you (include yourself)? Complete the following for everyone in the household. Include people who live with you who are not requesting assistance. You must give us the Social Security Number for each person for whom you are requesting benefits. You do not have to give us the number for any person for whom you are not requesting benefits, but if you do, it may speed up the application process. Household Composition Person 1 Mark the box for the program this person is applying for: SNAP Medical Cash First M.I. Last Suffix Former Name, if any

Relationship to you SELF Social Security # M F Sex Birth Date Marital Status Pregnant? If yes, due date How many babies expected? If you are applying for Medical assistance answer question 1. Yes No 1. Do you plan to file a Federal Tax Return next year? If yes, answer 2-4 below Yes No 2. Will you file jointly with a spouse? If yes, name of spouse: Yes No 3. Do you have any dependents? If yes, list name(s): 4. Will you be claimed as a dependent on someone else's tax return? No Yes If yes, list the name of the tax filer: How are you related to the tax filer? The following questions are for informational purposes only: (optional) Yes No Are you Hispanic or Latino? What is your race? (Select one or more) White Native Hawaiian or Other Pacific Islander Black or African American Asian American Indian/Alaskan Native Person 2 Mark the box for the program this person is applying for: SNAP Medical Cash First M.I. Last Suffix Former Name, if any Relationship to you Social Security # M F Sex Birth Date Marital Status Pregnant? If yes, due date How many babies expected? If this person is applying for Medical assistance answer question 1. Yes No 1. Does this person plan to file a Federal Tax Return next year? If yes, answer 2-4 below Yes No 2. Will this person file jointly with a spouse? If yes, name of spouse: Yes No 3. Does this person have any dependents? If yes, list name(s): 4. Is this person claimed as a dependent on someone else's tax return? No Yes If yes, list the name of the tax filer: How is this person related to the tax filer? The following questions are for informational purposes only: (optional) Yes No Is this person Hispanic or Latino? What is this person's race? (Select one or more) White Native Hawaiian or Other Pacific Islander Black or African American Asian American Indian/Alaskan Native TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

Page 4 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) State of Illinois Department of Human Services Household Composition (Continued) Person 4 Mark the box for the program this person is applying for: SNAP Medical Cash First M.I. Last Suffix Former Name, if any Relationship to you Social Security # Sex M F Birth Date Marital Status Pregnant? If yes, due date How many babies expected? If this person is applying for Medical assistance answer question 1. No Yes 1. Does this person plan to file a Federal Tax Return next year? If yes, answer 2-4 below No Yes 2. Will this person file jointly with a spouse? If yes, name of spouse: No Yes 3. Does this person have any dependents? If yes, list name(s): 4. Is this person claimed as a dependent on someone else's tax return? No Yes If yes, list the name of the tax filer: How is this person related to the tax filer? The following questions are for informational purposes only: (optional) No Yes Is this person Hispanic or Latino? What is this person's race? (Select one or more) White Native Hawaiian or Other Pacific Islander Black or African American Asian American Indian/Alaskan Native Person 3 Mark the box for the program this person is applying for: SNAP Medical Cash First M.I. Last Suffix Former Name, if any Relationship to you Social Security # M F Sex Birth Date Marital Status Pregnant? If yes, due date How many babies expected? If this person is applying for Medical assistance answer question 1. No Yes 1. Does this person plan to file a Federal Tax Return next year? If yes, answer 2-4 below No Yes 2. Will this person file jointly with a spouse? If yes, name of spouse: No Yes 3. Does this person have any dependents? If yes, list name(s): 4. Is this person claimed as a dependent on someone else's tax return? No Yes If yes, list the name of the tax filer: How is this person related to the tax filer? The following questions are for informational purposes only: (optional) No Yes Is this person Hispanic or Latino? What is this person's race? (Select one or more) White Native Hawaiian or Other Pacific Islander Black or African American Asian American Indian/Alaskan Native TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

Page 5 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) State of Illinois Department of Human Services Household Composition (Continued) If needed, please list extra household members on an additional piece of paper. Person 5 Mark the box for the program this person is applying for: SNAP Medical Cash First M.I. Last Suffix Former Name, if any Relationship to you Social Security # Sex M F Birth Date Marital Status Pregnant? If yes, due date How many babies expected? If this person is applying for Medical assistance answer question 1. No Yes 1. Does this person plan to file a Federal Tax Return next year? If yes, answer 2-4 below No Yes 2. Will this person file jointly with a spouse? If yes, name of spouse: No Yes 3. Does this person have any dependents? If yes, list name(s): 4. Is this person claimed as a dependent on someone else's tax return? No Yes If yes, list the name of the tax filer: How is this person related to the tax filer? The following questions are for informational purposes only: (optional) No Yes Is this person Hispanic or Latino? What is this person's race? (Select one or more) White Native Hawaiian or Other Pacific Islander Black or African American Asian American Indian/Alaskan Native Person 6 Mark the box for the program this person is applying for: SNAP Medical Cash First M.I. Last Suffix Former Name, if any Relationship to you Social Security # Sex M F Birth Date Marital Status Pregnant? If yes, due date How many babies expected? If this person is applying for Medical assistance answer question 1. No Yes 1. Does this person plan to file a Federal Tax Return next year? If yes, answer 2-4 below No Yes 2. Will this person file jointly with a spouse? If yes, name of spouse: No Yes 3. Does this person have any dependents? If yes, list name(s): 4. Is this person claimed as a dependent on someone else's tax return? No Yes If yes, list the name of the tax filer: How is this person related to the tax filer? The following questions are for informational purposes only: (optional) No Yes Is this person Hispanic or Latino? What is this person's race? (Select one or more) White Native Hawaiian or Other Pacific Islander Black or African American Asian American Indian/Alaskan Native TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) Page 6 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 If you are applying for SNAP benefits complete this page. Shelter Costs 1. How much are you charged each month for your rent or mortgage? $ If yes, please list the bills and the amounts paid: (For mortgage include property taxes and insurance.) Do you share this expense with anyone? Yes No 2. Are you receiving, or expecting to receive Low Income Home Energy Assistance Program (LIHEAP), Yes No (in Chicago paid through CEDA)? 3. If No, are you billed separately from rent or mortgage for: Yes No Please complete the following information if you answered No, to question 2 or 3 and are not billed for heat or air conditioning separately B. Excess cost for heat or air conditioning? C. Does anyone outside of your SNAP household pay or help pay for your housing costs? A. Heat or air conditioning? Yes No Yes No NOTE: Air conditioning is a window air or central air conditioning unit. Yes No D. Does anyone outside of your SNAP household pay your utility expenses? Expenses Amount How Often Due Amount You Pay Paid By Others Electricity Water and/or Sewerage Garbage Cooking Fuel Basic Phone Service (including cell phone) Septic Tank Installation Maintenance Well Installation /Maintenance A Fee for Starting Utility Service A Flat Amount for Utilities Explain: How much money do you or anyone who lives with you have in cash, checking, and/or savings? $ What is the monthly gross income (income of all sources before any deductions) for you and everyone who lives with you? $ Source: When? $ Who: How much money have you or anyone who lives with you received or expect to receive from any source in the month of application? TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) Page 7 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 If yes, did the income recently stop? Is this a SNAP household of migrant or seasonal farm workers? Yes No Yes No Migrant or Seasonal Farmworker Questions If yes, date the income stopped? Medical Deduction for Persons Disabled or Age 60 or Older Yes No If a SNAP household member is disabled or age 60 or older your SNAP household may be entitled to a Standard Medical Deduction. To get the Standard Medical Deduction, you have to prove you pay out of pocket monthly medical expenses of $36 or more. *If you do not live in a group home the Standard Medical Deduction is $245. *If you live in a group home the Standard Medical Deduction is $485. If yes and you give us proof, we will allow the Standard Medical Deduction that applies to your household. If your monthly medical expenses that you pay are more than $245/$485 and you give us proof, we will allow your actual medical expenses. Can you prove that you pay $36 or more monthly in medical expenses? Please complete the following: We will interview you within 14 days, or right away if you qualify for an expedited SNAP interview. And someone in my household is employed. Hours of work or educational activities conflict with office hours. Problems with health, transportation, caring for a child or disabled adult, ongoing severe weather or educational activities conflict with work hours. Problems with health, transportation, caring for a child or disabled adult, ongoing severe weather or educational activities conflict with work hours. Are liquid assets of household $100 or less AND does the household have a destitute migrant or seasonal farmworker? Are you or is anyone who lives with you expecting to receive more than $26 in income from a new source within the next 10 days? No Yes Yes No Benefit Information Has the primary applicant received SNAP benefits in any state in the month of application? Is the applicant a resident of a domestic violence shelter? No Yes Yes No I am able to come to an office interview. I must be interviewed by phone because: I am applying for SNAP I am applying for cash assistance I can be reached by phone Monday - Friday between 8:30 and 5:00 at: Application Interview - Cash and SNAP TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

Page 8 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) State of Illinois Department of Human Services Income - Benefits - Expenses Is anyone in your household currently employed? Yes No If yes, complete the following: Name of Person: Employer Address: Number of hours worked weekly: Employer: Employer Phone: Amount Paid (including tips) before taxes $ How often paid: Weekly Every two weeks Twice a month Monthly Name of Person: Employer Address: Number of hours worked weekly: Employer: Employer Phone: Amount Paid (including tips) before taxes $ How often paid: Weekly Every two weeks Twice a month Monthly Is anyone in your household self-employed? No Yes Yes No If yes, name of person: What kind of work do they do? How much will they make this month, once they pay business expenses? $ Does anyone named on this form RECEIVE money from any source other than employment (such as Social Security, educational benefits, child support, spousal support, rental property, unemployment benefits, pensions, retirement, trusts)? If yes, complete the following: (Include additional pages, if needed.) Name of Person: Source: Monthly Amount $ Name of Person: Monthly Amount $ Alimony paid: $ Student loan interest: $ Daycare: $ How often? Weekly Every two weeks Twice a month Monthly Child Support paid : $ Source: Name of Person: Source: Monthly Amount $ If this income is from rental property, is this person receiving the income also the property manager? In the past year, has anyone in your household changed jobs, stopped working or started working fewer hours? No Yes Yes No If yes, name of Person: Does anyone in your household pay any of the following expenses? How often? How often? Weekly Every two weeks Twice a month Monthly How often? Weekly Every two weeks Twice a month Monthly Weekly Every two weeks Twice a month Monthly Other deductions (Do not include any expenses you have already reported) Type of expense: $ How often? Weekly Every two weeks Twice a month Monthly Complete only if your income changes from month to month. If you don't expect changes, skip this section. What is the total income for each person for this year? If you anticipate a change, what will it be next year? Total income next year: $ Person: Total income next year: $ Total income this year: $ Person: Total income this year: $ Total income next year: $ Total income this year: $ Person: TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) Page 9 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 List any family members who received services from the Indian Health Service, a tribal health program, or urban Indian health program. If nobody received these services, is anyone qualified to receive them? American Indian or Alaska Native Family Member (AI/AN) Are you or anyone in your family American Indian or Alaska Native (AI/AN)? Are you or anyone in your household a member of a federally-recognized tribe? If No, skip to next section. No Yes No Yes If yes, tribe name: Indian Health Services List the names of anyone who received services: List the names of anyone who qualifies for services: Money from selling things that have cultural significance? Tribal Related Income Does the income you listed on Page 7 include money from any of the following? Payments from a tribe that come from natural resources, usage rights, leases or royalties? No Yes Payments from natural resources, farming, ranching, fishing, leases or royalties from land designated as Indian trust land by the Department of the Interior (including reservations and former reservations)? No Yes No Yes SNAP and Cash Applicants: Have you or any other person applying for Cash been convicted of a felony involving drugs on or after 08/22/96? No Yes If yes, Name of Person: If yes, amount: $ If yes, amount: $ If yes, amount: $ If yes, who If yes, who If yes, who If the drug-related felony conviction was NOT Class X or Class I, did the felony take place more than 2 years ago, or has the person completed a drug treatment program, or is the person in a drug treatment program now? No Yes Has any person been convicted in state or federal court of misrepresenting an address to receive assistance in two or more states at the same time? No Yes Is any person in violation of their parole or probation? No Yes Is anyone fleeing from felony prosecution, an outstanding felony warrant or jail? No Yes TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) Page 10 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Your Family's Health Coverage Medicaid CHIP Medicare Tricare (Don't check if you have Direct Care or a Line of Duty) Veteran's Health Insurance Program Peace Corps Health Insurance Employer Insurance Other Name of Insurance Policy Number Is this a retiree health plan? Is this COBRA coverage? Is this a limited-benefit plan (such as a school accident policy)? Is anyone listed on this application offered health coverage from a job? Tell us about the job that offers coverage: Can you get coverage now or sometime in the next 3 months? Yes No Yes No Yes No Yes No Check YES even if the coverage is from someone else's job, such as a parent's or spouse's.

If YES, complete Page 11. Employer Name: Employer Address: Employer Phone Number: Employer Identification Number (EIN): Who can we contact about employee health coverage at this job? Phone Number: E-Mail address: Yes No If yes, when?: List the name of anyone who can get coverage from this job: Is anyone enrolled in health coverage now from any of the following? If YES, check the type of coverage and write their names next to the coverage they have. Complete this page if you are applying for cash or medical benefits. TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) Page 11 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Your Family's Health Coverage Does the employer offer a health plan that pays at least 60% of the total costs of benefits? (The minimum value standard for health plans) Yes No Yes No Yes No For the lowest-cost minimum value plan offered to the employee ONLY (don't include family plans): Does the employer offer wellness programs? If yes, what premium would the employee pay if he or she got the maximum discount for a tobacco cessation program? $ a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every two weeks Twice a month Quarterly Yearly What changes will the employer make for the new plan year, if you know? Employer won't offer health coverage. Employer will start offering health coverage to employees. Employer will change the premium for the lowest-cost plan minimum value plan available to the employee only. a. How much would the employee have to pay in premiums for this plan? $ a. Name of household member: b. When did the insurance end? c. Reason insurance ended: b. How often? Weekly Every two weeks Twice a month Quarterly Yearly You must answer for all household members age 19 or younger: Did anyone lose health insurance from a job within the past three months? If yes, answer the questions below: Complete this page if you are applying for cash or medical benefits and anyone listed on this application is offered health coverage from a job. TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

Page 12 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) State of Illinois Department of Human Services Complete only for persons who are blind, have a disability or are age 65 or older. If married and living with spouse, also enter any resources the spouse owns. If yes to any of the following, enter the details below. Attach proof. Attach additional sheet(s) if needed. Does anyone own any property (ies) such as a home, vacation home, time share, building or land? Yes No Owner Address Type Value Amount Owed $ $ $ $ Does anyone own a car, truck, motorcycle, boat, trailer or other vehicle? Does anyone own any life insurance? Yes No Owner Type Make/Model/Year Value Amount Owed $ $ $ $ Yes No Owner Insurance Company Policy Number Face Value Cash Value $ $ $ $ Does anyone have an insurance policy that pays when he or she is in a nursing home? Yes No If yes, list the following: Policy Number: Name of Company: List, If other: Does anyone own any of the following resources? Check all that apply: Business Money Market Account Government Bonds Reverse Mortgage Inheritance Deferred Comp Stocks, Bonds Life Estate Trust Funds Certificates of Deposit Promissory Note/Loan Other Mutual Funds IRA/401 K Nursing Home Account Funeral/Burial Plans Savings Checking Account Annuity Burial Plots Mineral/Oil Rights Owner(s) Type of Resource Account/Policy # Value Name of Bank, Company, etc. $ $ Do you have resources that are held jointly with another person? Yes No (Jointly held resources are those held in two or more names; for example, in your name and in the name of another person(s). This includes resources that may be held by you and your spouse, son or daughter, brother or sister, grandchild, friend, companion, etc.) Resource: Value: Name and relationship of Other Person(s) Holding the Resource: Property in Illinois: $ Property in another state: $ Checking/Savings account: $ Certificate of Deposit: $ Stocks/Mutual Funds: $ Other: $ RESOURCE INFORMATION TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

Page 13 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) State of Illinois Department of Human Services Complete only for employed persons who are blind, have a disability or are age 65 or older. Also enter the employment expenses for an employed spouse or parent of a child under age 18 if they live together. Employed person's name: (1) Monthly amount: $ Yes No Must this person pay union dues, group life insurance premiums, group health insurance premiums, or retirement plan withholding as a condition of employment? If other transportation is used, enter type and cost. Attach proof. If this person person takes the bus, what is the fare to and from work? $ If this person uses his/her own car, how many miles to and from work? Please list. if other: Other Bus Own car Yes No How does this person get to and from work? Does this person buy uniforms or special tools? Does this person buy or bring lunch to work? Weekly Every two weeks Bi-Monthly Monthly Bring Lunch Buy Lunch How often paid: Social Security tax withheld: $ If yes, enter the items bought, how often, and cost. Attach proof. Federal, State and City taxes withheld: $ Amount received before deductions (gross amount): $ Employed person's name: (2) Amount received before deductions (gross amount): $ Federal, State and City taxes withheld: $ If yes, enter the items bought, how often, and cost. Attach proof. Social Security tax withheld: $ How often paid: Buy Lunch Bring Lunch Weekly Every two weeks Bi-Monthly Monthly Does this person buy or bring lunch to work? Does this person buy uniforms or special tools? How does this person get to and from work? Yes No Own car Bus Other Please list. if other: If this person uses his/her own car, how many miles to and from work? If this person person takes the bus, what is the fare to and from work? $ If other transportation is used, enter type and cost. Attach proof. Must this person pay union dues, group life insurance premiums, group health insurance premiums, or retirement plan withholding as a condition of employment? Yes No Monthly amount: $ Employment and Employment Related Expenses TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Read carefully before signing this application on page 18. Ask your caseworker to explain anything you do not understand.

Because the SNAP program requires a Social Security Number (SSN) for every member of your household who is applying for SNAP benefits, we are explaining how your SSN is used by DHS.

What does DHS do with your Social Security Number?

The SSN will be used in the administration of the SNAP program to check the identity of household members, prevent duplicate participation, and to facilitate making mass changes. If you or any member of your household wants to apply for SNAP benefits, but does not have a SSN, we can help you apply for one. The SSN (or any other information in this application) may be used in computer matching and program reviews or audits and to make sure the household is eligible for SNAP benefits, other Federal assistance programs, and Federally assisted state programs, such as school lunch, TANF, and Medicaid. This may result in criminal or civil action or administrative claims against persons fraudulently participating in the SNAP program. We do not require a Social Security Number for any member of your household who is not eligible for the SNAP program or who does not wish to apply.

Why does DHS collect your Social Security Number?

DHS will only use your SSN for the purpose for which it was collected. DHS will not: Sell, lease, loan, trade, or rent your SSN to a third party for any purpose; publicly post or publicly display your SSN; print your SSN on any card required for you to access our services; require you to transmit your SSN over the internet, unless the connection is secure or your SSN is encrypted; or print your SSN on any materials that are mailed to you, unless State or Federal law requires that number to be on documents mailed to you, or unless we are confirming the accuracy of your SSN.

Right to appeal.

A fair hearing may be requested either orally or in writing if there is a disagreement with any action taken on this case. The SNAP unit's case may be presented at the hearing by any person chosen by the SNAP unit.

Non-Discrimination.

In accordance with Federal Law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the department. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. You may also contact the Department of Human Services (DHS) at Department of Human Services, Bureau of Civil Affairs, 401 South Clinton St, 2nd Floor, Chicago, Illinois, 60607. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the DHS Helpline Number at 1-800-843-6154 or (800)447-6404 (TTY). DHS and USDA are equal opportunity providers and employers. Page 14 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 SNAP - CLIENT RIGHTS AND RESPONSIBILITIES TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) I understand that a change that happens after the eligibility interview and before the notice of decision must be reported within 10 calendar days unless otherwise notified. If I have any doubt about whether to report a change, I will ask my Human Services caseworker.

I understand that if I am approved for SNAP benefits and I receive more benefits than I am entitled to, whether an error on my part or an agency error, the amount of overpaid benefits may be subtracted from my monthly benefit amount. AT THE APPLICATION You Must Report You must report and verify: Child care expenses Medical expenses Rent or mortgage payment, property taxes and insurance and utility expenses. Child support paid to a non-SNAP Unit member Failure to report or verify above expenses will be seen as a statement by your SNAP Unit that you do not want to receive a deduction for the unreported expenses. Child support payments are subject to verification by computer matching with the records of the Division of Child Support Enforcement. Penalty Warning - What are the SNAP Program Penalties? If you........... Then you will lose SNAP benefits * Hide or give wrong information on purpose to get SNAP benefits

* Trade, steal or sell SNAP benefits, or resell food bought with SNAP benefits

* Use SNAP benefits to buy non-food items like alcohol or tobacco.

* Use someone else's SNAP benefits for yourself or someone else.

* Throw away beverages purchased with SNAP benefits just to get money back from a container deposit. * 12 months first time

* 24 months the second time

* Permanently the third time Trade SNAP benefits for controlled substance, such as drugs. * 24 months first time * Permanently the second time Trade SNAP benefits for firearms, ammunition or explosives. * Permanently Buy, sell, steal or trade SNAP benefits of more than $500.00 * Permanently * Give false information about who you are and where you live so you can get extra SNAP benefits. * 10 years You can also be fined up to $250,000 and put in prison up to 20 years or both. You can also be charged under other Federal Laws. Persons who are fleeing felons or probation/parole violators are ineligible for SNAP benefit. Page 15 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 SNAP - CLIENT RIGHTS AND RESPONSIBILITIES continued Declaration Regarding Citizenship/Alien Status I declare, under penalty of perjury, that the statements I have made regarding the citizenship or alien status of each person requesting assistance are true and correct. I understand that the alien status of each person requesting assistance who is not a citizen of the United States will be verified with the United States Citizenship and Immigration Services (USCIS). This will require the disclosure to USCIS of certain identifying information which I have provided. The information received from USCIS may affect eligibility for assistance and the benefit level.

I understand that documents may have to be provided to prove what I have said. I agree to do this. If documents are not available, I agree to give the name of the person or organization the FCRC may contact to obtain the necessary proof. The information on this form is subject to verification by Federal, State, and Local Officials. If any information is found to be inaccurate, I may be denied SNAP benefits, and/or be subject to criminal prosecution for knowingly providing false information. TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES Read carefully before signing this application on page 18. Ask your caseworker to explain anything that you do not understand.

To receive benefits, a person must have a valid Social Security Number (SSN) or proof that he or she has applied for one, unless exempt. If you or any member of your household wants to apply for assistance, but do not have a SSN, we can help you to apply for one. State law requires us to explain how your SSN is used by the State of Illinois.

9 Your Social Security Number (SSN) will be used in the administration of the cash and/or medical program to check the identity of household members, prevent duplicate participation, and to facilitate making mass changes to the cash and/or medical program.  • The SSN (or any other information in this application) may be used in computer matching and program reviews or audits and to make sure the household is eligible for assistance, other federal assistance programs, and federally assisted state programs, such as school lunch, TANF, and Medicaid. • DHS secures and uses information about all clients through the income and eligibility verification system. This includes such information as receipt of social security benefits, unemployment insurance, unearned income and wages from employment. • Any information obtained will be used in determining eligibility for assistance and the amount of assistance provided for all programs. • When discrepancies are found, verification of this information may be obtained through contacts with a third party, such as employers, claims representatives, or financial institutions. This information may affect your eligibility for assistance and the amount of assistance provided. • DHS will only use your SSN for the purpose for which it was collected. • DHS will not: sell, lease, loan, trade, or rent your SSN to a third party for any purpose; publicly post or publicly display your SSN; print your SSN on any card required for you to access our services; require you to transmit your SSN over the Internet, unless the connection is secure or your SSN is encrypted; or print your SSN on any materials that are mailed to you, unless State or Federal law requires that number be on documents mailed to you, or unless we are confirming the accuracy of your SSN. 9 When an application for cash or medical assistance is filed, a determination of eligibility under all of the programs administered by DHS will be made unless I do not want to be considered for a particular program(s). If I do not want to be considered for a particular program, DHS will not consider my eligibility for that program(s). 9 The information provided on this form will be subject to verification by Federal, State, and Local officials. If any information is found to be inaccurate, I may be denied cash benefits and/or medical assistance. I understand that anyone who knowingly misuses the medical card issued by the State of Illinois may be committing a crime. 9 All information related to the establishment of paternity and child support enforcement has been provided to the best of my knowledge. 9 If my application is approved, I give the State of Illinois the right to recover under the terms of any private or public health care coverage any amount for which I or a member of my family may be eligible. 9 I also authorize staff of the DHS to obtain information from my records or copy my records from the Social Security Administration (SSA). I authorize release of my records from SSA to the staff of DHS with respect to any claims for disability benefits and all related appeals. I certify that I understand that the materials requested may be protected under the Privacy Act. I authorize release of any material protected under the Privacy Act to the staff of DHS. Page 16 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) 9I understand that the State of Illinois will release information concerning medical services that I have received for any reason authorized by law.  9I understand that if the children I am applying for are approved for All Kids Share or All Kids Premium, then I am responsible for paying the premiums and copayment amounts.  9I understand that if the children I am applying for are approved for All Kids Rebate, then the State of Illinois is not responsible for additional premiums; deductibles or copayments required by the employer's or private health insurance policy. 9If I am approved for TANF Cash and/or medical benefits for myself and my children, and the State of Illinois pays medical bills for me, I give my right to collect medical support payments to the State of Illinois. I understand I must help to obtain medical support payments for members of my family unless I have a good reason not to. My children can get health insurance even if I do not help when the Department asks me to. 9As a condition of eligibility, if I am approved for TANF Cash and/or medical assistance for myself and my children, I understand that I may be required to cooperate with child support enforcement.  • Cooperation includes establishment of paternity and/or support enforcement and modification of child support orders. • I assign and give all my rights, title and interest of child support and medical support to Healthcare and Family Services (HFS) as long as I receive TANF Cash/or medical assistance. • I understand and agree that any child support payments paid through the clerk of the circuit court and through the State Disbursement Unit (SDU) may be forwarded to the HFS as long as I receive TANF Cash. • I understand that if I apply for TANF Cash and/or medical assistance for my children only, I am not required to cooperate with child support enforcement, but I may request services. 9 I declare under penalty of perjury, that the statements I have made regarding the citizenship or immigration status of each person requesting assistance are true and correct.  9I understand the Department will not share any information about immigration or any persons who do not have an Alien Registration Number.  9The Department will verify the immigration status of any person for whom I give an Alien Registration Number. To do that, the Department will check the number with the U.S. Citizenship and Immigration Service (USCIS). The Department may send other information to USCIS, such as copies of proof that I give of an Alien Registration Number and the person's Social Security Number, if they have one. 9If I am approved for Aid to the Aged, Blind, or Disabled (AABD) for cash and/or medical assistance, I understand that the DHS may have the right to place a lien on my home or other real property I own. The amount of the lien is the amount of assistance DHS has provided to me. 9I agree to inform the agency within 10 days of any change in my household's size, income, property, living arrangements, school attendance, or address. 9I understand that if approved for cash benefits, and I receive more benefits than I am entitled to, whether it be an error on my part or an agency error, the amount of overpaid benefits are subject to recoupment/recovery. Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES continued Page 17 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 9 I understand that a person convicted of a Class X or Class I felony or a comparable federal law, for acts that occurred on or after 08/22/96 involving possession, use, or distribution of a controlled substance is ineligible to receive Cash assistance. I understand that a person convicted of drug-related felony, other than a Class X or Class I, under Illinois or any comparable federal law an act that occurred on or after 08/22/96, is ineligible for Cash assistance for 2 years following the date of the conviction, unless they are in drug treatment or aftercare, or successfully participated in and completed drug treatment and/or aftercare subsequent to their conviction. TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) 9Right to Appeal I understand that if I am not satisfied with the action taken on my application that I have the right to a fair hearing. I understand that I can ask for a fair hearing by getting in touch with the office where I applied or by  writing to: Illinois Department of Human Services, Bureau of Assistance Hearings, 401 South Clinton Street, 6th Floor, Chicago, Illinois 60607, or by calling 1-800-435-0774.

9I understand that if I am mentally and physically able to apply and I want someone else to apply for cash and/or medical benefits for me, I must attach a written statement that gives the person permission. The statement must include the person's name, address, and phone number. The statement must say that I am still responsible for the information provided by the person.

9I understand that by signing this application form, I consent to any investigation made by the Department to verify or confirm the information I have given or any other investigation made by them in connection with my request for public assistance. I understand that I must cooperate in these efforts to verify information. Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES continued Page 18 of 18 IL444-2378B (R-09-13) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program Printed by Authority of the State of Illinois PO# 14-0527 120,000 I declare under penalties of perjury that I have examined this form and all accompanying statements or documents pertaining to the income and resources of myself (the applicant) or any member of my family (the applicant's family) included in this application for aid, or pertaining to any other matter having bearing upon my (the applicant's) eligibility for aid, and to the best of my knowledge and belief the information supplied is true, correct, and complete. I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil or both. I certify under the penalty of perjury that the information I have provided on this application form is the truth to the best of my knowledge. Applicant Signature Signature: Applicant Makes a Mark (X) Applicant: Spouse: Signature of Witness: Date Date Date If you have made your mark (X) instead of signing your name, one witness must sign here: Signature of Witness: Signature of Witness: Date Date Applications based on blindness must be attested to by two witnesses. Signature: Applicant Blind Home Address: Signature of Approved Representative: APPROVED REPRESENTATIVE SIGNATURE If the application is initiated by someone else for the applicant, they must sign below. If an approved representative completes and signs this application, written authorization from the applicant is required.

I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil or both. I certify under the penalty of perjury that the information I have provided on this application form is the truth to the best of my knowledge. Apt. Number: Relationship: Phone Number: TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

FOR ILLINOIS RESIDENTS ONLY TO VOTE YOU MUST: · Be a United States citizen · Be at least 18 years old · Live in your election precinct at least 30 days · Not be convicted and in jail · Not claim the right to vote anywhere else TO VOTE IN THE NEXT ELECTION: Mail or deliver this application to your County Clerk or Board of Election Commissioners no later than 28 days before the next election. (click here for County Clerk/Election Board listings) or go to www.elections.il.gov IMPORTANT INFORMATION: If you do not have a driver's license, State Identification Card or social security number, and this form is submitted by mail, and you have never registered to vote in the jurisdiction you are now registering in, then you must send, with this application, either (i) a copy of a current and valid photo identification, or (ii) a copy of a current utility bill, bank statement, government check, pay check, or other government document that shows the name and address of the voter. If you do not provide the information required above, then you will be required to provide election officials with either (i) or (ii) described above the first time you vote at a voting place or by absentee ballot. If you change your name you must re-register. If you register at a public service agency, any information regarding the agency that assisted you will remain confidential as will any decision not to register. If you do not receive a Notice within 2 weeks of mailing or delivering this application, call your County Clerk or Board of Election Commissioners. ILLINOIS VOTER REGISTRATION APPLICATION Suggested, August 2008, SBE R-19 S N E W If you have questions about completing this form, please call the State Board of Elections at (217)782-4141 or (312)814-6440 (or webmaster@elections.il.gov). TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK Are you a citizen of the United States of America? (check one) Will you be 18 years of age on or before election day? (check one) Yes No No Yes If you checked "No" in response to either of these questions, then do not complete this form. You can use this form to: (check one) Change your address apply to register to vote in Illinois Change your name 1. Last name First Name Middle Name or Initial Suffix (Jr. Sr. II III IV) 2. Address where you live (House No., Street Name, Apt No.) City/Village/Town Zip Code County Township 3. Mailing Address (P.O. Box) City/Village/Town Zip Code County Township 4. Former Registration Address: (include City and State and Zip Code) Former County 5. Former Name: (if changed) 6. Date of Birth: MM/DD/YYYY 7. Sex (check one) Female Male 8. Home Telephone number including area Code (optional) 9. ID Number-Check the applicable box and provide the appropriate number IL Driver's License or, if none, Sec. of State ID or Last 4 digits of SSN I have none of the above-listed identification numbers TO COMPLETE THIS FORM: · Box 1-If you do not have a middle name, leave blank. · Box 3-If mailing address is same as Box 2, write "same". · Box 4-If you have never registered before, leave blank. If you do not remember your former address; provide as much information as possible. · Box 5-If you have not changed your name, leave blank. · Box 9-If you have an Illinois Driver's License or Secretary of State ID, check the first box and fill in the number. If you do not have a Driver's License or SOS ID, check the second box and fill in the last four digits of your Social Security Number. If you do not have a SSN, check the third box and send a copy of the appropriate document (as described in the "Important Information" section) along with this form. · 10-Read, date and personally sign your name or make your mark in the box. IF YOU HAVE NO STREET ADDRESS, below describe your home: list the name of subdivision; cross streets; roads; landmarks; mileage and/or neighbors names. 10. Voter affidavit - Read all statements and sign within the box to the right. I swear or affirm that · I am a citizen of the United States; · I will be at least 18 years old on or before the next election; · I will have lived in the State of Illinois and in my election precinct at least 30 days as of the date of the next election · The information I have provided is true to the best of my knowledge under penalty of perjury. If I have provided false information, then I may be fined, imprisoned, or if I am not a U.S. citizen, deported from or refused entry into the United States. 11. If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number. Today's Date: This is my signature or mark in the space below. Name of person assisting: Full Address Telephone No. TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

Back of SBE No. R-19

______________ PUT FIRST CLASS STAMP HERE _______________ YOUR ADDRESS ___________________________________________________ MAIL TO: ___________________________________________________

CHANGE OF ADDRESS PCT WARD CODE ADDRESS CITY ZIP COUNTY DATE CLERK

SUSPENSION, CANCELLATION AND REINSTATEMENT DATE EXPLAIN CLERK DATE EXPLAIN CLERK

To Election Judges Voting Record 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 For Primary, mark Primary

D for Democrat General

R for Republican NonPartisan

for all other elections markV Special TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE State of Illinois Department of Healthcare and Family Services Application for Health Coverage & Help Paying Costs • Health coverage means Medicaid, All Kids, or insurance you buy from the Health Insurance Marketplace. • You can get comprehensive benefits to help you stay well. • You may qualify for low-cost coverage under Medicaid or All Kids or you may qualify to get a tax credit to help pay your premiums for health insurance from the Health Insurance Marketplace. Use this application to apply for health coverage. Do not use this application if you want to apply for SNAP or cash assistance at the same time. By using this application, you are stating that you only want to apply for health coverage and you do not want to apply for SNAP or cash assistance. Apply faster online. You can apply faster online at ABE.Illinois.gov. Who should use this application? • Use this application to apply for health coverage for children, parents or other caretaker relatives raising dependent children, pregnant women and other adults older than 19, but younger than age 65. • If someone is helping you fill out this application, you may need to complete Appendix C. • Immigrants can apply. You can apply for your children even if you do not qualify for coverage. Applying will not affect your immigration status or your chances of becoming a permanent resident or citizen. Seniors, persons on Medicare and people who receive SSI or SSDI payments from Social Security should apply online at ABE.illinois.gov or use a different paper application, Form 2378H. You can get it at: http://www2.illinois.gov/hfs/SiteCollectionDocuments/hfs2378h.pdf or call the number below. • Social Security numbers or document numbers for any legal immigrants who need health coverage. What you may need to apply. • Employer and income information for everyone in your family. You can get this from paystubs, W-2 forms, or wage and tax statements. • Policy numbers for any current health insurance. Information about any job-related health insurance you can get. Page 1 of 20 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 1. First name, Middle name, Last name & Suffix Why do we ask this information? We ask for the information to decide what health coverage you qualify for and to decide if you can get any help to pay for it. The law requires that we have to keep all the information you give us private. What happens next? Fill out your application, sign it and send it to the address on page 14. If you cannot answer all the questions, sign your application and send it anyway. We will contact you if we need more information. We will send you a notice when we decide if the people you apply for qualify for Medicaid or All Kids. If anyone does not qualify for Medicaid or All Kids, we will send the information from the application to the Health Insurance Marketplace to see if they can get help to buy insurance. Get help with this application. • Online: Log onto GetCoveredIllinois.gov/get-help/ • Phone: Call the ABE Customer Call Center at 1-800-843-6154. • In person: to find a local office near you log-on to: https://www.dhs.state.il.us/page.aspx?module=12&officetype=&county Step 1: Tell us about yourself. (We need one adult in the family to be the contact person for your application.) 2. Home address (Leave blank if you don't have one.) 3. Apartment or suite number 4. City 5. State 6. Zip 7. County 8. Mailing address (if different from home address) 9. Apartment or suite number 13. County 12. Zip 11. State 10. City 14. Phone number 15. What is the best number to reach you during the day? 16. Do you want to get information from us by e-mail? Yes No E-mail address: 17. Preferred spoken or written language (if not English) Spanish Other Page 2 of 20 (_______) - _______ - ________ (_______) - _______ - ________ TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE Step 2: Tell us about your family. Who do you need to include on this application? Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. (You don't have to file taxes to get health coverage.) • Your children under 19 who live with you • Anyone else under 19 who you take care of and lives with you • Anyone you include on your tax return, even if they don't live with you • Your unmarried partner who needs health coverage • Your spouse • Yourself DO Include: You DON'T have to include: • Other adult relatives who file their own tax return • Your parents who live with you, but file their own tax return (if you're over 19) • Your unmarried partner's children • Your unmarried partner who doesn't need health coverage

The amount of assistance and type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can. Complete Step 2 for each person in your family. Start with yourself, and then add other adults and children. If you have more than 2 people in your family, you'll need to make a copy of the pages and attach them. You don't need to provide immigration status of a Social Security Number (SSN) for family members who don't need health coverage. We'll keep all the information you provide private and secure as required by law. We'll use personal information to check if you're eligible for health coverage. PERSON 1 (Start with yourself) Complete PERSON 1 for yourself. See page 3 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you. 1. First name, Middle name, Last name, & Suffix 2. Relationship to you?

SELF / / 3. Date of birth (mm/dd/yyyy) 4. Sex Male Female 5. Social Security Number (SSN): We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don't want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who's eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. Page 3 of 20 _________ - _______ - _________ TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 6. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.) If yes, please answer questions a - c. YES If no, SKIP to question c NO a. Will you file jointly with a spouse? No Yes If yes, name of spouse: b. Will you claim any dependents on your tax return? Yes No If yes, name of dependents: Yes No c. Will you be claimed as a dependent on someone's tax return? If yes, please list the name of the tax filer: How are you related to the tax filer? 7. Are you pregnant or have you been pregnant in the last 3 months? Yes No If yes, how many babies are expected: 8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) If no, SKIP to the income questions on page 5. NO If yes, answer all the questions below. YES 9. Do you live in a medical facility or nursing home or do you need support services to help you stay in your home to prevent going into a nursing home or other facility? Yes No Yes No 10. Are you a U.S. citizen or U.S. national? 11. If you aren't a U.S. citizen or U.S. National, do you have eligible immigration status? Yes Fill in your document type and ID number below. a. Immigration document type: b. Document ID number: c. Have you lived in the U.S. since 1996? No Yes d. Are you a veteran or an active-duty member of the U.S. military? Yes No e. What is the date of entry into the United States? 12. Do you want help paying for medical bills from the last 3 months? Yes No 13. Do you live with at least one child under the age of 19, and are you the main person taking care of this child? Yes No Page 4 of 20 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 14. Were you in foster care at age 18 or older? Yes No 15. Are you a full-time student? No Yes 16. If Hispanic/Latino, ethnicity (OPTIONAL - check all that apply.) Mexican Mexican American Chicano/a Puerto Rican Cuban Other 17. Race (OPTIONAL - check all that apply.) White American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Other Black or African American Current Job & Income Information Employed If you're currently employed, tell us about your income. Start with question 18.. Not employed Skip to question 28. Self-employed Skip to question 27. Current Job 1: 18. Employer name and address: 19. Employer phone number 20. Wages/tips before taxes: $ Hourly Weekly Every 2 weeks Twice a month Monthly Yearly 21. Average hours worked each week: 22. Employer name and address: 25. Average hours worked each week: Hourly Twice a month Weekly Monthly Every 2 weeks Yearly $ 24. Wages/tips before taxes: 23. Employer phone number Current Job 2: (If you have more jobs and need more space, attach another sheet of paper.) Page 5 of 20 (_______) - _______ - ________ (________) - _______ - _________ TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 26. In the past year, did you: Change Jobs Stop working Start working fewer hours None of these 27. If self-employed, answer the following questions: a. Type of work: b. How much net income (profits once

business expenses are paid) will you get from this self-employment this month? $ 28. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran's payment, or supplemental security income (SSI). None Unemployment $ How often? How often? $ Net farming/fishing Pensions How often? How often? $ $ Net rental/royalty Social Security How often? How often? $ $ Retirement accounts Alimony recieved How often? $ How often? $ Other If other, type: 29. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 27b.) Alimony paid: $ How often? Other deductions: $ How often? Student loan interest: $ How often? If other, type: 30. YEARLY INCOME: Complete only if your income changes from month to month. If you don't expect changes to your monthly income, skip to the next person. Your total income this year: $ Your total income next year (If you think it will be different): $ THANKS! This is all we need to know about you. Page 6 of 20 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE PERSON 2 Complete Step 2 for your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 3 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you. If you have more than two people to include, make a copy of Person 2 (pages 7 through 10) and complete. We need this if you want health coverage and have an SSN. Providing an SSN can be helpful if PERSON 2 doesn't want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who's eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. 5. Social Security Number (SSN): / / Male Female 4. Sex 3. Date of birth (mm/dd/yyyy) 1. First name, Middle name, Last name, & Suffix 2: Relationship to you? 7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.) If yes, please answer questions a - c. YES If no, SKIP to question c. NO a. Will PERSON 2 file jointly with a spouse? Yes No If yes, name of spouse: b. Will PERSON 2 claim any dependents on his or her tax return? No Yes If yes, list name(s) of dependents: No Yes c. Will PERSON 2 be claimed as a dependent on someone's tax return? If yes, please list the name of the tax filer: How is PERSON 2 related to the tax filer? 8. Is PERSON 2 pregnant or have they been pregnant in the last 3 months? No Yes If yes, how many babies are expected: 6. Does PERSON 2 live at the same address as you? Yes No If no, list address: Page 7 of 20 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 9. Does PERSON 2 need health coverage? If no, SKIP to the income questions on page 9, Step 2, PERSON 2. NO If yes, answer all the questions below. YES (Even if PERSON 2 has insurance, there might be a program with better coverage or lower costs.) 10. Does PERSON 2 live in a medical facility or nursing home or does this person need support services to prevent them going into a nursing home or other facility? Yes No 11. Is PERSON 2 a U.S. citizen or U.S. national? Yes No 12. If PERSON 2 isn't a U.S. citizen or U.S. National, do they have eligible immigration status? Yes Fill in their document type and ID number below. a. Immigration document type: b. Document ID number: c. Has PERSON 2 lived in the U.S. since 1996? No Yes d. Is PERSON 2 or their spouse or parent a veteran or an active-duty member of the U.S. military? Yes No 13. Does PERSON 2 want help paying for medical bills from the last 3 months? 14. Does PERSON 2 live with at least one child under the age of 19, and are they the main person taking care of this child? Yes No Yes No 15. Was PERSON 2 in foster care at age 18 or older? No Yes Please answer the following questions if PERSON 2 is 20 or younger: 16. Did PERSON 2 have insurance through a job and lose it within the past 3 months? Yes No a. If yes, end date: b. Reason the insurance ended: Yes No 17. Is PERSON 2 a full-time student? Page 8 of 20 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 18. If Hispanic/Latino, ethnicity (OPTIONAL - check all that apply.) 19. Race (OPTIONAL - check all that apply.) Other Cuban Puerto Rican Chicano/a Mexican American Mexican Current Job & Income Information for PERSON 2 Employed If PERSON 2 is currently employed, tell us about their income. Start with question 20.. Not employed Skip to question 30. Self-employed Skip to question 29. Current Job 1: 20. Employer name and address: 21. Employer phone number 22. Wages/tips before taxes: $ Hourly Weekly Every 2 weeks Twice a month Monthly Yearly 23. Average hours worked each week: 24. Employer name and address: 27. Average hours worked each WEEK: Hourly Twice a month Weekly Monthly Every 2 weeks Yearly $ 26. Wages/tips before taxes: 25. Employer phone number Current Job 2: (If PERSON 2 has more jobs and needs more space, attach another sheet of paper.) 28. In the past year, did PERSON 2: None of these Start working fewer hours Stop working Change Jobs Page 9 of 20 (________) - _______ - _________ (________) - _______ - _________ Native Hawaiian or Other Pacific Islander Black or African American White American Indian or Alaska Native Asian Other TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE a. Type of work: b. How much net income (profits once

business expenses are paid) will PERSON 2 get from this self-employment this month? $ 30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often PERSON 2 gets it. NOTE: There is no need to tell us about child support, veteran's payment, or supplemental security income (SSI). None Unemployment $ How often? How often? $ Net farming/fishing Pensions How often? How often? $ $ Net rental/royalty Social Security How often? How often? $ $ Retirement accounts Alimony recieved How often? $ How often? $ Other If other, type: 31. DEDUCTIONS: Check all that apply, and give the amount and how often PERSON 2 gets it. If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: Don't include a cost that is already considered in the answer to net self-employment (question 29b). 32. YEARLY INCOME: Complete only if PERSON 2's income changes from month to month. If you don't expect changes to PERSON 2's monthly income, skip to the next section and complete. PERSON 2's total income this year: $ PERSON 2's total income next year (If you think it will be different): $ THANKS! This is all we need to know about PERSON 2. 29. If self-employed, answer the following questions: Page 10 of 20 Student loan interest: $ If other, type: How often? Other deductions: $ How often? How often? Alimony paid: $ TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE Step 3: American Indian or Alaska Native (AI / AN) family member(s) Are you or is anyone in your family American Indian or an Alaska Native? 1. YES. If Yes, go to Appendix B. NO. If No, skip to Step 4. Step 4: Your Family's Health Coverage Answer these questions for anyone who needs health coverage. 1. Is anyone enrolled in health coverage now from the following? NO. Medicaid CHIP Medicare TRICARE (Don't check if you have direct care or Line of Duty) VA health care programs Peace Corps Employer insurance Name of health insurance: Policy number: Is this COBRA coverage? Yes No Is this a retiree health plan? Yes No Other Yes No Is this a limited-benefit plan (like a school accident policy)? Policy number: Name of health insurance: Page 11 of 20 YES. If yes, check the type of coverage and write the person(s) name(s) next to the coverage they have. TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse. YES. If yes, you'll need to complete and include Appendix A. Is this a state employee benefit plan? Yes No If no, continue to Step 5. NO. Step 5: Other Questions 33. Is anyone on this application currently in jail or prison? Yes No If yes, who? If they have a release date, show it here: 34. Does any child on this application have a parent living outside of the home? Yes No Step 6: Read carefully and sign this application.

These are your Rights and Responsibilities as an applicant for medical benefits. 1. We will keep what you tell us private as required by law.

2. Be sure to answer the questions correctly. We may check all information on your application. You must help us if we ask you to prove that your information is correct.

3. We will use the information you provided as well as information from other sources such as Social Security benefits, unemployment insurance, unearned income and wages from employment to decide if you qualify.

4. You agree the state may seek reimbursement for services the state covered for your family if those services should have been paid for by any other health coverage your family may have.

5. If we pay medical bills for you, you give your right to collect medical support payments to the State of Illinois. You must help us if we ask you to establish parentage or obtain medical support payments for members of your family. You may not have to do this if you have a good reason not to. Your children can get health insurance even if you do not help us when we ask you to help.

6. You must apply for other financial benefits for which you may qualify such as Social Security Benefits or Unemployment Insurance.

7. We will not share any information about immigration of any person who does not have an Alien Registration Number. We will verify the immigration status of any person if you gave us their Alien Registration Number. To do that, we will check the number with the U.S. Citizenship and Immigration Service (USCIS). We may send other information to USCIS, such as copies of proof you sent of an Alien Registration Number and the person's Social Security Number, if they have one.

Page 12 of 20 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 8. If you are seeking benefits as a person with a disability, you authorize staff at the Illinois Department of Healthcare and Family Services (HFS) and the Illinois Department of Human Services (DHS) to obtain information from your records or copy your records from the Social Security Administration (SSA) with respect to any claims for disability benefits and all related appeals. You certify that you understand that the materials requested may be protected under state and federal privacy laws. You authorize release of any material protected under state and federal privacy laws to the staff of HFS and DHS.

9. Some families or individuals have to make a payment each month for this health insurance. This payment is called a premium. The amount of the premium depends on the family's income.

10. Some families or individuals have to pay part of the bill when they visit the doctor, go into the hospital or get a prescription filled. These payments are called co-payments. The amount of the co-payment depends on the family's income.

11. You must report changes within 10 days if any of the following happens: • Your income changes. • The number of people in your family who live with you changes. • Your address or phone number changes. • Someone who gets health benefits moves out of Illinois, dies, or goes to jail or prison. • Someone becomes covered by other insurance.

12. You understand that anyone who knowingly misuses the medical card issued by or on behalf of the State of Illinois may be committing a crime.

13. You understand that if you have given false information or intentionally failed to disclose information, you may be subject to civil prosecution, criminal prosecution or both.

14. You may withdraw your application or cancel your benefits at any time.

15. The State of Illinois does not discriminate on the basis of race, color, national origin, sex, age, or disability, religion or political belief. The State of Illinois provides reasonable accommodations according to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.

16. If you are not satisfied with the actions taken on your application, you have the right to a fair hearing. You can ask for a fair hearing by calling 1-800-435-0774 (TTY: 1-877-734-7429), by writing to the Department of Human Services, Bureau of Hearings. at 401 South Clinton Street, 6th Floor, Chicago, IL 60607, or by e-mailing your request to DHS.BAHNewAppeal@illinois.gov. The call is free. Use this phone number, e-mail and address only for appeal-related inquiries. All other inquiries should be directed to 1-800-843-6154 (TTY 1-800-447-6404.)

17. You understand that if you or anyone you have applied for is not eligible for Medicaid or All Kids, the state will send the information from the application to the Health Insurance Marketplace. The Health Insurance Marketplace needs detailed information about health coverage that your employer may offer even if you do not take it. The information requested on Appendix A may be required if the state sends your application to the Health Insurance Marketplace.

18. If you qualify to buy health insurance from the Marketplace, to make it easier to determine your eligibility for help paying for it in the future years, you agree to allow the Marketplace to use income data, including information from tax returns. The Marketplace will send you a notice, let you make any changes, and you can opt out at any time. Indicate below if you agree and for how many years. Check only 1 box. 5 years - This is the maximum number of years allowed, or check 4 years 3 years 2 years 1 year Do not use information from tax returns to renew my coverage. Page 13 of 20 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE Sign this application. The person who filled out Step 1 should sign this application. If you are an authorized representative you may sign here, as long as you have provided the information required in Appendix C. Signature Date (mm/dd/yyyy) Step 7: Mail completed application. Mail your signed application to:

Illinois Department of Healthcare and Family Services

P.O. Box 19122

Springfield, IL 62794-9122

If you want to register to vote, you can complete a voter registration form at www.elections.il.gov.

Appendixes:

Appendix A - Health Coverage from Jobs Appendix B - American Indian or Alaskan Native Family Member (AI / AN) Appendix C - Assistance with Completing this Application Page 14 of 20 / / TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 3. Employer APPENDIX A Health Coverage from Jobs You DON'T need to answer these questions unless 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. Employee name (First, Middle, Last) 2. Employee Social Security number _________ - _______ - _________ EMPLOYER Information 4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 9. Zip 8. State 7. City 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. E-mail address 13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? Yes (Continue) 13a. If you're in a waiting or probationary period, when can you enroll in coverage? Date (mm/dd/yyyy) List the names of anyone else who is eligible for coverage from this job. Name Name Name No (Stop here and go to Step 5 in the application.) _________ - _______ - _________ (________) - _______ - _________ (________) - _______ - _________ Page 15 of 20 / / TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 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 will 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. See question 15.) a. How much will the employee have to pay in premiums for this plan? $ b. How often? Yearly Quarterly Twice a month Every 2 weeks Weekly Date of change (mm/dd/yyyy) * An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed health benefit costs covered by the plan is no less than 60 percent of such costs. (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) Page 16 of 20 TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE EMPLOYER COVERAGE TOOL Use this tool to help answer questions in Appendix A about any employer health coverage that you're eligible for (even if it's from another person's job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.

Write your name and Social Security Number in boxes 1 and 2 and ask the employer to fill out the rest of the form. EMPLOYEE Information The employee needs to fill out this section. 1. Employee name (First, Middle, Last) 2. Employee Social Security number Ask the employer for this information. EMPLOYER Information 3. Employer 4. Employer Identification Number (EIN) 5. Employer address (the Marketplace will send notices to this address) 6. Employer phone number 9. Zip 8. State 7. City 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. E-mail address 13. Is the employee currently eligible for coverage offered by this employer, or will the employee become eligible in the next 3 months? Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? Date (mm/dd/yyyy) No (Stop and return this form to the employee) _________ - _______ - _________ _________ - _______ - _________ (______) - ______ - _________ (________) - _______ - _________ Page 17 of 20 / / TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE Tell us about the health plan offered by this employer. Does the employer offer a health plan that covers an employee's spouse or dependent? Yes. Which people? Spouse Dependent(s) No 14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return the form to the employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much will the employee have to pay in premiums for this plan? $ b. How often? Yearly Quarterly Twice a month Every 2 weeks Weekly If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return the form to employee. 16. What change will the employer make for the new plan year? 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. See question 15.) a. How much will the employee have to pay in premiums for this plan? $ b. How often? Yearly Quarterly Twice a month Every 2 weeks Weekly Date of change (mm/dd/yyyy) * An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed health benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986.) Page 18 of 20 / / TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE 4. Certain money received may not be counted for Medicaid or the Children's Health Insurance Program (CHIP). List any income (amount and how often) reported on your application that includes money from these sources: APPENDIX B American Indian or Alaska Native Family Member

(AI/AN) Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health Coverage & Help Paying Costs. Tell us about your American Indian or Alaska Native Family Member(s) American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. NOTE: If you have more people to include, make a copy of this page and attach.

1. NAME AI/AN PERSON 1 AI/AN PERSON 2 First Middle Last First Middle Last 2. Member of a federally recognized tribe? Yes If yes, tribe name No If yes, tribe name Yes No 3. Has the person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? Yes Yes No No If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? • Per capita payments from a tribe that come from natural resources, usage rights, leases, 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. $ How often? $ How often? Page 19 of 20 No Yes No Yes TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

If you need help, visit GetCoveredIllinois.gov or call 1-800-843-6154. If you use a TTY call 1-800-447-6404. Tenemos esta solicitud en español. For other languages, call 1-800-843-6154. HFS 2378ABE APPENDIX C Assistance with Completing this Application You can choose an authorized representative. You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an "authorized representative." If you ever need to change your authorized representative, contact the Marketplace. If you're a legally appointed representative for someone on this application, submit proof with the application. 1. Name of authorized representative (First name, Middle name, Last name) 2. Address 3. Apartment or suite number 6. ZIP code 5. State 4. City 7. Phone number 8. Organization name 9. ID number (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 this agency. 11. Date (mm/dd/yyyy) 10. Signature For certified application counselors, navigators, agents, and brokers only. Complete this section if you're a certified application counselor, navigator, agent, or broker filling out this application for somebody else. 1. Application start date (mm/dd/yyyy) 2. First name, Middle name, Last name & Suffix 3. Organization name 9. ID number (if applicable) Printed by the Authority of the State of Illinois . IOCI14-427 (________) - _______ - _________ Page 20 of 20 / / TN No: IL-13-0017-MM2 Illinois Approval Date: March 19, 2015 Effective Date: October 1, 2013

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

 Paper Application  Online Application

TRANSMITTAL NUMBER:

13-0017-MM2

STATE:

Illinois

Through December 31, 2015, the state is using an interim alternative single streamlined application. After December 31, 2015, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 13-018 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

March 19, 2014

Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN 13-018

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #13-018 - Approves Illinois’ request to add coverage of tobacco cessation counseling for pregnant women.

--Effective Date: January 1, 2014

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Mary Doran, HFS

Beth Green, HFS

January 1, 2014 12/30/13 3/19/14 /s/ Verlon Johnson Associate Regional Administrator

Attachment 3.1-A

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGROICALLY NEEDY

TN # 13-018 Approval date: 3/19/14 Effective date: 01/01/2014 Supersedes TN # 93-27

4. a. Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.

Provided:  No limitations.  With limitations.*

4. b. Early and periodic screening, diagnostic and treatment services for individuals under 21 years of age and treatment of conditions found.*

4. c. Family planning services and supplies for individuals of childbearing age.

Provided:  No limitations.  With limitations.* 01/14 4. d. Face-to-Face Tobacco Cessation Counseling Services for Pregnant Women

Provided:  No limitations.  With limitations.*

5. a. Physicians’ services whether furnished in the office, the patient’s home, a hospital, a nursing facility or elsewhere.

Provided:  No limitations.  With limitations.*

5. b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act.

Provided:  No limitations.  With limitations.*

6. 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.

a. Podiatrists’ services.

Provided:  No limitations.  With limitations.*

* Description provided on attachment

Attachment 3.1-B

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP (S):

TN # 13-018 Approval date: 3/19/14 Effective date: 01/01/2014 Supersedes TN # 93-12

1. Inpatient hospital services other than those provided in an institution for mental diseases.

 Provided:  No limitations  with limitations* 2. a. Outpatient hospital services.

 Provided:  No limitations  with limitations*

b. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

 Provided:  No limitations  with limitations*

*c. Federally qualified health center(FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with section 4231 of the State Medicaid Manual (HCFA Pub.45-4).

 Provided:  No limitations**  with limitations 3. Other laboratory and x-ray services.

 Provided:  No limitations

with limitations* 4. a. Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.

 Provided:  No limitations  with limitations*

b. Early and periodic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of conditions found.

c. Family planning services and supplies for individuals of childbearing age.

 Provided:  No limitations  with limitations

d. Face-to-Face Tobacco Cessation Counseling Services for Pregnant Women

 Provided:  No limitations  with limitations*

*Description provided on attachment.

*c. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with section 4231 of the State Medicaid Manual (HCFA-Pub.45-4).

X__ Provided X_ _No limitations** ___with limitations **Limitations for participation in Healthy Moms/Healthy Kids are defined in the Appendix.

Attachment 3.1-A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

TN # 13-018 Approval date: 3/19/14 Effective date: 01/01/2014 Supersedes TN # 91-25

1.

Inpatient hospital services other than those provided by in institution for mental diseases.

Provided:  No limitations.  With limitations.* 2.

a. Outpatient hospital services.

Provided:  No limitations.  With limitations.*

b. Rural health clinic services and other ambulatory services furnished by a rural health clinic. (Which are otherwise included in the State Plan.)

Provided:  No limitations.  With limitations.*

c. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with section 4231 of the State Medicaid Manual (HCFA-Pub. 45- 4).

Provided:  No limitations.**  With limitations.* 3.

Other laboratory and x-ray services.

Provided:  No limitations.

With limitations.*

Appendix to Attachment 3.1-A

Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois AMOUNT, DURATION, AND SCOPE OF SERVICES

TN # 13-018 Approval date: 3/19/14 Effective date: 01/01/2014 Supersedes TN # 09-01

04/09 3. OTHER LABORATORY AND X-RAY SERVICES

Limits on services or treatments are not applicable to EPSDT (Healthy Kids) clients. All services or treatments which are medically necessary to correct or lessen health problems detected or suspected by the screening process must be provided to individuals under age 21.

4a. SKILLED NURSING FACILITIES (OTHER THAN SERVICES IN AN INSTITUTION FOR MENTAL DISEASES) FOR INDIVIDUALS 21 YEARS OF AGE OR OLDER

A preadmission screening assessment is required.

4b. EARLY AND PERIODIC SCREENING AND DIAGNOSIS TREATMENT SERVICES

Clients shall be referred for dental screenings beginning at age 2 if the client is not in the continuing care of an enrolled dental provider.

All medically necessary diagnosis and treatment services will be furnished to EPSDT (Healthy Kids) clients to treat conditions detected by periodic and inter-periodic screening services even if the services are not included in the State Plan.

In addition to services provided under this State Plan, covered Medicaid (Section 1905(a) of the Social Security Act) services for individuals under age 21 include: case management, personal care services, Christian Science nurse and respiratory care services.

Limits on services or treatments are not applicable to EPSDT (Healthy Kids) clients. All services or treatments, including organ transplants which are “medically necessary”, to correct or lessen health problems detected or suspected by the screening process must be provided to individuals under age 21.

4c. Reserved 01/14 4d. TOBACCO CESSATION COUNSELING SERVICES FOR PREGNANT WOMEN

1) Face-to-Face Tobacco Cessation Counseling Services provided (by):

(i) By or under supervision of a physician;

(ii) By any other health care professional who is legally authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; or*

(iii) Any other health care professional legally authorized to provide tobacco cessation services under State law and who is specifically designated by the Secretary in regulations. (None are designated at this time; this item is reserved for future use.)

*describe if there are any limitations on who can provide these counseling services. 2) Provided: X No limitations

With Limitations

Tobacco cessation counseling services for pregnant women shall include four (4) individual face-to-face counseling sessions per quit attempt, with a maximum of three (3) quit attempts per calendar year.

Table of Contents

State/Territory Name: IL State Plan Amendment (SPA) #: 14-0002

This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

June 16, 2014

Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building

201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN 14-0002

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #14-0002 - Approves Illinois’ request to end medically needy coverage to parents and other caretakers relatives in light of the state’s action toward Medicaid expansion and pursuant to Public Act 098-0104 of the Illinois General Assembly in anticipation of the availability of health coverage through the federally facilitated exchange.

--Effective Date: January 1, 2014

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Jacquetta Ellinger, HFS Pat Curtis, HFS Jamie Ursch, HFS

03/20/14 06/16/14 01/01/14 /s/ Verlon Johnson Associate Regional Administrator

06/16/14

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 14-0003B This file contains the following documents in the order listed:

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

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

CENTERS FOR MEDICARE & MEDICAID SERVICES

June 17, 2014

Julie Hamos, Director

Illinois Department of Healthcare and F amily Services (HFS) Prescott E. Bloom Building

201 South Grand Avenue East

Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN IL-14-0003B

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #IL-14-0003B __-Eligibility of Mandatory Coverage Groups -Effective Date: January 1, 2014

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs. gov.

Sincerely,

/s/ Verlon Johnson Associate Regional Administrator Division of Medicaid and Children’s Health Operations

Enclosure

ce: Jaime Ursch, HFS Pat Curtis, HFS Jacquetta Ellinger, HFS

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Illinois

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.

14-0003B

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

Federal Statute/Regulation Citation [1 902(a)(10)(A)(i)(VIT1) & (IX); 42 CFR 435.119; 42 CFR 435.150

Federal Budget Impact Federal Fiscal Year Amount

First Year bo14 s{.00 Second Year fois sf0.00 = COtCS~S

Subject of Amendment Eligibility Groups-Mandatory Coverage: Adult Group (S32)& Former Foster Care Children (S33)

(See SPA 14-0003 for federal budget impact)

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

© Comments of Governor's office received Describe:

© No reply received within 45 days of submittal

@ Other, as specified Describe: The Governor has authorized the director of Healthcare and Family Services to act as his designee to review, approve and submit state plan amendments under Title XIX of the Social Security Act. The director has reviewed this submission and has no comments.

Signature of State Agency Official

Submitted By: Jamie Ursch Last Revision Date: Jun 16, 2014 Submit Date: Jun 16, 2014 DATE RECEIVED DATE APPROVED: 03/27/2014 6/17/14 PLAN APPROVED - ONE COPY ATTACHED SIGNATURE OF REGIONAL OFFICIAL: EFFECTIVE DATE OF APPROVED MATERIAL: Is/ 1/1/2014 TITLE: TYPED NAME Associate Regional Administrator

Verlon Johnson

RUSTE As 0 SRB SR OR OR ERNE co meaaeaRuRILTAIe ae ccCmMms Medicaid Eligibility

OMB Control Number 0938-1 148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage $32 1902(a)(10)(A)(i)( VII) 42 CFR 435.119

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

[m) Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. The state attests that it operates this eligibility group in accordance with the following provisions: | {m] Individuals qualifying under this eligibility group must meet the following criteria: [m) Have attained age 19 but not age 65. [m] Are not pregnant.

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

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

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

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

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

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

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

(@ Under age 19, or C A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010:

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

C Yes @ No |

PRA Disclosure Statement

TN No: 14-0003B Approval Date: June 17, 2014 Effective Date: January 1, 2014 Illinois

Medicaid Eligibility

CENTERS FOE MAEDA A AME SCARS CERES

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 nu:

mber for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments conceming the accuracy of

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

TN No: 14-0003B Approval Date: June 17, 2014 Effective Date: January 1, 2014 Illinois

SE SR A AR REY

CCMS Medicaid Eligibility

OMB Control Number 0938-1 148 OMB Expiration date: 10/31/2014

Eligibility Groups - Mandatory Coverage a Former Foster Care Children _ bs S33

42 CFR 435.150 | 1902(a)(10)(A)(i)(EX)

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

The state attests that it operates this eligibility group under the following provisions: | {m) Individuals qualifying under this eligibility group must meet the following criteria: [im] Are under age 26.

Hy Are not otherwise eligible for and enrolled for mandatory Coverage under the state plan, except that eligibility under

this group takes precedence over eligibility under the Adult Group. |

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

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

C Yes @No

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.1 16) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

C Yes @No

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

TN No: 14-0003B Approval Date: June 17, 2014 Effective Date: January 1, 2014 Illinois

Table of Contents State/Territory Name: Illinois State Plan Amendment (SPA) #: IL-14-0003-MM1 This file contains the following documents in the order listed:

1) Approval Letter

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

4) Approved SPA Pages

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600

Chicago, Illinois 60601-5519 CENTERS FOR MEDICARE & MEDICAID SERVICES

June 3, 2016

Felicia Norwood, Director

Illinois Department of Healthcare and Family Services Prescott E. Bloom Building

201 South Grand Avenue East

Springfield, Illinois 62763-0001

Attn: Teresa Hursey

Dear Ms. Norwood:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA). Transmittal #14-0003-MM1 — Medicaid MAGI-Based Eligibility Groups --Effective Date: January 1, 2014

If you have any questions, please have a member of your staff contact Courtenay Savage at 312-353-3721 or via email at Courtenay.Savage@cms.hhs.gov.

Sincerely,

/s/ Ruth A. Hughes Associate Regional Administrator Division of Medicaid and Children’s Health Operations

Enclosure

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Illinois 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.

IL-14-0003-MM1

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

Federal Statute/Regulation Citation 1902(a)(10)(A)i)(D),AID,(IV),(VD),(VID & (iiMD,(IV); 1905(a)(i); 1920; 1931(b)(d)

Federal Budget Impact Federal Fiscal Year Amount

First Year 2014 $ 1,500,000,000.00

Second Year 2015 $2,700,000,000.00

Subject of Amendment Eligibility Groups-Mandatory & Optional Coverage

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified

Describe: The Governor has authorized the director of Healthcare and Family Services to act as his designee to review, ¥ approve and submit state plan amendments under Title XIX of the Social Security Act. The director has reviewed this submission and has no comments.

Signature of State Agency Official

Submitted By: Jamie Ursch Last Revision Date: May 6, 2016 Submit Date: Mar 27,2014 Date Received: March 27, 2014 Date Approved: June 3, 2016 Effective Date of Approved Material: January 1, 2014 Signature of Regional Official /s/ Typed Name: Ruth A. Hughes Title: Associate Regional Administrator

Remarks:

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: 14-0003-MM1

STATE: Illinois

Pages or sections of pages being superseded by S25,

S28,

$30, S51, S52, S53,

S54, S55, and S14 and related pages or sections of pages being deleted as obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A.2.b Page 3 Page 2, A.2.c Page 3a Page 2a, A.3 Page 4 Page 5, A.10 Page 4a Page 9c, B.1 remove Page 12 “Caretaker Attachment 2.2-A Page 13 relatives” and Page 13a “Pregnant women” Page 14 Page 20, B.14 Page l4a Page 23c, B.20 Page 21 Page 25, C.4 Page 23 Page 23b Page 23d Page 23dl Supplement 1 to Attachment Page 1, #A 2.2-A Page 3b Page 1, A.2.a(i) Page lla and (iii) Page 19 Page 6 related to Page 19a AFDC recipients, Page 21 pregnant women, Attachment 2.6-A infants, and children Page 7, l.a(1) and (2) Page 12, 1.e(2) Page 18, 5.e Page 25, 11.a(3) Supplement 1 to Attachment Pages 1, la, 1b, lc, 2, 2.6-A 3, 4 Supplement 2 to Attachment Pages 1-5 2.6-A Page 2, for 1, 2, & Supplement 8a to Attachment 4 2.6-A Page 2a, Related to categorically needy

pregnant women and children Page 3, #7-9

Supplement 12 to Attachment 2.6-A

Pages 3 - 4

Supplement 14 to Attachment 2.6-A

Page 1

Page 1 of 20 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by some other way Remove Name Standard varies by region and living arrangement: Group I counties for caretaker relative & child. Description The Group I counties are Boone, Champaign, Cook, Dekalb, DuPage, Kane, Kankakee, Kendall, Lake, McHenry, Ogle, Whiteside,Winnebago and Woodford. Household size Standard ($) + 1 225 x + 2 286 x + 3 387 x + 4 440 x + 5 516 x + 6 580 x + 7 616 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 2 of 20 Medicaid Eligibility + 8 653 x + 9 692 x + 10 733 x + 11 775 x + 12 818 x + 13 865 x + 14 912 x + 15 962 x + 16 1,013 x + 17 1,067 x + 18 1,124 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group I Counties for child only. Description The Group I counties are Boone, Champaign, Cook, Dekalb, DuPage, Kane, Kankakee, Kendall, Lake, McHenry, Ogle, Whiteside,Winnebago and Woodford. Household size Standard ($) + 1 99 x + 2 192 x + 3 238 x + 4 304 x + 5 362 x + 6 389 x + 7 419 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 3 of 20 Medicaid Eligibility + 8 449 x + 9 481 x + 10 516 x + 11 552 x + 12 589 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group II Counties for caretaker relative & child. Description The Group II counties are: Adams, Bureau, Carroll, Clinton, Coles, DeWitt, Douglas, Effingham, Ford, Fulton, Grundy, JoDaviess, Knox, LaSalle, Henry, Iroquois, Jackson, Lee, Livingston, Logan, Macon, Macoupin, Madison, McLean, McDonough, Mercer, Monroe, Morgan, Moultrie, Peoria, Piatt, Putnam, Rock Island, Sangamon, St. Clair, Stephenson, Tazewell, Vermillion, Wabash, Warren, Will. Household size Standard ($) + 1 216 x + 2 276 x + 3 375 x + 4 428 x + 5 502 x + 6 565 x + 7 600 x + 8 637 x + 9 675 x + 10 714 x + 11 755 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 4 of 20 Medicaid Eligibility + 12 797 x + 13 842 x + 14 888 x + 15 936 x + 16 987 x + 17 1,040 x + 18 1,094 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group II Counties for child only. Description The Group II counties are: Adams, Bureau, Carroll, Clinton, Coles, DeWitt, Douglas, Effingham, Ford, Fulton, Grundy, JoDaviess, Knox, LaSalle, Henry, Iroquois, Jackson, Lee, Livingston, Logan, Macon, Macoupin, Madison, McLean, McDonough, Mercer, Monroe, Morgan, Moultrie, Peoria, Piatt, Putnam, Rock Island, Sangamon, St. Clair, Stephenson, Tazewell, Vermillion, Wabash, Warren, Will. Household size Standard ($) + 1 95 x + 2 186 x + 3 232 x + 4 297 x + 5 353 x + 6 380 x + 7 409 x + 8 439 x + 9 470 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 5 of 20 Medicaid Eligibility + 10 504 x + 11 538 x + 12 575 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group III Counties for caretaker relative & child. Description The Group III counties are: Alexander, Bond, Brown, Calhoun, Cass, Christian, Clark, Clay, Crawford, Cumberland, Edgar, Edwards, Fayette, Franklin, Gallatin, Greene, Hamilton, Hancock, Hardin, Henderson, Jasper, Jefferson, Jersey, Johnson, Lawrence, Marion, Marshall, Mason, Massac, Menard, Montgomery, Perry, Pike, Pope, Pulaski, Randolph, Richland, Saline, Schuyler, Scott, Shelby, Stark, Union, Washington, Wayne, White, Williamson. Household size Standard ($) + 1 187 x + 2 265 x + 3 360 x + 4 415 x + 5 483 x + 6 546 x + 7 580 x + 8 615 x + 9 653 x + 10 691 x + 11 731 x + 12 772 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 6 of 20 Medicaid Eligibility + 13 815 x + 14 860 x + 15 906 x + 16 955 x + 17 1,006 x + 18 1,059 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group III Counties for child only. Description The Group III counties are: Alexander, Bond, Brown, Calhoun, Cass, Christian, Clark, Clay, Crawford, Cumberland, Edgar, Edwards, Fayette, Franklin, Gallatin, Greene, Hamilton, Hancock, Hardin, Henderson, Jasper, Jefferson, Jersey, Johnson, Lawrence, Marion, Marshall, Mason, Massac, Menard, Montgomery, Perry, Pike, Pope, Pulaski, Randolph, Richland, Saline, Schuyler, Scott, Shelby, Stark, Union, Washington, Wayne, White, Williamson. Household size Standard ($) + 1 92 x + 2 180 x + 3 227 x + 4 288 x + 5 343 x + 6 370 x + 7 397 x + 8 426 x + 9 457 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 7 of 20 Medicaid Eligibility + 10 490 x + 11 523 x + 12 558 x Additional incremental amount Yes No Increment amount $ Add The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by some other way Remove Name Standard varies by region and living arrangement: Group I Counties for caretaker relative & child. Description The Group I counties are Boone, Champaign, Cook, Dekalb, DuPage, Kane, Kankakee, Kendall, Lake, McHenry, Ogle, Whiteside,Winnebago and Woodford. Household size Standard ($) + 1 212 x + 2 278 x + 3 377 x + 4 414 x + 5 485 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 8 of 20 Medicaid Eligibility + 6 545 x + 7 574 x + 8 604 x + 9 635 x + 10 669 x + 11 705 x + 12 741 x + 13 781 x + 14 822 x + 15 866 x + 16 911 x + 17 959 x + 18 1,010 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group I Counties for child only. Description The Group I counties are Boone, Champaign, Cook, Dekalb, DuPage, Kane, Kankakee, Kendall, Lake, McHenry, Ogle, Whiteside,Winnebago and Woodford. Household size Standard ($) + 1 102 x + 2 201 x + 3 249 x + 4 319 x + 5 379 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 9 of 20 Medicaid Eligibility + 6 407 x + 7 438 x + 8 469 x + 9 503 x + 10 538 x + 11 576 x + 12 614 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group II Counties for caretaker relative & child. Description The Group II counties are: Adams, Bureau, Carroll, Clinton, Coles, DeWitt, Douglas, Effingham, Ford, Fulton, Grundy, JoDaviess, Knox, LaSalle, Henry, Iroquois, Jackson, Lee, Livingston, Logan, Macon, Macoupin, Madison, McLean, McDonough, Mercer, Monroe, Morgan, Moultrie, Peoria, Piatt, Putnam, Rock Island, Sangamon, St. Clair, Stephenson, Tazewell, Vermillion, Wabash, Warren, Will. Household size Standard ($) + 1 204 x + 2 269 x + 3 365 x + 4 403 x + 5 471 x + 6 529 x + 7 557 x + 8 588 x + 9 619 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 10 of 20 Medicaid Eligibility + 10 651 x + 11 685 x + 12 721 x + 13 760 x + 14 799 x + 15 841 x + 16 886 x + 17 934 x + 18 982 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group II Counties for child only. Description The Group II counties are: Adams, Bureau, Carroll, Clinton, Coles, DeWitt, Douglas, Effingham, Ford, Fulton, Grundy, JoDaviess, Knox, LaSalle, Henry, Iroquois, Jackson, Lee, Livingston, Logan, Macon, Macoupin, Madison, McLean, McDonough, Mercer, Monroe, Morgan, Moultrie, Peoria, Piatt, Putnam, Rock Island, Sangamon, St. Clair, Stephenson, Tazewell, Vermillion, Wabash, Warren, Will. Household size Standard ($) + 1 97 x + 2 194 x + 3 242 x + 4 311 x + 5 369 x + 6 397 x + 7 427 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 11 of 20 Medicaid Eligibility + 8 459 x + 9 491 x + 10 525 x + 11 561 x + 12 599 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group III Counties for caretaker relative & child. Description The Group III counties are: Alexander, Bond, Brown, Calhoun, Cass, Christian, Clark, Clay, Crawford, Cumberland, Edgar, Edwards, Fayette, Franklin, Gallatin, Greene, Hamilton, Hancock, Hardin, Henderson, Jasper, Jefferson, Jersey, Johnson, Lawrence, Marion, Marshall, Mason, Massac, Menard, Montgomery, Perry, Pike, Pope, Pulaski, Randolph, Richland, Saline, Schuyler, Scott, Shelby, Stark, Union, Washington, Wayne, White, Williamson. Household size Standard ($) + 1 173 x + 2 247 x + 3 339 x + 4 389 x + 5 453 x + 6 511 x + 7 538 x + 8 566 x + 9 597 x + 10 628 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 12 of 20 Medicaid Eligibility + 11 662 x + 12 696 x + 13 733 x + 14 771 x + 15 812 x + 16 855 x + 17 900 x + 18 948 x Additional incremental amount Yes No Increment amount $ Remove Name Standard varies by region and living arrangement: Group III Counties for child only. Description The Group III counties are: Alexander, Bond, Brown, Calhoun, Cass, Christian, Clark, Clay, Crawford, Cumberland, Edgar, Edwards, Fayette, Franklin, Gallatin, Greene, Hamilton, Hancock, Hardin, Henderson, Jasper, Jefferson, Jersey, Johnson, Lawrence, Marion, Marshall, Mason, Massac, Menard, Montgomery, Perry, Pike, Pope, Pulaski, Randolph, Richland, Saline, Schuyler, Scott, Shelby, Stark, Union, Washington, Wayne, White, Williamson. Household size Standard ($) + 1 94 x + 2 188 x + 3 237 x + 4 302 x + 5 359 x + 6 387 x + 7 414 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 13 of 20 Medicaid Eligibility + 8 445 x + 9 477 x + 10 510 x + 11 545 x + 12 581 x Additional incremental amount Yes No Increment amount $ Add The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 14 of 20 Medicaid Eligibility The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 15 of 20 Medicaid Eligibility Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Group I Counties Description The Group I counties are Boone, Champaign, Cook, Dekalb, DuPage, Kane, Kankakee, Kendall, Lake, McHenry, Ogle, Whiteside,Winnebago and Woodford. Household size Standard ($) + 1 243 x + 2 318 x + 3 432 x + 4 474 x + 5 555 x + 6 623 x + 7 657 x + 8 691 x + 9 727 x + 10 765 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region Group II Counties Description Group II counties are: Adams, Bureau, Carroll, Clinton, Coles, DeWitt, Douglas, Effingham, Ford, Fulton, Grundy, JoDaviess, Knox, LaSalle, Henry, Iroquois, Jackson, Lee, Livingston, Logan, Macon, Macoupin, Madison, McLean, McDonough, Mercer, Monroe, Morgan, Moultrie, Peoria, Piatt, Putnam, Rock Island, Sangamon, St. Clair, Stephenson, Tazewell, Vermillion, Wabash, Warren, Will. TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 16 of 20 Medicaid Eligibility Household size Standard ($) + 1 233 x + 2 307 x + 3 417 x + 4 461 x + 5 540 x + 6 605 x + 7 638 x + 8 673 x + 9 709 x + 10 746 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region Group III Counties Description Group III counties are: Alexander, Bond, Brown, Calhoun, Cass, Christian, Clark, Clay, Crawford, Cumberland, Edgar, Edwards, Fayette, Franklin, Gallatin, Greene, Hamilton, Hancock, Hardin, Henderson, Jasper, Jefferson, Jersey, Johnson, Lawrence, Marion, Marshall, Mason, Massac, Menard, Montgomery, Perry, Pike, Pope, Pulaski, Randolph, Richland, Saline, Schuyler, Scott, Shelby, Stark, Union, Washington, Wayne, White, Williamson. Household size Standard ($) + 1 198 x + 2 294 x + 3 399 x + 4 445 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 17 of 20 Medicaid Eligibility + 5 519 x + 6 585 x + 7 616 x + 8 647 x + 9 683 x + 10 718 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Group I Counties Description The Group I counties are Boone, Champaign, Cook, Dekalb, DuPage, Kane, Kankakee, Kendall, Lake, McHenry, Ogle, Whiteside,Winnebago and Woodford. Household size Standard ($) + 1 590 x + 2 784 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 18 of 20 Medicaid Eligibility + 3 1,018 x + 4 1,180 x + 5 1,381 x + 6 1,568 x + 7 1,722 x + 8 1,876 x + 9 2,031 x + 10 2,189 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region Group II Counties Description Group II counties are: Adams, Bureau, Carroll, Clinton, Coles, DeWitt, Douglas, Effingham, Ford, Fulton, Grundy, JoDaviess, Knox, LaSalle, Henry, Iroquois, Jackson, Lee, Livingston, Logan, Macon, Macoupin, Madison, McLean, McDonough, Mercer, Monroe, Morgan, Moultrie, Peoria, Piatt, Putnam, Rock Island, Sangamon, St. Clair, Stephenson, Tazewell, Vermillion, Wabash, Warren, Will. Household size Standard ($) + 1 557 x + 2 743 x + 3 965 x + 4 1,121 x + 5 1,312 x + 6 1,489 x + 7 1,634 x + 8 1,781 x TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 19 of 20 Medicaid Eligibility + 9 1,929 x + 10 2,078 x Additional incremental amount Yes No Increment amount $ Remove Region Name of region Group III Counties Description Group III counties are: Alexander, Bond, Brown, Calhoun, Cass, Christian, Clark, Clay, Crawford, Cumberland, Edgar, Edwards, Fayette, Franklin, Gallatin, Greene, Hamilton, Hancock, Hardin, Henderson, Jasper, Jefferson, Jersey, Johnson, Lawrence, Marion, Marshall, Mason, Massac, Menard, Montgomery, Perry, Pike, Pope, Pulaski, Randolph, Richland, Saline, Schuyler, Scott, Shelby, Stark, Union, Washington, Wayne, White, Williamson. Household size Standard ($) + 1 421 x + 2 594 x + 3 776 x + 4 899 x + 5 1,050 x + 6 1,193 x + 7 1,301 x + 8 1,409 x + 9 1,522 x + 10 1,634 x Additional incremental amount Yes No Increment amount $ Add Region The dollar amounts increase automatically each year Yes No PRA Disclosure Statement TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 20 of 20 Medicaid Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN NO: IL-14-0003-MM1 Illinois S14 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives S25 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. ■ The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative (select any that apply): The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. Definition of domestic partner: The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: Caretaker relatives who are related by blood to the child to within the 5th degree of kinship; step relatives, adoptive relatives; spouse of a relative. The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): TN NO: IL-14-0003-MM1 Illinois S25 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 2 of 4 Medicaid Eligibility Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard ■ The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: TN NO: IL-14-0003-MM1 Illinois Approval Date: Effective Date: January 1, 2014 S25 6/3/16

Page 3 of 4 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other dollar amount % Income standard chosen: ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. Another income standard in-between the minimum and maximum standards allowed The state's AFDC payment standard in effect as of July 16, 1996, not converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, not converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other income standard in-between the minimum and the maximum standards allowed. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement TN NO: IL-14-0003-MM1 Illinois Approval Date: Effective Date: January 1, 2014 S25 6/3/16

Page 4 of 4 Medicaid Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: IL-14-0003-MM1 Illinois Approval Date: Effective Date: January 1, 2014 S25 6/3/16

Page 1 of 4 Medicaid Eligibility Transmittal Number: IL State Name: Illinois OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 14 - 0003 Eligibility Groups - Mandatory Coverage Pregnant Women S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I), (IV) and (IX) 1931(b) and (d) 1920 Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. ■ Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. Yes No MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for this eligibility group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN NO: IL-14-0003-MM1 Illinois S28 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 2 of 4 Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL The amount of the maximum income standard is: 208 % FPL Income standard chosen ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard Another income standard in-between the minimum and maximum standards allowed. There is no resource test for this eligibility group. ■ Benefits for individuals in this eligibility group consist of the following: ■ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. Presumptive Eligibility ■ The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes No The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. There may be no more than one period of presumptive eligibility per pregnancy. ■ A written application must be signed by the applicant or representative. TN NO: IL-14-0003-MM1 Illinois S28 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 3 of 4 Medicaid Eligibility Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: ■ The woman must be pregnant ■ Household income must not exceed the applicable income standard at 42 CFR 435.116. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. ■ List of Qualified Entities S17 A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP) Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV-D of the Act Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act TN NO: IL-14-0003-MM1 Illinois S28 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 4 of 4 Medicaid Eligibility Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description + Any of the entities marked and described above Is an entity that is described in 89 IL Admin Code 120.66(e) x + Federally Qualified Health Centers as described in this table Is a facility that receives funding under the federal community or migrant health programs under sections 330 and 330A of the Public Health Service Act as described in 89 IL Admin Code 120.66(e) x + Local Public Health Departments as described in this table Is a facility that participates in the State's perinatal program as described in 89 IL Admin Code 120.66(e) x + Community Service Organizations as described in this table Is an organization that receives a grant under the Commodity Supplemental Food Program under the Agriculture and Consumer Protection Act as described in 89 IL Admin Code 120.66(e) x + Community based health clinics including maternal/child health centers as described in this table Is an organization that receives funding under Title V of the Social Security Act as described in 89 IL Admin Code 120.66(e) x The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included. ✔ An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20140415 TN NO: IL-14-0003-MM1 Illinois S28 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 1 of 8 Medicaid Eligibility Transmittal Number: IL State Name: Illinois OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 14 - 0003 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for infants under age one is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN NO: IL-14-0003-MM1 Illinois S30 Approval Date: Effective Date: January 1, 2014 6/3/16

Page 2 of 8 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. The amount of the income standard for infants under one is: 142 % FPL Income standard for children age one through age five, inclusive ■ Minimum income standard ■ TN NO: IL-14-0003-MM1 Illinois S30 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 3 of 8 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 142 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. TN NO: IL-14-0003-MM1 Illinois S30 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 4 of 8 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Enter the amount of the maximum income standard: 142 % FPL Income standard chosen ■ TN NO: IL-14-0003-MM1 Illinois S30 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 5 of 8 Medicaid Eligibility The state's income standard used for children age six through eighteen is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No Presumptive Eligibility for Children S16 1902(a)(47) 1920A 42 CFR 435.1101 42 CFR 435.1102 The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions: ■ TN NO: IL-14-0003-MM1 Illinois S30 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 6 of 8 Medicaid Eligibility If the state has elected to cover Optional Targeted Low-Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR 435.118), for that child’s age. If the state has not elected to cover Optional Targeted Low Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child’s age. Children under the following age may be determined presumptively eligible: ■ Under age 19 The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: ■ Household income must not exceed the applicable income standard described above, for the child's age. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. ■ List of Qualified Entities S17 TN NO: IL-14-0003-MM1 Illinois S30 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 7 of 8 Medicaid Eligibility A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP) Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV-D of the Act Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description + State of Illinois Illinois elected to limit presumptive eligibility determinations to caseworkers employed by either Department of Human Services or Department of Healthcare and Family Services x The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included. ✔ An attachment is submitted. TN NO: IL-14-0003-MM1 Illinois S30 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 8 of 8 Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20140415 TN NO: IL-14-0003-MM1 Illinois S30 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals above 133% FPL S50 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: IL-14-0003-MM1 Illinois S50 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 S52 42 CFR 435.222 1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: ■ Be under age 21, or a lower age, as defined within the reasonable classification. ■ Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification. ■ Not be eligible and enrolled for mandatory coverage under the state plan. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group. ✔ An attachment is submitted. Current Coverage of All Children under a Specified Age TN NO: IL-14-0003-MM1 Illinois S52 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 2 of 5 Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 Reasonable Classifications of Children S11 Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals placed in foster care homes by public agencies Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals placed in foster care homes by private, non-profit agencies Individuals placed in private institutions by public agencies Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals placed in private institutions by private, non-profit agencies Individuals in adoptions subsidized in full or part by a public agency Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals in nursing facilities, if nursing facility services are provided under this plan TN NO: IL-14-0003-MM1 Illinois S52 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 3 of 5 Medicaid Eligibility Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Other reasonable classifications Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23, 2010 and no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Click here once S11 form above is complete to view the income standards form. Individuals placed in foster care homes by public agencies Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Individuals placed in private institutions by public agencies TN NO: IL-14-0003-MM1 Illinois S52 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 4 of 5 Medicaid Eligibility Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Individuals in adoptions subsidized in full or part by a public agency Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No TN NO: IL-14-0003-MM1 Illinois S52 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 5 of 5 Medicaid Eligibility No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Other Reasonable Classifications Previously Covered The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group. Yes No Additional new age groups or reasonable classifications covered If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. Yes No There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: IL-14-0003-MM1 Illinois S52 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ■ Are under the following age (see the Guidance for restrictions on the selection of an age): ■ Under age 21 Under age 20 Under age 19 Under age 18 MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. ■ The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ TN NO: IL-14-0003-MM1 Illinois S53 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 2 of 2 Medicaid Eligibility No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this eligibility group under (check all that apply): ■ The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age: This eligibility group does not use an income test (all income is disregarded). There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: IL-14-0003-MM1 Illinois S53 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Targeted Low Income Children S54 1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: IL-14-0003-MM1 Illinois S54 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis S55 1902(a)(10)(A)(ii)(XII) 1902(z) Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: IL-14-0003-MM1 Illinois S55 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents S57 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: IL-14-0003-MM1 Illinois S57 Approval Date: 6/3/16 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services S59 1902(a)(10)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: IL-14-0003-MM1 Illinois S59 Approval Date: 6/3/16 Effective Date: January 1, 2014

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 14-0004-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

September 22, 2014

Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN IL-14-0004-MM5

Dear Ms. Hamos:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #IL-14-0004-MM5-MAGI-based Residency

-Effective Date: January 1, 2014

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Mary Doran, HFS

Beth Green, HFS

Pat Curtis, HFS

Jacquetta Ellinger, HFS

State/Territory name: Illinois Submitted By: Jamie Ursch Last Revision Date: Aug 11, 2014 Submit Date: Mar 20, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IL-14-0004 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.403 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Non-Financial Eligibility: State Residency Governor's Office Review       Governor's office reported no comment       Comments of Governor's office received Describe:           No reply received within 45 days of submittal       Other, as specified Describe: The Governor has authorized the director of Healthcare and Family Services to act as his designee to review, approve and submit state plan amendments under Title XIX of the Social Security Act. The director has reviewed this submission and has no comments. Signature of State Agency Official DATE RECEIVED 03/20/2014 EFFECTIVE DATE OF APPROVED MATERIAL: 1/1/2014 TYPED NAME Verlon Johnson

PLAN APPROVED - ONE COPY ATTACHED DATE APPROVED: 09/22/2014 SIGNATURE OF REGIONAL OFFICIAL: /s/ TITLE: Associate Regional Administrator

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: 14-0004 MM5 STATE: Illinois PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: S88 – State Residency Attachment 2.6-A: Page 3, Item 4, TN 97-14 (Section 2.3: Page 13- Page Removed) PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): (None- New Page) Attachment 2.6-A: Page 3, Item 4, TN 14-0023 MM6 Section 2.3: Page 13, TN 87-15

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ TN No: IL-14-0004-MM5 Illinois Approval Date: 09/22/2014 Effective Date: January 1, 2014

Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ TN No: IL-14-0004-MM5 Illinois Approval Date: 09/22/2014 Effective Date: January 1, 2014

Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual The state has a policy related to individuals in the state only to attend school. Yes No Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No TN No: IL-14-0004-MM5 Illinois Approval Date: 09/22/2014 Effective Date: January 1, 2014

Medicaid Eligibility Provide a description of the definition: An individual may be temporarily absent from the State, and retain Illinois residency, if the individual intends to return when the purpose of the absence has been accomplished, unless another State has determined the individual is a resident there for the purposes of Medicaid. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No: IL-14-0004-MM5 Illinois Approval Date: 09/22/2014 Effective Date: January 1, 2014

Attachment 2.6-A

Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of Illinois GROUPS COVERED _____________________________________________________________________________________

_____________________________________________________________________________________ TN No. 14-0004-MM5 Approval Date: _09/22/2014__ Effective Date: _01/01/2014_ Supersedes TN No. _97-14_

d. Is a person paroled under Section 212(d)(5) of the Immigration and Nationality Act for at least one year and who entered the United States before August 22, 1996, or is a person paroled under Section 212(d)(5) for at least one year and who entered the United States on or after August 22, 1996 and has resided in the United States for five years.

e. Is a conditional entrant under Section 203(a)(7) or meets the Veteran or active duty exceptions of the Immigration and Nationality Act.

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 14-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

June 24, 2014

Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: Theresa Eagleson

RE: TN IL-14-0013

Dear Ms. Hamos:

Enclosed for your records is an approved copy of Illinois’ Alternative Benefit Plan (ABP) state plan amendment TN 14-0013: Medicaid Alternative Benefit Plan. This ABP, which was submitted on March 27, 2014, meets all federal statutory and regulatory requirements for establishing an ABP.

All requirements pertaining to ABPs must be met including, but not limited to: benefits, payment rates, reimbursement methodologies, cost-sharing state plan pages, and (if applicable) managed care service delivery systems (waivers and contracts). Amendments to the state’s approved Medicaid program (SPAs, waivers, contracts) may require corresponding amendments to the ABP if the changes to the benefit in the approved State plan will be mirrored in the ABP.

This ABP SPA is approved effective January 1, 2014, as requested by the state.

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Jaime Ursch, HFS

Pat Curtis, HFS

Jacquetta Ellinger, HFS

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Illinois Transmittal Number: IL-14-0013

Proposed Effective Date: 1/1//2014

Federal Statute/Regulation Citation: Social Security Act 1937; 42 CFR Part 440 Federal Budget Impact Federal Fiscal Year Amount First Year 2014

$ 0

Second Year 2015

$ 0

Subject of Amendment: This amendment establishes the Alternative Benefit Plan for ACA Adults in Illinois. Governor's Office Review Governor's office reported no comment  Comments of Governor's office received  No reply received within 45 days of submittal  Other, as specified The Governor has authorized the director of Healthcare and Family Services to act as his designee to review, approve and submit state plan amendments under Title XIX of the Social Security Act. The director has reviewed this submission and has no comments. Signature of State Agency Official  Submitted By: Gabriela Moroney  Submit Date:

Mar 27, 2014

DATE RECEIVED: 3/27/14 DATE APPROVED:

6/24/14 PLAN APPROVED – ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL:

1/1/14 SIGNATURE OF REGIONAL OFFICIAL:

/s/ TYPED NAME Verlon Johnson TITLE Associate Regional Administrator

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Alternative Benefit Plan Populations ABP1 Identify and define the population that will participate in the Alternative Benefit Plan. Alternative Benefit Plan Population Name: ACA Adult Group Identify eligibility groups that are included in the Alternative Benefit Plan's population, and which may contain individuals that meet any targeting criteria used to further define the population. Eligibility Groups Included in the Alternative Benefit Plan Population: Eligibility Group: Enrollment is mandatory or voluntary? + Adult Group Mandatory x Enrollment is available for all individuals in these eligibility group(s). Yes Geographic Area The Alternative Benefit Plan population will include individuals from the entire state/territory. Yes Any other information the state/territory wishes to provide about the population (optional) PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Voluntary Benefit Package Selection Assurances - Eligibility Group under Section 1902(a)(10)(A) (i)(VIII) of the Act ABP2a The state/territory has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements. Therefore the state/territory is deemed to have met the requirements for voluntary choice of benefit package for individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan. Yes Explain how the state has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements. The State has compared the services covered by its Medicaid state plan with the services covered by its selected base benchmark plan. Services covered by base benchmark but not the Medicaid state plan were excluded from the ABP through the appropriate substitution process. Specific details are captured in ABP 5. 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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 2 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package ABP3 Select one of the following: The state/territory is amending one existing benefit package for the population defined in Section 1. The state/territory is creating a single new benefit package for the population defined in Section 1. Name of benefit package: ACA Adult Alternative Benefit Plan Selection of the Section 1937 Coverage Option The state/territory selects as its Section 1937 Coverage option the following type of Benchmark Benefit Package or Benchmark- Equivalent Benefit Package under this Alternative Benefit Plan (check one): Benchmark Benefit Package. Benchmark-Equivalent Benefit Package. The state/territory will provide the following Benchmark Benefit Package (check one that applies): The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP). State employee coverage that is offered and generally available to state employees (State Employee Coverage): A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (Commercial HMO): Secretary-Approved Coverage. The state/territory offers benefits based on the approved state plan. The state/territory offers an array of benefits from the section 1937 coverage option and/or base benchmark plan benefit packages, or the approved state plan, or from a combination of these benefit packages. The state/territory offers the benefits provided in the approved state plan. Benefits include all those provided in the approved state plan plus additional benefits. Benefits are the same as provided in the approved state plan but in a different amount, duration and/or scope. The state/territory offers only a partial list of benefits provided in the approved state plan. The state/territory offers a partial list of benefits provided in the approved state plan plus additional benefits. Please briefly identify the benefits, the source of benefits and any limitations: Illinois is including all of the benefits from the approved state plan and no additional benefits. Selection of Base Benchmark Plan TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 2 of 2 Alternative Benefit Plan The state/territory must select a Base Benchmark Plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package. The Base Benchmark Plan is the same as the Section 1937 Coverage option. No Indicate which Benchmark Plan described at 45 CFR 156.100(a) the state/territory will use as its Base Benchmark Plan: Largest plan by enrollment of the three largest small group insurance products in the state's small group market. Any of the largest three state employee health benefit plans by enrollment. Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment. Largest insured commercial non-Medicaid HMO. Plan name: Blue Cross Blue Shield BlueAdvantage Entrepreneur Other Information Related to Selection of the Section 1937 Coverage Option and the Base Benchmark Plan (optional): The state assures that all services in the base benchmark have been accounted for throughout the benefit chart found in ABP5.

The state assures the accuracy of all information in ABP5 depicting amount, duration and scope parameters of services authorized in the currently approved Medicaid state plan. 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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Alternative Benefit Plan Cost-Sharing ABP4 Any cost sharing described in Attachment 4.18-A applies to the Alternative Benefit Plan. ✔ Attachment 4.18-A may be revised to include cost sharing for ABP services that are not otherwise described in the state plan. Any such cost sharing must comply with Section 1916 of the Social Security Act. The Alternative Benefit Plan for individuals with income over 100% FPL includes cost-sharing other than that described in Attachment 4.18-A. No Other Information Related to Cost Sharing Requirements (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 41 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Benefits Description ABP5 The state/territory proposes a “Benchmark-Equivalent” benefit package. No Benefits Included in Alternative Benefit Plan Enter the specific name of the base benchmark plan selected: BlueCross BlueShield of Illinois BlueAdvantage Entrepreneur PPO Enter the specific name of the section 1937 coverage option selected, if other than Secretary-Approved. Otherwise, enter “Secretary-Approved.” Secretary-Approved. TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 2 of 41 Alternative Benefit Plan Essential Health Benefit 1: Ambulatory patient services ■ Collapse All Benefit Provided: Outpatient hospital services Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 2a from state plan. Prior authorization is required for a limited array of devices and practitioner administered drugs. Remove Benefit Provided: Family planning services and supplies Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 4c from state plan. Remove Benefit Provided: Physician services Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: See below Duration Limit: See below Scope Limit: See below TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 3 of 41 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Items 5a and 5b from state plan; includes medical and surgical services furnished by a dentist. Authorization requirements and limits apply in certain circumstances: -Prior approval is required for surgeries for morbid obesity. -Group psychotherapy services rendered by a physician are subject to program integrity controls. Remove Benefit Provided: Podiatrists' services Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Services are limited to those with diabetes. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 6a from state plan.

For clients 21 years of age and older, podiatric services are limited to those diagnosed with diabetes.

Covered services are limited to those provided by Podiatrist meeting the requirements of 42 CFR 440.60.

Certain services and unusual procedures require prior approval.

Limits on services or treatments are not applicable to EPSDT (Healthy Kids) clients. All services or treatments, which are medically necessary to correct or lessen health problems detected or suspected by the screening process, must be provided to individuals under age 21.

Remove Benefit Provided: Home health - intermittent or part time nursing Source: State Plan 1905(a) Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 4 of 41 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 7a from state plan: intermittent or part-time nursing services provided by a home health agency or by a registered nurse when no home health agency exists in the area. Prior authorization is required with the following exceptions: -Visits within a 60 calendar day period immediately following inpatient discharge from an acute care or rehabilitation hospital. -The client is eligible for these services under Medicare. Remove Benefit Provided: Home health - home health aide by agency Source: State Plan 1905(a) Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 7b from state plan: home health aide services provided by a home health agency. Prior authorization is required with the following exceptions: -Visits within a 60 calendar day period immediately following inpatient discharge from an acute care or rehabilitation hospital -The client is eligible for these services under Medicare. Remove Benefit Provided: Diagnostic services Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 13a from state plan. Remove Benefit Provided: Hospice services Source: State Plan 1905(a) TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 5 of 41 Alternative Benefit Plan Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Limited to services related to terminal illness. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 18 from state plan. Requires notice of election from provider. For individuals whose illness is deemed terminal with a life expectancy of six months or less. Individuals age 19 and 20 may receive concurrent treatment while also receiving hospice services. Remove Benefit Provided: Pediatric or family NP services Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 23 from state plan. Remove Benefit Provided: Advance practice nurse services Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 25 from Appendix to Attachment 3.1. Advance practice nurses include: certified registered nurse anesthetist; certified nurse midwife; certified nurse practitioner; and clinical nurse specialist. Remove TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 6 of 41 Alternative Benefit Plan Benefit Provided: Dental services Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Scope limits are described below. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 10 from state plan.

Dental services are categorized below and comport with 42 CFR 440.100. Procedures covered under each category and prior approval or emergency post approval provisions are specified in the Department’s Dental Office Reference Manual or Provider Notices.

All services or treatment that are medically necessary to correct or lessen health problems detected or suspected by the Early and Periodic Screening, Diagnosis and Treatment program will be provided to individuals younger than age 21.

Limitations on dental service for individuals younger than age 21: ● Coverage of orthodontia is limited to case which present a severe handicapping malocclusion or a handicapping dentofacial deformity. All orthodontia requires prior approval. ● Experimental dental services are not covered. ● Dental services performed only for cosmetic reasons are not covered. Adults Residing in ICF/ID Facilities: ● Initial oral exams ● Oral Surgery ● Radiographs ● Anterior Endodontics ● Prophylaxis ● Complete Dentures ● Restorative ● Denture relining or repair ● Periodontics ● Adjunctive general services

All Other Adults – Services are limited to: ● Extractions medically necessary to treat emergency dental conditions of pain, infection, swelling, uncontrolled bleeding, or traumatic injury. Covered services related to the extraction include: initial oral exams, radiographs, sedation and, if necessary oral surgery; and ● Dental services that are medically necessary as a prerequisite for necessary medical care.

Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 7 of 41 Alternative Benefit Plan Essential Health Benefit 2: Emergency services ■ Collapse All Benefit Provided: Emergency hospital services (outpatient hospital) Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 24e from state plan. Remove Benefit Provided: Other medical care - transportation Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 24a in state plan.

Ambulance Service: Requires prior approval except in case of emergency, or transfer from one hospital to another hospital for admission .

Medicar, service car, taxi, private auto: Requires prior approval .

Other (bus, train, airplane, etc.): Requires prior approval.

Limits on services or treatments are not applicable to EPSDT (Healthy Kids) clients. All services or treatments, which are medically necessary to correct or lessen health problems detected or suspected by the screening process, must be provided to individuals under age 21. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 8 of 41 Alternative Benefit Plan Essential Health Benefit 3: Hospitalization ■ Collapse All Benefit Provided: Inpatient hospital services Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 1 from state plan. Certain services require authorization: -Beginning in February 2014, all elective back and coronary artery bypass grafting surgeries will require prior approval. -Specific admitting diagnosis codes require concurrent review upon admission. Remove Benefit Provided: Physician services: inpatient Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Items 5a and 5b from state plan. Note that prior approval is required for surgeries for morbid obesity. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 9 of 41 Alternative Benefit Plan Essential Health Benefit 4: Maternity and newborn care ■ Collapse All Benefit Provided: Pregnancy-related and post partum services Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 20a from state plan. Includes pregnancy-related and postpartum services for a 60-day period after the pregnancy ends and any remaining days in the month in which the 60th day falls. Remove Benefit Provided: Inpatient hospital services: Maternity Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 1 from state plan. Remove Benefit Provided: Physician services: Maternity Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 10 of 41 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Items 5a and 5b from state plan. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 11 of 41 Alternative Benefit Plan Essential Health Benefit 5: Mental health and substance use disorder services including behavioral health treatment ■ Collapse All Benefit Provided: Clinic services - Community mental health services Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Services are limited to: assessment; treatment plan development and modification; psychotropic medication monitoring and training; crisis intervention; psychiatric therapy; and day treatment. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 9 from state plan. Remove Benefit Provided: Rehabilitative services - ETOH/substance abuse Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Services are limited to: outpatient services (Level I); intensive outpatient (Level II); day treatment (Level III); medically monitored outpatient detoxification (Level III); psychiatric diagnostic service. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 13d from state plan. Remove Benefit Provided: Inpatient hospital services: MH/SU Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: Certain limits apply, see below. Duration Limit: Certain limits apply, see below. TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 12 of 41 Alternative Benefit Plan Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 1 from state plan. Inpatient detoxification limited to once every 60 days. Excludes services provided in an institution for mental disease. Remove Benefit Provided: Physician services: MH/SU Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Items 5a and 5 b from state plan. Group psychotherapy services rendered by a physician are subject to program integrity controls. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 13 of 41 Alternative Benefit Plan Essential Health Benefit 6: Prescription drugs ■ Benefit Provided: Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. Prescription Drug Limits (Check all that apply.): Limit on days supply Limit on number of prescriptions Limit on brand drugs Other coverage limits Preferred drug list Authorization: Yes Provider Qualifications: State licensed Coverage that exceeds the minimum requirements or other: The State of Illinois’s ABP prescription drug benefit plan is the same as under the approved Medicaid state plan for prescribed drugs. The Department may require prior authorization for the reimbursement of any covered outpatient drugs TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 14 of 41 Alternative Benefit Plan Essential Health Benefit 7: Rehabilitative and habilitative services and devices ■ Collapse All Benefit Provided: Skilled nursing facilities for persons age 21+ Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 4a from state plan. This entry represents short term nursing facility care for rehabilitation. The same item is captured under "other 1937 covered benefits" for the purposes of long-term custodial care. A preadmission screening assessment is required. Remove Benefit Provided: Physical therapy - rehabilitation & habilitation Source: State Plan 1905(a) Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: 20 visits Duration Limit: per year Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 11a from state plan.

Services are prescribed by a physician and provided by a qualified physical therapist as defined in 42 CFR 440.110(a). Prior approval is required for the provision of services by an independent physical therapist or by a community health agency, unless client is under the age of 21 or eligible for these benefits under Medicare. Physical therapy visits are limited to 20 per state fiscal year.

All services or treatments, which are medically necessary to correct or lessen health problems detected or suspected by the screening process, must be provided to individuals under age 21. Remove Benefit Provided: Occupational therapy - rehab & habilitation Source: State Plan 1905(a) Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 15 of 41 Alternative Benefit Plan Amount Limit: 20 visits Duration Limit: per year Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 11b from state plan.

Services are prescribed by a physician and provided by a qualified occupational therapist as defined in 42 CFR 440.110(b). Prior approval is required for the provision of services by an independent occupational therapist or by a community health agency, unless client is under the age of 21 or eligible for these benefits under Medicare. Occupational therapy visits are limited to 20 per state fiscal year.

All services or treatments, which are medically necessary to correct or lessen health problems detected or suspected by the screening process, must be provided to individuals under age 21. Remove Benefit Provided: Speech, hearing & language therapy - rehab & hab Source: State Plan 1905(a) Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: 20 visits Duration Limit: per year Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 11c from state plan.

Services are referred by a physician and provided by a speech pathologist or audiologist as defined 42 CFR 440.110(c). Prior approval is required for the provision of services by an independent speech/language therapist or by a community health agency, unless client is under the age of 21 or eligible for these benefits under Medicare. Speech, hearing and language therapy visits are limited to 20 per state fiscal year.

All services or treatments, which are medically necessary to correct or lessen health problems detected or suspected by the screening process, must be provided to individuals under age 21. Remove Benefit Provided: Home health - med supplies, equipment, appliances Source: State Plan 1905(a) Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 16 of 41 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 7c from state plan. Medical supplies, equipment, and appliances suitable for use in the home. Reimbursement for standard medical equipment/supplies are included in all-inclusive per visit rate. Includes coverage for hearing aids. Remove Benefit Provided: Eyeglasses and other optical materials Source: State Plan 1905(a) Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: 1 pair every two years Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 12d from state plan. Prior approval is required for the following: Contact lens/lenses and related service; custom-made artificial eye; low vision devices; polycarbonate eyeglass lenses for adults, age 21 and over; eyeglasses fabricated by suppliers other than the Illinois Department of Corrections; service/ materials not otherwise identified on the schedule of procedures for optical services and supplies. Remove Benefit Provided: Home health - PT/OT/ST by agency or rehab Source: State Plan 1905(a) Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: 20 visits Duration Limit: per year Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 7d from state plan. Physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility. Remove TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 17 of 41 Alternative Benefit Plan Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 18 of 41 Alternative Benefit Plan Essential Health Benefit 8: Laboratory services ■ Collapse All Benefit Provided: Other laboratory and x-ray services Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Radiological and X-ray services are covered when essential for the diagnosis and treatment of disease or injury. Laboratory tests and examinations, which are essential for diagnosis and evaluation of treatment, are covered.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Item 3 from state plan. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 19 of 41 Alternative Benefit Plan Essential Health Benefit 9: Preventive and wellness services and chronic disease management ■ Collapse All The state/territory must provide, at a minimum, a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA’s Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). Benefit Provided: Source: State Plan 1905(a) Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 20 of 41 Alternative Benefit Plan Essential Health Benefit 10: Pediatric services including oral and vision care ■ Collapse All Benefit Provided: Medicaid State Plan EPSDT Benefits Source: State Plan 1905(a) Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: All EPSDT services are covered for members under the age of 21 years. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 21 of 41 Alternative Benefit Plan Other Covered Benefits from Base Benchmark Collapse All TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 22 of 41 Alternative Benefit Plan Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All Base Benchmark Benefit that was Substituted: Primary care visit to treat an injury or illness. Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Physician services." Remove Base Benchmark Benefit that was Substituted: Specialist visit Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Physician services." Remove Base Benchmark Benefit that was Substituted: Other practitioner visit Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Advance Practice Nurse Services" and "Pediatric or family nurse practitioners' services." Remove Base Benchmark Benefit that was Substituted: Outpatient facility fee (e.g., ambulatory surgery) Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Outpatient hospital services." Remove Base Benchmark Benefit that was Substituted: Outpatient surgery physician/surgical services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Physician services." Remove Base Benchmark Benefit that was Substituted: Hospice services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Hospice services." Remove TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 23 of 41 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Infertility treatment Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with EHB 1 "Dental services." Remove Base Benchmark Benefit that was Substituted: Private duty nursing Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with EHB 1 "Dental services." Remove Base Benchmark Benefit that was Substituted: Urgent care centers or facilities Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Outpatient hospital services."" Remove Base Benchmark Benefit that was Substituted: Home health care services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Home health - intermittent or part time nursing services" and "Home Health - home health aide by agency" and EHB 7 "Home health - med supplies, equipment, appliances," and Home health - PT/OT/ST by agency or rehab." Remove Base Benchmark Benefit that was Substituted: Emergency room services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 2 "Emergency hospital services (outpatient hospital)." Remove Base Benchmark Benefit that was Substituted: Emergency transportation/ambulance Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 2 "Other medical care - transportation." Remove TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 24 of 41 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Inpatient hospital services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 3 "Inpatient hospital services." Remove Base Benchmark Benefit that was Substituted: Inpatient physician and surgical services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 3 "Physician services." Remove Base Benchmark Benefit that was Substituted: Bariatric surgery Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 3 "Physician services" and "Inpatient hospital services." Remove Base Benchmark Benefit that was Substituted: Cosmetic surgery for correction of deformities Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 3 "Physician services" and "Inpatient hospital services," which include reconstructive surgery for accidents and to correct deformities. Remove Base Benchmark Benefit that was Substituted: Skilled nursing facility Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 7 "Skilled nursing facilities for persons age 21 and older." Remove Base Benchmark Benefit that was Substituted: Prenatal and post natal care Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 4 "Pregnancy-related and post partum services." Remove TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 25 of 41 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Delivery & inpatient services for maternity care Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 4 "Inpatient hospital services" and "Physician services." Remove Base Benchmark Benefit that was Substituted: Mental /behavioral health outpatient services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 5 "Clinic services - Community mental health services." Remove Base Benchmark Benefit that was Substituted: Mental/behavioral health inpatient services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 5 "Inpatient hospital services" and "Physician services." Remove Base Benchmark Benefit that was Substituted: Substance abuse disorder outpatient services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 5 Rehabilitative services - Alcohol (ETOH) and substance abuse services. Remove Base Benchmark Benefit that was Substituted: Substance abuse disorder inpatient services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 5"Inpatient hospital services" and "Physician services." Remove Base Benchmark Benefit that was Substituted: Chiropractic care Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with EHB 7: Eyeglasses and other optical materials. Remove TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 26 of 41 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Durable medical equipment Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 7 "Home health - med supplies, equipment, and appliances." Remove Base Benchmark Benefit that was Substituted: Hearing aids - bone anchored only Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB7 "Home Health - med supplies, equipment, appliances." Remove Base Benchmark Benefit that was Substituted: Diagnostic test (x-ray and lab work) Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Diagnostic services" and EHB 8 "other laboratory and x-ray services." Remove Base Benchmark Benefit that was Substituted: Imaging Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Diagnostic services" and EHB 8 "other laboratory and x-ray services." Remove Base Benchmark Benefit that was Substituted: Routine foot care for individuals with diabetes Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Podiatrists' services." Remove Base Benchmark Benefit that was Substituted: Additional surgical opinion Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Physician services." Remove TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 27 of 41 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Human organ transplants Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 3 "Inpatient hospital services" and "Physician services." Base benchmark will provide benefits only for cornea, kidney, bone marrow, heart valve, muscular-skeletal, parathyroid, heart, lung, heart/lung, liver, pancreas, or pancreas/kidney human organ or tissue transplants. ABP will provide benefits for bone marrow, stem cell, pediatric small bowel and liver/small bowel, heart, heart/lung, lung (single or double), liver, pancreas, kidney/pancreas and other types of transplant procedures (including those covered by the base benchmark) that a hospital is certified by the Illinois Department of Healthcare and Family Services to perform. Remove Base Benchmark Benefit that was Substituted: Cardiac rehabilitation services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with EHB 7: Eyeglasses and other optical materials. Remove Base Benchmark Benefit that was Substituted: Oral surgery/TMJ Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Physician services" and "Dental services." Remove Base Benchmark Benefit that was Substituted: Nutrition Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 7 "Home health - med supplies, equipment, appliances." Remove Base Benchmark Benefit that was Substituted: Blood and blood components Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Outpatient hospital services," EHB 2 "Emergency hospital services," and EHB 3 "Inpatient hospital services." Remove Base Benchmark Benefit that was Substituted: Chemotherapy and radiation therapy Source: Base Benchmark TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 28 of 41 Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Outpatient hospital services," EHB 3 "Inpatient hospital services," and EHB 6 "Prescription drugs." Remove Base Benchmark Benefit that was Substituted: Emerg med care for criminal sexual assault/abuse Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 2 "Emergency hospital services (outpatient hospital)." Remove Base Benchmark Benefit that was Substituted: End stage renal disease Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates multiple services, including but not limited to: EHB 1 "Outpatient hospital services" and "Physician services"; EHB 3 "Inpatient hospital services" and Physician services: inpatient"; EHB 6 "Prescription drugs"; and EHB 7 "Home health – medical supplies." Remove Base Benchmark Benefit that was Substituted: Physical therapy Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 7 "Physical therapy services." Actuarial variance between uncapped base benchmark benefit and capped EHB 7 benefit is substituted with the state plan hearing aid benefit (see EHB 7 "Home health - med supplies, equipment, appliances"), which is actuarially richer than the limited base benchmark benefit for hearing aids. Remove Base Benchmark Benefit that was Substituted: Occupational therapy Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 7 "Physical therapy services." Actuarial variance between uncapped base benchmark benefit and capped EHB 7 benefit is substituted with the state plan hearing aid benefit (see EHB 7 "Home health - med supplies, equipment, appliances"), which is actuarially richer than the limited base benchmark benefit for hearing aids. Remove Base Benchmark Benefit that was Substituted: Speech therapy Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 7 "Physical therapy services." Actuarial variance between uncapped base benchmark TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 29 of 41 Alternative Benefit Plan benefit and capped EHB 7 benefit is substituted with the state plan hearing aid benefit (see EHB 7 "Home health - med supplies, equipment, appliances"), which is actuarially richer than the limited base benchmark benefit for hearing aids. Remove Base Benchmark Benefit that was Substituted: Detoxification Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 5 "Rehabilitative services - ETOH and substance abuse services." Remove Base Benchmark Benefit that was Substituted: Assistant surgeon according to Medicare guidelines Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 3 "Hospitalization (inpatient hospital)." Remove Base Benchmark Benefit that was Substituted: Allergy testing Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Diagnostic services." Remove Base Benchmark Benefit that was Substituted: Generic drugs Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 6 "Prescription drugs." Remove Base Benchmark Benefit that was Substituted: Preferred brand drugs Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 6 "Prescription drugs." Remove Base Benchmark Benefit that was Substituted: Non-preferred brand drugs Source: Base Benchmark TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 30 of 41 Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 6 "Prescription drugs." Remove Base Benchmark Benefit that was Substituted: Specialty drugs Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 6 "Prescription drugs." Remove Base Benchmark Benefit that was Substituted: Habilitation services for children Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 10 "Medicaid state plan EPSDT benefits." Remove Base Benchmark Benefit that was Substituted: Autism spectrum disorders Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 10 "Medicaid state plan EPSDT benefits." Remove Base Benchmark Benefit that was Substituted: Outpatient contraceptive services Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplicates EHB 1 "Family planning services and supplies." Remove Base Benchmark Benefit that was Substituted: Dental accident care Source: Base Benchmark Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with EHB 1 "Dental services." Remove Base Benchmark Benefit that was Substituted: Naprapathic services Source: Base Benchmark TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 31 of 41 Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substituted with EHB 7: Eyeglasses and other optical materials. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 32 of 41 Alternative Benefit Plan Other Base Benchmark Benefits Not Covered Collapse All Base Benchmark Benefit not Included in the Alternative Benefit Plan: Non-emergency care when traveling outside U.S. Source: Base Benchmark Explain why the state/territory chose not to include this benefit: Medicaid regulations do not allow Illinois to make payments to providers outside the US. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 33 of 41 Alternative Benefit Plan Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All Other 1937 Benefit Provided: Skilled nursing facility for persons age 21+ Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 4a from state plan. This entry represents long term custodial care. Same item is noted under EHB 7 - Rehabilitative services. A preadmission screening assessment is required and individuals must meet an institutional level of care. Remove Other 1937 Benefit Provided: Intermediate care facility services Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 15a from state plan. Excludes services in an institution for mental disease. A screening assessment is required prior to admission. Remove Other 1937 Benefit Provided: Services provided in a public institution for MR Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 34 of 41 Alternative Benefit Plan Other: Item 15b from state plan. A screening assessment is required prior to admission. Remove Other 1937 Benefit Provided: Case management services - target group A Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Yes, see description below. Other: Item 19 from state plan. No authorization is required. Case management services for individuals in the community who are receiving mental health services under the rehabilitative or clinic options, including: assessment; planning; advocacy; linkage; monitoring; problem-solving assistance, interagency service coordination, and crisis response management. Remove Other 1937 Benefit Provided: Case management services - target group D Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: 60 days from initial assessment in ED Scope Limit: Yes, see description below. Other: Item 19 under state plan. Case management services for persons between 21 and 65 years of age with chronic mental illness. Services are also targeted geographically. Eligibility and services are defined in Illinois Medicaid State Plan, Supplement to Attachment 3.1-A, Page 7 and following. Remove Other 1937 Benefit Provided: Rural health clinic Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: 1 encounter of each type per day Duration Limit: None TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 35 of 41 Alternative Benefit Plan Scope Limit: None Other: Item 2b from state plan. No authorization is required. Limited to 1 medical encounter, 1 dental encounter & 1 behavioral health encounter per day. Remove Other 1937 Benefit Provided: Federally qualified health center Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: 1 encounter of each type per day Duration Limit: None Scope Limit: None Other: Item 2c from state plan. No authorization is required. Limited to 1 medical encounter, 1 dental encounter & 1 behavioral health encounter per day. Remove Other 1937 Benefit Provided: Medical conditions that complicate pregnancy Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 20b from state plan. No authorization is required. Covers services for any other medical conditions that may complicate pregnancy. Remove Other 1937 Benefit Provided: Free-standing birth center services Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 36 of 41 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: No authorization is required. Remove Other 1937 Benefit Provided: Tobacco cessation for pregnant women Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: See below. Duration Limit: See below. Scope Limit: See below. Other: No authorization is required. Includes four (4) individual face-to-face counseling sessions per quit attempt, with a maximum of three (3) quit attempts per calendar year. Remove Other 1937 Benefit Provided: Nurse-midwife services Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 17 from state plan. Remove Other 1937 Benefit Provided: Prosthetic devices Source: Section 1937 Coverage Option Benchmark Benefit Package TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 37 of 41 Alternative Benefit Plan Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 12c from state plan. Prior approval for purchase, repair and replacement is required (unless the recipient is eligible for Medicare and the item is covered under the Medicare Program); or -the cost of repairs does not exceed 75% of the purchase price, or -the item is being loaned while the recipient's own item is being repaired or replaced, or items are replaced within 24 months of the purchase date and all of the following conditions are met: --the item is not under warranty --the item was not faulty at the time of purchase --the original purchase was made by the Department for the same recipient or for whom the replacement is needed --the original item is either not repairable or the cost of repairs is more than or equal to the replacement; and --the replacement item is new and of equal value to the original item. Remove Other 1937 Benefit Provided: Mental health rehab services - assessment Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 13d from state plan. Authorization is not required. Remove Other 1937 Benefit Provided: Mental health rehab - treatment plan development Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 38 of 41 Alternative Benefit Plan Scope Limit: None Other: Item 13d from state plan. Authorization is not required. Remove Other 1937 Benefit Provided: Mental health rehab - psychiatric treatment Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: See below Other: Item 13d from state plan. Authorization is not required. Includes psychotherapy/counseling and psychotropic medication management. Remove Other 1937 Benefit Provided: Mental health rehab services- crisis intervention Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 13d from state plan. Authorization is not required. Remove Other 1937 Benefit Provided: Mental health rehab - psychosocial rehabilitation Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 39 of 41 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 13d from state plan. Authorization is not required. Remove Other 1937 Benefit Provided: Mental health rehab - community support Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 13d from state plan. Authorization is not required. Remove Other 1937 Benefit Provided: Mental health rehab-assertive community treatment Source: Section 1937 Coverage Option Benchmark Benefit Package Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other: Item 13d from state plan. Authorization is not required. Remove Other 1937 Benefit Provided: Mental health rehab - comprehensive rehab services Source: Section 1937 Coverage Option Benchmark Benefit Package TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 40 of 41 Alternative Benefit Plan Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: See below Other: An array of mental health rehabilitation services included in ABP5 "Other Covered Benefits that are not Essential Health Benefits" except assertive community treatment provided on an encounter basis to an eligible enrollee under 21 who is in a state-approved living arrangement that is not an IMD; does not cover room and board. Remove Add TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 41 of 41 Alternative Benefit Plan Additional Covered Benefits (This category of benefits is not applicable to the adult group under section 1902(a)(10)(A)(i)(VIII) of the Act.) Collapse All 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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 2 Alternative Benefit Plan Attachment 3.1-L- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Benefits Assurances ABP7 EPSDT Assurances If the target population includes persons under 21, please complete the following assurances regarding EPSDT. Otherwise, skip to the Prescription Drug Coverage Assurances below. The alternative benefit plan includes beneficiaries under 21 years of age. Yes The state/territory assures that the notice to an individual includes a description of the method for ensuring access to EPSDT services (42 CFR 440.345). ✔ The state/territory assures EPSDT services will be provided to individuals under 21 years of age who are covered under the state/ territory plan under section 1902(a)(10)(A) of the Act. ✔ Indicate whether EPSDT services will be provided only through an Alternative Benefit Plan or whether the state/territory will provide additional benefits to ensure EPSDT services: Through an Alternative Benefit Plan. Through an Alternative Benefit Plan with additional benefits to ensure EPSDT services as defined in 1905(r). Other Information regarding how ESPDT benefits will be provided to participants under 21 years of age (optional): Prescription Drug Coverage Assurances The state/territory assures that it meets the minimum requirements for prescription drug coverage in section 1937 of the Act and implementing regulations at 42 CFR 440.347. Coverage is at least the greater of one drug in each United States Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. ✔ The state/territory assures that procedures are in place to allow a beneficiary to request and gain access to clinically appropriate prescription drugs when not covered. ✔ The state/territory assures that when it pays for outpatient prescription drugs covered under an Alternative Benefit Plan, it meets the requirements of section 1927 of the Act and implementing regulations at 42 CFR 440.345, except for those requirements that are directly contrary to amount, duration and scope of coverage permitted under section 1937 of the Act. ✔ The state/territory assures that when conducting prior authorization of prescription drugs under an Alternative Benefit Plan, it complies with prior authorization program requirements in section 1927(d)(5) of the Act. ✔ Other Benefit Assurances The state/territory assures that substituted benefits are actuarially equivalent to the benefits they replaced from the base benchmark plan, and that the state/territory has actuarial certification for substituted benefits available for CMS inspection if requested by CMS. ✔ The state/territory assures that individuals will have access to services in Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) as defined in subparagraphs (B) and (C) of section 1905(a)(2) of the Social Security Act. ✔ The state/territory assures that payment for RHC and FQHC services is made in accordance with the requirements of section 1902(bb) of the Social Security Act. ✔ TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 2 of 2 Alternative Benefit Plan The state/territory assures that it will comply with the requirement of section 1937(b)(5) of the Act by providing, effective January 1, 2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section 1302(b) of the Patient Protection and Affordable Care Act. ✔ The state/territory assures that it will comply with the mental health and substance use disorder parity requirements of section 1937(b)(6) of the Act by ensuring that the financial requirements and treatment limitations applicable to mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan. ✔ The state/territory assures that it will comply with section 1937(b)(7) of the Act by ensuring that benefits provided to Alternative Benefit Plan participants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section. ✔ The state/territory assures transportation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431.53. ✔ The state/territory assures, in accordance with 45 CFR 156.115(a)(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). ✔ 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 5 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.20131219 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 2 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Service Delivery Systems ABP8 Provide detail on the type of delivery system(s) the state/territory will use for the Alternative Benefit Plan's benchmark benefit package or benchmark-equivalent benefit package, including any variation by the participants' geographic area. Type of service delivery system(s) the state/territory will use for this Alternative Benefit Plan(s). Select one or more service delivery systems: Managed care. Managed Care Organizations (MCO). Prepaid Inpatient Health Plans (PIHP). Prepaid Ambulatory Health Plans (PAHP). Primary Care Case Management (PCCM). Fee-for-service. Other service delivery system. Managed Care Options Managed Care Assurance The state/territory certifies that it will comply with all applicable Medicaid laws and regulations, including but not limited to sections 1903(m), 1905(t), and 1932 of the Act and 42 CFR Part 438, in providing managed care services through this Alternative Benefit Plan. This includes the requirement for CMS approval of contracts and rates pursuant to 42 CFR 438.6. ✔ Managed Care Implementation Please describe the implementation plan for the Alternative Benefit Plan under managed care including member, stakeholder, and provider outreach efforts. Illinois is requiring ACA adults to enroll in Illinois Health Connect with the exception of those in Cook County (where Illinois' early Medicaid expansion, via waiver, to ACA adults offers a robust care coordination option). Illinois Health Connect is the already- established primary care case management program in Illinois. Upon determination of Medicaid eligibility as an ACA adult, enrollees are notified by mail of Illinois Health Connect and receive an enrollment packet that enables enrollees to select a primary provider. PCCM: Primary Care Case Management The PCCM delivery system is the same as an already approved PCCM program. Yes The PCCM program is operating under (select one): Section 1915(b) managed care waiver. Section 1932(a) mandatory managed care state plan amendment. Section 1115 demonstration. Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment. Identify the date the managed care program was approved by CMS: Dec 27, 2013 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 2 of 2 Alternative Benefit Plan Describe program below: Illinois' Primary Care Case Management (PCCM) program, called Illinois Health Connect (IHC), is a statewide program available to Medicaid enrollees. People who are enrolled in IHC have a "medical home" through a Primary Care Provider (PCP). IHC is based on the American Academy of Pediatrics' initiative to create medical homes to make sure that primary and preventive healthcare is provided in the most appropriate setting.

Potential enrollees choose a PCP, who will coordinate and manage their care. Illinois Health Connect enrollees must see their Illinois Health Connect PCP first for most of their primary healthcare. If they want to see a different Illinois Health Connect PCP, they will need a referral from their PCP. Referrals will be registered with Illinois Health Connect. Additional Information: PCCM (Optional) Provide any additional details regarding this service delivery system (optional): Fee-For-Service Options Indicate whether the state/territory offers traditional fee-for-service and/or services managed under an administrative services organization: Traditional state-managed fee-for-service Services managed under an administrative services organization (ASO) arrangement Please describe this fee-for-service delivery system, including any bundled payment arrangements, pay for performance, fee-for- service care management models/non-risk, contractual incentives as well as the population served via this delivery system. The fee-for-service delivery system for the Alternative Benefit Plan is the same system described in Illinois' approved Medicaid State Plan. Additional Information: Fee-For-Service (Optional) Provide any additional details regarding this service delivery system (optional): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Employer Sponsored Insurance and Payment of Premiums ABP9 The state/territory provides the Alternative Benefit Plan through the payment of employer sponsored insurance for participants with such coverage, with additional benefits and services provided through a Benchmark or Benchmark-Equivalent Benefit Package. Yes Provide a description of employer sponsored insurance, including the population covered, the amount of premium assistance by population, employer sponsored insurance activities including required contribution, cost-effectiveness test requirements, and benefit information: Any individual who qualifies for Medicaid and has access to employer sponsored insurance may apply to Illinois' Health Insurance Premium Program. The amount of premium assistance for state fiscal year 2013 (July 1, 2012-June 30, 2013) was $577,810. Illinois' Medicaid state plan requires a cost effectiveness calculation of at least 2.5/1.

The state assures that ESI coverage is established in sections 3.2 and 4.22(h) of the state’s approved Medicaid state plan. The beneficiary will receive a benefit package that includes a wrap of benefits around the employer sponsored insurance plan that equals the benefit package to which the beneficiary is entitled. The beneficiary will not be responsible for payment of premiums or other cost sharing that exceeds nominal levels as established at 42 CFR part 447 subpart A. The state/territory otherwise provides for payment of premiums. No Other Information Regarding Employer Sponsored Insurance or Payment of Premiums: 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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-L- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 General Assurances ABP10 Economy and Efficiency of Plans The state/territory assures that Alternative Benefit Plan coverage is provided in accordance with Federal upper payment limit requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained. ✔ Economy and efficiency will be achieved using the same approach as used for Medicaid state plan services. Yes Compliance with the Law The state/territory will continue to comply with all other provisions of the Social Security Act in the administration of the state/ territory plan under this title. ✔ The state/territory assures that Alternative Benefit Plan benefits designs shall conform to the non-discrimination requirements at 42 CFR 430.2 and 42 CFR 440.347(e). ✔ The state/territory assures that all providers of Alternative Benefit Plan benefits shall meet the provider qualification requirements of the Base Benchmark Plan and/or the Medicaid state plan. ✔ 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 5 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.20131219 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Page 1 of 1 Alternative Benefit Plan Attachment 3.1-C- OMB Control Number: 0938‐1148 OMB Expiration date: 10/31/2014 Payment Methodology ABP11 Alternative Benefit Plans - Payment Methodologies The state/territory provides assurance that, for each benefit provided under an Alternative Benefit Plan that is not provided through managed care, it will use the payment methodology in its approved state plan or hereby submits state plan amendment Attachment 4.19a, 4.19b or 4.19d, as appropriate, describing the payment methodology for the benefit. ✔ An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 TN# 14-0013 IL Approval Date: Effective Date: 1/1/2014 6/24/14

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #:14-0023-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

March 11, 2015

Felicia F. Norwood, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001

ATTN: James Parker

RE: TN IL-14-0023-MM6

Dear Ms. Norwood:

Enclosed for your records is an approved copy of the following State Plan Amendment (SPA).

Transmittal #IL-14-0023-MM6 - Citizenship and Non-citizen Eligibility

-Effective Date: January 1, 2014

If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov.

Sincerely,

/s/

Alan Freund

Acting Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Jamie Ursch, HFS

Kim Pearce, HFS

Pat Curtis, HFS

Jacquetta Ellinger, HFS

State/Territory name: Illinois Submitted By: Jamie Ursch Last Revision Date: Feb 17, 2015 Submit Date: Mar 31, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. 14-0023 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(46)(B); 8 U.S.C. 1611, 1612, 1613, 1641; 1903(v)(2),(3) and (4); 42 CFR 435.4 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Non-Financial Eligibility: Citizenship and Non-Citizen Eligibility Governor's Office Review       Governor's office reported no comment       Comments of Governor's office received Describe:           No reply received within 45 days of submittal       Other, as specified Describe: The Governor has authorized the director of Healthcare and Family Services to act as his designee to review, approve and submit state plan amendments under Title XIX of the Social Security Act. The director has reviewed this submission and has no comments. Signature of State Agency Official g , DATE RECEIVED 03/31/2014 EFFECTIVE DATE OF APPROVED MATERIAL: 01/01/2014 TYPED NAME Alan Freund

PLAN APPROVED - ONE COPY ATTACHED DATE APPROVED: 03/11/15 SIGNATURE OF REGIONAL OFFICIAL: /s/ TITLE: Acting Associate Regional Administrator

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

TN IL-14-0023-MM6

STATE:

Illinois

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S89 Non-Financial Eligibility- Citizenship and Non- Citizen Eligibility

Attachment 2.6-A: Page 2

Attachment 2.6-A: Page 2a, (Deleted) Attachment 2.6-A, Page 2b, (Deleted) Attachment 2.6-A, Page 2c, (Deleted) Attachment 2.6-A, Page 3 (Deleted) PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

None (New Page)

Attachment 2.6-A: Page 2, TN 09-06 Attachment 2.6-A: Page 2a, TN 09-06 Attachment 2.6-A, Page 2b, TN 09-06 Attachment 2.6-A, Page 2c, TN 09-06 Attachment 2.6-A, Page 3, TN 14-0004 MM5

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ✔ The state provides Medicaid eligibility to otherwise eligible individuals: ■ Who are citizens or nationals of the United States; and

■ Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and ■ Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: The State will begin furnishing benefits on the first day of the month of application containing the declaration of citizenship or immigration status. The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: TN No: IL-14-0023-MM6 Illinois Approval Date: March 11, 2015 Effective Date: January 1, 2014

Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No Pregnant women Individuals under age 21: Individuals under age 21 Individuals under age 20 Individuals under age 19 An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ TN No: IL-14-0023-MM6 Illinois Approval Date: March 11, 2015 Effective Date: January 1, 2014

Page 3 of 3 Medicaid Eligibility 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: IL-14-0023-MM6 Illinois Approval Date: March 11, 2015 Effective Date: January 1, 2014

Attachment 2.6-A

Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois Eligibility Conditions and Requirements

Citation Condition or Requirement

TN# 14-0023 Approval Date: March 11, 2015 Effective Date: 01-01-2014 Supersedes TN # 09-06

b. For the medically needy, meets the non-financial eligibility conditions of 42 CFR Part 435.

c. For financially eligible qualified Medicare Act beneficiaries covered under section 1902(a)(10)(E)(ii) of the Act, meet the non-financial criteria of section 1905(p) of the Act.

d. For financially eligible qualified disabled and working individuals covered under section 1902(a)(10)(E)(ii) of the Act, meets the non-financial criteria of section 1905(s).

1905(p) of the Act 1905(s) of the Act

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 14-0028 This file contains the following documents in the order listed:

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

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

November 7, 2014 Julie Hamos, Director Illinois Department of Healthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand Avenue East Springfield, Illinois 62763-0001 ATTN: Theresa Eagleson RE: TN 14-0028 Dear Ms. Hamos: Enclosed for your records is an approved copy of the following State Plan Amendment (SPA). Transmittal #14-0028 - Approves Illinois’ request to authorize the Chicago Public Schools to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a CPS system school.

--Effective Date: September 1, 2014

If you have any questions, please have a member of your staff contact Cathy Song at

(312) 353-5184 or by email at Catherine.Song!@cms.hhs.gov. Sincerely, /s/_ Mara Siler-Price, acting Verlon Johnson Associate Regional Administrator Division of Medicaid and Children’s Health Operations

Enclosure

cc: Mary Doran, HFS Teresa Hursey, HFS

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTER FOR MEDICARE & MEDICAID SERVICES

TRANSMITTAL AND NOTICE OF APPROVAL

OF STATE PLAN MATERIAL FOR: CENTER FOR MEDICARE AND MEDICAID SERVICES

FORM APPROVED OMB NO. 0938-0193 1. TRANSMITTAL NUMBER, 2. STATE: 14-0028 ILLINOIS

3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act (Madicald)

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

4, PROPOSED EFFECTIVE DATE: September 1, 2014

5. TYPE OF PLAN MATERIAL (Check One)

[ ] NEWSTATEPLAN [ ] AMENDMENT TOBE CONSIDERED AS NEWPLAN [X] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Section 1902 of the Social Security Act

7. FEDERAL BUDGET IMPACT a. FFY 2014 $0.0 b. FFY 2015 $0.0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Appendix to Attachment 3.1-A, Page 13

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

Appendix to Attachment 3.1-A, Page 13

10. SUBJECT OF AMENDMENT: Eyeglass Vendor(s)

11, GOVERNOR'S REVIEW (Check Ona) { } GOVERNOR'S OFFICE REPORTED NO COMMENT [| ] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED { ] NOREPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

{X] OTHER, AS SPECIFIED: Not submitted for raviaw by prior approval.

Julle Hamos

13. TYPED NAME:

16. RETURN TO: Department of Healthcare and Family Services Bureau of Program and Reimbursement Analysis Attn: Mary Doran

201 South Grand Avenue East

14, TE: Psat Se eecee ase Springfield, {L 62763-0001 w.oaTesuamiTteo of /1

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 8/15/14

| 18. DATE APPROVED: 11/7/14

PLAN APPROVED—ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: 9/4/14

20. SIGNATURE OF REGIONAL OFFICIAL: /s/

21. TYPED NAME Mara Siler-Price

22. TMLE: Acting Associate Regional Administrator

23. REMARKS:

FORM CMS-179 (07/92)

Instructions on Back

Appendix to Attachment 3.1-A Page 13

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Illinois

AMOUNT, DURATION, AND SCOPE OF SERVICES

13b.

13c.

© Lenses and frames obtained from a source other than the DOC (Department of Corrections) laboratory or a vendor or vendors procured by the Chicago Public Schools (CPS) to manufacture eyeglasses for individuals enrolled in a school with the CPS system, unless the specific type of eyeglasses or frames is not available from the DOC laboratory or the CPS vendor or vendors, and prior approval is obtained to secure the item from another source.

e Trifocals. e Tinted lenses. e Provider’s transportation cost.

All lenses and frames shall be obtained from the DOC laboratory or a vendor or vendors

procured by the CPS serving individuals enrolled in a school within the CPS system, unless

the particular type of eyeglasses or frames is not available from the DOC laboratory or the CPS vendor or vendors, and prior approval is obtained to secure the item from another source. DOC shall not engage in Ne ae services, e.g., examinations or wari of eyeglasses to recipients.-be eyeglasses—Individual optical suppliers shall conten to provide examinations, frame parts for eyeglasses and frames not available from the DOC laboratory or CPS vendor(s), frame repairs, contact lenses, artificial eyes and low vision devices, as well as dispensing of eyeglasses obtained from the DOC laboratory or CPS vendor(s).

SCREENING

Medically necessary screening and diagnostic tests and procedures, in accordance with generally accepted medical practice, for the prevention or diagnosis of a primary disease, or the prevention of complications of a chronic disease are covered. Screening and diagnostic tests and procedures are provided by or under the direction of a physician.

PREVENTIVE SERVICES

Medically necessary preventive services, in accordance with generally accepted medical practice, to prevent, correct, or lessen health problems are covered. Preventive services are provided by or under the direction of a physician.

TN # 14-0028 Approval date: 11/7/14 Effective date: 09/01/2014

Supersedes TN # 07-13

Table of Contents

State/Territory Name: IL

State Plan Amendment (SPA) #: 14-032

This file contains the following documents in the order listed:

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

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

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

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

Financial Management Group

JAN 18 2016

Felicia Norwood, Director

Illinois Department of Healthcare and Family Services Prescott E Bloom Building

201 South Grand Avenue East

Springfield IL 62763-0002

RE: Illinois State Plan Amendment (SPA) 14-032 Dear Ms. Norwood:

We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 14-032. Effective July 1, 2014, this SPA increases the RUG-IV nursing base per diem from $83.49 to $85.25; implements a per diem add-on to the RUGS methodology of $0.63 for each resident that scores 14200 Alzheimer's Disease or 14800 non-Alzheimer's Dementia and $2.67 for each resident that scores "1" or "2" in any items $1200A and through $12001 and also scores in the RUG groups PA1, PA2, BA1, and BA2; effective 1/1/15 implements a per diem add-on of $5.00 for each resident with TBI; and increases the support component of a nursing facility's rate for facilities licensed under the Nursing Home Care Act or intermediate care facilities by 8.17%.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the regulations at 42 CFR 447 Subpart C. We hereby inform you that Medicaid State plan amendment 14-032 is approved effective July 1, 2014. We are enclosing the CMS-179 and the amended plan pages.

If you have any questions, please contact Fredrick Sebree, of my staff, at (217) 492-4122 or by e-mail at Fredrick.sebree@ems.hhs.gov.

Sincerely,

Kristin Fan Director

Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTER FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL

OF STATE PLAN MATERIAL FOR: CENTER FOR MEDICARE AND MEDICAID SERVICES

2. STATE: ILLINOIS

4. TRANSMITTAL NUMBER, 14-0032

3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act (Medicaid)

TO: REGIONAL ADMINISTRATOR

4, PROPOSED EFFECTIVE DATE:

CENTERS FOR MEOICARE AND MEDICAID SERVICES duly 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One)

L] NEWSTATEPLAN [ ] AMENDMENT TO BE CONSIDERED AS NEW PLAN [X] AMENDMENT

COMPLETE BLOCKS 6 THRU 101F THIS IS AN AMENDMENT (Separate Trangmitis! for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT

a. FFY 2074 $12,600,000 Section 1932{a) of the Social Security Act a FEY 20t4 $12,500.00

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 4.19-D pages 17,18 , 80, 120 and 121

9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (M Appiicabla):

Attachment 4.19-D pages 17,18, 89, and 120

“iO. SUBJECT OF AMENDMENT: Long Term Care facility reimbursement

11, GOVERNOR'S REVIEW (Check Ona}

1] GOVERNOR'S OFFICE REPORTED NO COMMENT

[ ] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

{] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[(X] OTHER, AS SPECIFIED: Not submitted for review by prior approval.

42, SIGNATURE OF OFFICIAL: 16. RETURN TO: rn Deparment of Hodthcar and Family Sovoas of P rsement Anaiys! 13, TYPED NEE: dulie Hamos nie iter Doran mb is 201 South Grand Avenue East 44, TITLE: rector rantySerucosand Springfield, IL 62763-0001 ws.natesuaMnTeO = fn fry FOR REGIONAL OFFICE USE ONLY 17, DATE RECEIVED: | 18. DATE APPROVED:

JAN 1.9 2016

PLAN APPROVED—ONE COPY ATTACHED

19, EFFECTIVE DATE OF APPROVED MATERIAL:

JUL 04 2014 21. TYPED NAME Wvarstial LAM

IF REGIONAL OFFICIAL:

23, REMARKS:

FORM CMS-179 (67/92) Instructions on Back

State: MMinois

Attachment 4.19-D Page 17

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES— REIMBURSEMENT TO LONG TERM CARE FACILITIES

4. Nursing and Program Costs

a.

Effective January 1, 2014. an evidence-based payment methodology will be used for the reimbursement of nursing services. The methodology takes into consideration the needs of individual residents, as assessed and reported by the most current version of the nursing facility Minimum Data Set (MDS), adopted and in use by the federal government.

1

iti.

This Section establishes the method and criteria used to determine the resident reimbursement classification based upon the assessments of residents in nursing facilities. Resident reimbursement classification shall be established utilizing the 48-group, Resource Utilization Groups 1V (RUG-tY) classification scheme and weights as published by the United States Department of Health and Human Services. Centers for Medicare and Medicaid Services (CMS). An Ilinois specific default group is established in subsection (v)(C) of this Section and identified as AA] with an assigned weight equal to the weight assigned to group PAT.

The statewide RUG-IV nursing base per diem rate effective on; A) January 1, 2014, shall be $83.49, B) July 1. 2014, shall be $85.25.

For services provided on or after January 1. 2014:

A) The Department shall compute and pay a facility-specific nursing,

component of the per diem rate as the arithmetic mean of the resident- specific nursing components assigned to Medicaid-enrolled residents on record, as of 30 days prior to the beginning of the rate period, in the Department’s Medicaid Management Information System (MMIS), or any successor system, as present in the facility on the last day of the second quarter preceding the rate period. The RUG-IV nursing component per diem for a nursing facility shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index to be calculated quarterly, and the regional wage adjustor. Transition rates for services provided between January 1. 2014 and December 31. 2014. shall be as fallows:

1). The transition RUG-IV per diem nursing rate for nursing facilities whose rate calculated in this subsection is greater than the nursing component rate in effect July 1. 2012, shall be paid the sum of:

a) ‘The nursing component rate in effect July 1, 2012; plus

b) The difference of the RUG-IV nursing component per diem calculated for the current quarter minus the nursing component rate in clfect July 1, 2012. multiplied by 0.88.

TN# 14-032

Supersedes TN# 14-010

Approval date: 7 JAN 13 9016 Effective date: o7/01/2014

Attachment 4.19-D Page 18

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES— REIMBURSEMENT TO LONG TERM CARE FACILITIES

2) The transition RUG-IV per diom nursing rate for nursing facilities whose rate calculated in this subsection is less than the nursing component rate in cffect July 1, 2012. shall be paid the sum oft

a) The nursing component rate in effect July 1. 2012: plus

b) The difference of the RUG-IV uursing component per diem calculated for the current quarter minus the nursing component rate in effect duly 1. 2012. multiplied by 0.13.

8) Effective for dates of service on or alter July |. 2014, a per diem add-on tn the RUGS methodology will be included as follows:

1) $0.63 for cach resident that scores 14200 Alzheimer's Disease or 14800 non-Alzheimer’s Dementia,

2)_ $2.67 for cach resident that scores “1” or "2" in any items S1200A through $1200] and also scores in the RUG vroups PAL, PA2. BAL and BA2.

CB)The Department shall determine the graup to which resident is assigned using the 48-group RUG-IV classification scheme with an index maximization approach, A resident for whom RUGs resident identification information is missing, or inaccurate, or for whom there is no current MDS record for that quarter, shall be assigned to default group AAT, A resident for whom a MDS assessment does not mect the CMS edit requirements as described in the Long Term Care Resident Assessment Instrument (RAB Users Manual or for whom a MDS assessment has not been submitted timely shall be assigned to default group AAI.

DGE)The assessment used for the purpose of rate calculation shall be identified as an Omnibus Budget Reconciliation Act (OBRA) assessment on the MDS following the guidance in the RAT Manual.

ED)The MDS used for the purpose of rate calculation shall be determined by the Assessment Reference Date (ARD) identified on the MDS assessment.

vi. The Departnent shall provide cach nursing facility with information that identifies the group to which cach resident has been assigned.

TN 14-032 Approvaldate, WAN LS 2016 Effective date: o7/0120%4 Supersedes TIN# 14-010

Attachment 4.19-D Page 80

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Stale: Minois

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES— REIMBURSEMENT TO LONG TERM CARE FACILITIES

O14 d. Tier If reimbursement includes residents who have reached a plateau in rehabilitation ability, but still require services related to the TBI. The payment amount is $486.49 per day and cannot exceed twelve months, This tier includes residents who have reached a plateau in rehabilitation ability, but still require services related to the TBE A resident must score a Level TV-VIT on the Rancho Los Amigos Cognitive Scale, and score the following on the MDS 3.0.

i, C0500: BIMS is less than 13 or CLO00=2 or 3: cognitive skills for decision making are moderately to severely impaired:

ii. 03001 or £1000=1; resident has behaviors. and EQSQ0A-C=1: these behaviors impact resident or EOGO0A-C=1: impact others:

iti, Section G: 3 or more ADL require extensive assistance:

iv. Two or more of the following restoratives: O0500D=1. Bed Mobility, O0500E=1; Transfer, O0500F=1; Walking, 00500G=!: Dressing/Grooming, OOSOOH=E: Rating or OO500= 1: Communication: and

v. O04Q0E2>1: Psychological or OO400F2>1: Recreational Therapy at least two or more days a week.

e. Tier J reimbursement includes acutcly diagnosed residents with high rehabilitation needs. The payment amount is $767.46 per day and cannot exceed nine months, This tier includes residents with an injury resulting ina TBI diagnosis within the prior six months that are acutely diagnosed with high rehabilitation needs. A resident must score a Level [V-VI] on the Rancho Los Amigos Cognitive Scale, and score the following on the MDS 3.0.

i. C0300; counition-MMIS is less than 13 or C1000=2 or 3: cognitive skills for decision making are moderately to severely impaired:

ii. 0400; Rehabilitation Therapy (OT. PT or ST) received at least 500 minutes per week and at least | rehab discipline 5 days a week: and O04OOE2> 1: Psychological ‘Therapy at least 2 days per week.

Effective for services on or after January |. 2015, facilities licensed by the

$5.00 for cach resident scoring ag TBLon the MDS 3.0 but otherwise nat qualifving for Tier 1.2. or 3,

TN# 14.032 Approval date WAN 2S 2UIG Elfective date: o7sot/2014 Supersedes TN# 44-010

State: Minois

Attachment 4.19-D Page 120

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES— REIMBURSEMENT TO LONG TERM CARE FACILITIES

08/08

05/11

O72

07/2

Notwithstanding any other provision of this Section. the socio-development component for facilities that are classified as institutions for mental discases shall equal 6.6% of the facility’s nursing component rate as of January }, 2006, multiplied by a factor of 3.53.

Notwithstanding the provisions set forth for maintaining rates at the levels in effect on January 18. 1994, for services beginning May 1, 2011, facilities that are federally defined as Institutions for Mental Disease (IMD) will have the nursing component of their rate calculated using the MDS methodology, and will also receive an increase to their socio- development component rate. The socio-development component rate increase will be equal to (wo-thirds of the difference between the highest nursing rate among the Medicaid certified IMD facilities and the individual {MD's nursing rate.

Notwithstanding any other provisions of the Section, for dates of service on or after July 1, 2012. the nursing facilities not atherwise designated as ICF/DDs, including skilled nursing facilitics for persons under 22 years of age (SNF/Ped), shall have rates effective May |. 2011. reduced as follows:

1, Individual nursing rate for residents classified as Resource Utilization Groups IV (RUG-TV). PAL. PA2, BAL, and BA, during the quarter ending March 31, 2012. shall be reduced by 10 percent.

2, Individual nursing rates for residents classified in all olher RUG-IV groups shall be reduced by 1.0 percent.

3. Facility rates for support and capital components shall be reduced by 1.7 percent.

4. The portion of the rate or payment paid to a provider that is operated by a unit of lacal government and provides the non-federal share of such services, shall not be further reduced,

Notwithstanding any ather provisions of this Section. for dates of service on or afier July (, 2012, nursing facilitics designated as Institutions for Mental Disease and facilities licensed under the Spevialized Mental Health Rehabilitation Act shall have their nursing, socio-development. capital and support components of their rate effective May t, 2011, reduced in total by 2.7%,

Notwithstanding any other provisions of this Section, for services provided on ar after

duly 1, 2014. the support component of a mursing facility's rate for facilities licensed -

shall be the rate in effect on line 30, 2014, increased by 8.17%.

LAN 13 9N4n.

TN # 14-032

Supersedes TN # 12-020

A Approval date: P/"* aviv Effective date: 07/01/2014

Attachment 4.19-D Page 121

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Illinots

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES-— REIMBURSEMENT TO LONG TERM CARE FACILITIES

0199 «VII. —_— Public Notice Process

01/89 The Department has in place a public process, which complies with the requirements of Section 1902(a)(13){A) of the Social Security Act.

TN@ 14.032 Approvaldate: (GAN 2 2010 Effective date: 07/01/2014

Supersedes ‘TN # New Page

Table of Contents State/Territory Name: IL State Plan Amendment (SPA)#: 14-0035 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519 December 11, 2014 Julie Hamos, Director Illinois Department ofHealthcare and Family Services (HFS) Prescott E. Bloom Building 201 South Grand A venue East Springfield, Illinois 62763-0001 ATTN: James Parker RE: TN 14-0035 Dear Ms. Hamos: - CMS CENTERS FOR MEDICARE & MEDICAID SERVICES Enclosed for your records is an approved copy ofthe following State Plan Amendment (SPA). Transmittal #14-0035 - Approves Illinois' request to remove the 20 visit limit on physical, occupational, and speech therapy services. --Effective Date: October 1, 2014 If you have any questions, please have a member of your staff contact Cathy Song at (312) 353-5184 or by email at Catherine.Song1@cms.hhs.gov. Enclosure cc: Mary Doran, HFS Teresa Hursey, HFS Sara Barger, HFS Sincerely,

Alan Freund Acting Associate Regional Administrator Division of Medicaid and Children's Health Operations

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTER FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTER FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) 1. TRANSMITTAL NUMBER 2. STATE: FORM APPROVED OMB NO. 0938-0193 14-0035 ILLINOIS 3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act (Medicaid) 4. PROPOSED EFFECTIVE DATE: October 1, 2014 [ ) NEW STATE PLAN [ ] AMENDMENT TO BE CONSIDERED AS NEW PLAN [X] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittalfor each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Section 1902 of the Social Security Act 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Appendix to Attachment 3.1-A, Page 9 10. SUBJECT OF AMENDMENT: Therapy Services 11. GOVERNOR'S REVIEW (Check One) [ ] GOVERNOR'S OFFICE REPORTED NO COMMENT [ ] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED ( ] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 7. FEDERAL BUDGET IMPACT a. FFY 2014 $0.0 b. FFY 2015 $0.0 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Appendix to Attachment 3.1-A, Page 9 [X] OTHER, AS SPECIFIED: Not submitted for review by prior approval. 12. SIGNATURE OF 13. TYPED NAME: 14. TITLE: 15. DATE SUBMITTED Director of Health care and Family Services ''1 16. RETURN TO: Department of Healthcare and Family Services Bureau of Program and Reimbursement Analysis Attn: Mary Doran 201 South Grand Avenue East Springfield, IL 62763-0001 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 9/29/14 18. DATE APPROVED: 12/11/14 PLAN APPROVED-ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 10/1/14 21 . TYPED NAME Alan Freund 23. REMARKS: FORM CMS-179 (07/92) 20. SIGNATURE OF REGIONAL OFFICIAL: /s/ 22. TITLE: Acting Associate Regional Administrator Instructions on Back

Appendix to Attachment 3.1-A Page 9 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois AMOUNT, DURATION, AND SCOPE OF SERVICES 11a. PHYSICAL THERAPY ~10/14 Services are prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided by a qualified physical therapist as defined in 42 CFR 440.110(a). lR most eases, ruiim: approval is required for the provision of services by an independent physical therapist or by a community health agency, unless client is under the age of 21 or eligible for these benefits under Medicare. Physieal therapy visits are limitecl to 20 per state fiseal year. All services or treatments, which are medically necessary to correct or lessen health problems detected or suspected by the screening process, must be provided to individuals under age 21. 11 b. OCCUPATIONAL THERAPY ~10/14 Services are prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided by a qualified occupational therapist as defined in 42 CFR 440.110(b). lR most eases, ruiim: approval is required for the provision of services by an independent occupational therapist or by a community health agency, unless client is under the age of21 or eligible for these benefits under Medicare. Oeet:tpatioaal therapy visits are limitecl to 20 per state fiseal year. All services or treatments, which are medically necessary to correct or lessen health problems detected or suspected by the screening process, must be provided to individuals under age 21. 11c. SPEECH, HEARING AND LANGUAGE ~10/14 Services are referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided by a speech pathologist or audiologist as defined 42 CFR 440.11 0( c). lR most eases, mi!m: approval is required for the provision of services by an independent speech pathologist or audiologist or by a community health agency, unless client is under the age of 21 or eligible for these benefits under Medicare. Speeeh, heariag aacllaagt:tage therapy visits are limitecl to 20 per state fiseal year. All services or treatments, which are medically necessary to correct or lessen health problems detected or suspected by the screening process, must be provided to individuals under age 21. TN# 14-0035 Supersedes TN# 12-019 Approval date: 12/11/14 Effective date: 10/01/2014

Table of Contents

State/Territory Name: IL

State Plan Amendment (SPA) #: 14-037

This file contains the following documents in the order listed:

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

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

7500 Security Boulevard, Mail Stop $2-26-12 < M S Baltimore, Maryland 21244-1850

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

Financial Management Group

JAN 13 2016

Felicia Norwood, Director

Illinois Department of Healthcare and Family Services Prescott E Bloom Building

201 South Grand Avenue East

Springfield IL 62763-0002

RE: Illinois State Plan Amendment (SPA) 14-037 Dear Ms. Norwood:

We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 14-037. Effective July 1, 2014, this SPA provides for a per diem rate reimbursement for long-term care facilities serving persons less than 22 years of age with clinically complex residents.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the regulations at 42 CFR 447 Subpart C. We hereby inform you that Medicaid State plan amendment 14-037 is approved effective July 1, 2014. We are enclosing the CMS-179 and the amended plan pages.

If you have any questions, please contact Fredrick Sebree, of my staff, at (217) 492-4122 or by e-mail at Fredrick.sebree@cms.hhs.gov.

Sincerely,

Kristin Fan Director

Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED CENTER FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0193

1. TRANSMITTAL NUMBER | 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL 14-0037 ILLINOIS

OF STATE PLAN MATERIAL

3. PROGRAM IDENTIFICATION: FOR: CENTER FOR MEDICARE AND MEDICAID SERVICES

Title XIX of the Social Security Act (Medicaid)

TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE:

CENTERS FOR MEDICARE AND MEDICAID SERVICES July 1, 2014 DEPARTMENT OF HEALTH AND HUMAN SERVICES .

5. TYPE OF PLAN MATERIAL (Check One)

[ ] NEW STATE PLAN [ ] AMENDMENT TO BE CONSIDERED AS NEW PLAN [X] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT Section 1902 of the Social Security Act a FRY 2044 $275,000 b. FFY 2015 = $1.1 million 8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 4.19-D, Page 88, ¥4 + SGA OR ATTACHMENT (If Applicable):

Attachment 4.19-D, Page 88 and 89

10. SUBJECT OF AMENDMENT: Long Term Care Facilities for Persons under 22 years of age

11, GOVERNOR'S REVIEW (Check One)

{ ] GOVERNOR'S OFFICE REPORTED NO COMMENT

[ ] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

[ ] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[X} OTHER, AS SPECIFIED: Not submitted for review by prior approval.

12, SIGNATURE OF AGENCY OFFICIAL: 16, RETURN TO:

Department of Healthcare and Family Services Bureau of Program and Reimbursement Analysis Attn: Mary Doran . 201 South Grand Avenue East 14, TITLE: Director of Healthcare and . Family Services Springfield, IL 62763-0001

13, TYPED NAME:

15. DATE SUBMITTED

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: | 18. DATE APPROVED: JAN TS 2016 PLAN APPROVED—-ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGN. E OF REGIONAL OFFICIAL: JUL 04 2014

21. TYPED NAME A a ci Ad FA Ww) 22, TITLE: Ty fecky UC

23. REMARKS:

FORM CMS-179 (07/92) Instructions on Back

Attachment 4.19-D Page 88

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES— REIMBURSEMENT TO LONG TERM CARE FACILITIES

04/98 c. The provider must submit a request for exceptional care to DHS/ODD. An authorized DHS/ODD representative will conduct a medical review of the required care and related costs of equipment and supplies. DHS/ODD will compute the exceptional care rate as the licensed staff cost in excess of the licensed staff cost of the standard rate methodology of the medical level 3 add-on plus a related cost factor of 15% for equipment and supplies. The exceptional care rate is the licensed staff time cost in excess of the standard rate methodology at the medical level III amount once a threshold of 150% of the standard rate methodology at the medical level III is met. DHS/ODD clinical staff assesses the medical care plan of each applicant resident to determine the amount of licensed minutes of care needed. The exceptional care staff time, in minutes, which is in excess of the standard rate methodology at the medical level II! is then multiplied by the geographic area licensed wage factor to obtain the exceptional care staff time rate amount. To this exceptional care staff time rate amount is added a related cost factor of 15% as specified in subsection III.C.4.b.ii(D)(1). DHS/ODD will notify the provider of the rate to be paid for the exceptional care services provided.

07/14 12. Long-term care facilities for persons under 22 years of age serving clinically complex residents. ‘

a. Effective for dates of service on or after July 1, 2014, long-term care facilities for persons under 22 years of age serving clinically complex residents, means facilities licensed by the Department of Public Health as a long-term care facility for persons under 22 years of age that serve severely and chronically ill pediatric patients requiring:

i, exceptional care; and ii, have 30% or more of their patients receiving ventilator care.

b._Effective for dates of service on or after July 1, 2014, for purposes of this Section, a

person under 22 years of age, is considered clinically complex if the person requires at least one of the following medical services:

i, Tracheostomy care with dependence on mechanical ventilation for a minimum of six hours each day.

ii, Tracheostomy care requiring suctioning at least every six hours, room air mist or oxygen as needed, and dependence on one of the treatment procedures listed under subsection iv., excluding the procedure listed in subsection iv.(A) of this Section.

iii, Total parenteral nutrition or other intravenous nutritional support and one of the treatment procedures listed under subsection iv. of this Section. -

TN # 14-037 Approval date: / J AN 13 2016 Effective date: 07/01/2014 Supersedes TN # 14-0011

State: Mlinois

Attachment 4.19-D Page 89

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES—

REIMBURSEMENT TO LONG TERM CARE FACILITIES

07/14 —

04/98

04/98

04/98

iv. The following treatment procedures apply to the conditions in subsection ii. and iii, of this Section:

(A) Intermittent suctioning at least every eight hours and room air mist or oxygen as needed.

(B) Continuous intravenous therapy including administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals; or intravenous

pharmaceutical administration of more than one agent via a peripheral or central line, without continuous infusion.

(C) Peritoneal dialysis treatments requiring at least four exchanges every 24 hours.

(D) Tube feeding via nasogastric or gastrostomy tube.

(E) Other medical technologies required continuously, which in the opinion of the attending physician require the services of a professional nurse.

. Reimbursement.

i. Effective July 1. 2014, long-term care facilities for persons under 22 years of age

serving clinically complex residents, shall receive a per diem rate of $304 for clinically complex residents.

ii. Effective July 1, 2014, long-term care facilities for persons under 22 years of age serving clinically complex residents. that have a policy documenting their method of routine assessment of a resident’s potential for being weaned from a ventilator with interventions implemented noted in the resident’s record, shall receive a per diem rate of $669 for clinically complex residents on a ventilator.

Monitoring

DHS/ODD shall provide for a program of delegated utilization review and quality assurance.

DHS/ODD shall review exceptional care residents’ utilization of services at a minimum of every 90 days. A review may be waived by DHS/ODD staff if one or more previous assessments show that a resident’s condition has stabilized. However, two consecutive reviews shall not be waived. DHS/ODD exceptional care staff will maintain contact with the SNF/Ped regarding the resident’s condition during the time period any assessment is waived.

In the event that it is determined that the resident is no longer in need of or receiving exceptional care services, DHS/ODD shall discontinue the exceptional care payment rate for the resident and reduce the rate of payment to the provider to the facility’s standard Medicaid per diem rate, effective the later of either the date of the review or the determination by DHS/ODD. Notice of this action shall be sent to the provider within 30 days.

TN # 14-037

Supersedes TN # 98-03

Approval date. / SAN IT 2019 Effective date: 07/01/2014

Attachment 4.19-D

Page 89A STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES— REIMBURSEMENT TO LONG TERM CARE FACILITIES 04/98 d. Providers shall be reviewed annually to determine whether they do/do not continue to

meet all the criteria to participate in the exceptional care program. If the annual review indicates the facility does not meet the exceptional care criteria or the resident is no longer in need of or receiving exceptional care services, DHS/ODD shall terminate the agreement. Should DHS/ODD terminate the agreement, the exceptional care rate will be reduced to the facility’s standard Medicaid per diem rate. Termination of the agreement shall be effective 30 days after the date of the notice. DHS/ODD will review each formerly approved exceptional care client to determine whether he/she may remain in the facility. For the duration of the time that formerly approved exceptional care clients remain in the facility, the provider must meet the needs of the individual. Should a transfer to another facility be necessary, the provider must contact the responsible case-coordinating agency, which will assist in locating another provider.

at} TN # 14-037 Approval date: fan t3-ong Effective date: 07/01/2014

Supersedes TN # New Page

Table of Contents

State/Territory Name: IL

State Plan Amendment (SPA) #: 15-010

This file contains the following documents in the order listed:

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

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

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

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

Financial Management Group

JAN 19 2016

Felicia Norwood, Director

Illinois Department of Healthcare and Family Services Prescott E Bloom Building

201 South Grand Avenue East

Springfield IL 62763-0002

RE: Illinois State Plan Amendment (SPA) 15-010 Dear Ms: Norwood:

We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 15-010. Effective July 1, 2015, this SPA allows hospitals separate reimbursement for Long Acting Reversible Contraceptive (LARC) devices provided in the inpatient hospital setting immediate postpartum. The coverage will be in addition to the Diagnostic Related Group (DRG) reimbursement for labor and delivery. The change is being made in order to maintain access to necessary medical services.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the regulations at 42 CFR 447 Subpart C. We hereby inform you that Medicaid State plan amendment 15-010 is approved effective July 1, 2015. We are enclosing the CMS-179 and the amended plan pages.

If you have any questions, please contact Fredrick Sebree, of my staff, at (217) 492-4122 or by e- mail at Fredrick.sebree@cms.hhs.gov.

Sincerely,

Kristin Fan Director

Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTER FOR MEDICARE & MEDICAID SERVICES OMB NO, 0938-0193. 1. TRANSMITTAL NUMBER: 2. STATE: — i TRANSMITTAL AND NOTICE OF APPROVAL 15-0010 ILLINOIS OF STATE PLAN MATERIAL 3. PROGRAM IDENTIFICATION: FOR: CENTER FOR MEDICARE AND MEDICAID SERVICES Title XIX of the Social Security Act (Medicaid)

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE: CENTERS FOR MEDICARE AND MEDICAID SERVICES duly 1, 2015 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One)

{.] NEW STATE PLAN [ ] AMENDMENT TO BE CONSIDERED AS NEW PLAN [X] AMENOMENT

COMPLETE BLOCKS 6 THRU 10 1F THIS IS AN AMENDMENT (Separate Transnmttal for each amendment)

6, FEDERAL STATUTE/REGULATION CITATION: 7, FEDERAL BUDGET IMPACT

Section 1902 of the Social Security Act . : ry ore (ea ition)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attaehmrent 46-8, Pageto4— OR ATTACHMENT (if Applicable}:

ATIALHK LAT 19 A, SHEE [Of Attachment 4.19-A, Page 10.1

10 SUBJECT OF AMENDMENT: Postpartum Long Acting Reversible Contraceptives

11, GOVERNOR'S REVIEW (Check One}

|] GOVERNOR'S OFFICE REFORTED NO COMMENT { ] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED } NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL [X] OTHER. AS SPECIFIED: Not suomitted for review by prior approval.

12. SIGNAZURE OF AGENCY QFFICIAL’ 16. RETURN TO: . Department of Healthcare and Family Services Bureau of Program and Reimbursement Analysis

13. TYPED NAME: Felicia F. Norwood Attn: Mary Doran 201 South Grand Avenue East

14 THLE: Pech Bewviees and Springfield, IL 62763-0001 18, DATE SUBMITTED a/izf/1s FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18, DATE APPROVED: JAN 1.9 2016 PLAN APPROVEO—ONE COPY ATTACHED 19, EFFECTIVE DATE OF APPROVED WEST 2015 20. SIG E OF REGIONAL OFFICIAL: awe pti LA 23. REMARKS:

FORM CMS-179 (07/92) (nsiructions on Back

Attachment 4,19-A Page 10.1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois

METHODS AND STANDARDS FOR ESTABLISHING INPATIENT RATES FOR HOSPTIAL REIMBURSEMENT; MEDICAL ASSISTANCE-GRANT (MAG) and MEDICAL ASSISTANCE-NO GRANT (MANG)

B. Excluded from DRG PPS reimbursements are: 1. Psychiatric services provided by: a. Apsychiatric hospital, as described in Chapter VIE. b. A distinct part of psychiatric unit, as described in Chapter VII. 2. Physical rehabilitation services provided by: a. Arehabilitation hospital, as described in Chapter VIII. b. A distinct part rehabilitation unit, as described in Chapter VIII.

3. Services provided by a long term acute care hospital, as described in Chapter VIII that are not psychiatric services or‘ services described in subsections 1 and 2 of this Section.

4. Inpatient services, reimbursed pursuant to negotiation as described in Section A.5 of Chapter VII.

Services provided by a large public hospital, as described in Chapter XXX. 6. Hospital residing long term care services, as described in Chapter XI.

7. Sub-acute alcoholism and substance abuse treatment services, as defined in Section P. of Chapter VII.

8. Inpatient services provided by Children’s Specialty Hospitals as described in Chapter VIIL

9. Inpatient services provided by non-cost reporting hospitals, excluding transplants, which will be reimbursed at a rate of $672.24 per day.

07/15 10, Long Acting Reversible Contraception. TN # 15-0010 Approval date: JAN i § 2016 Effective date: 07/01/2015 Supersedes

TN# 14-0014A

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 17-0014 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

July 20, 2018

Patricia R. Bellock, Director Illinois Department of Healthcare and Family Services Prescott E. Bloom Building

201 South Grand Avenue East Springfield, Illinois 62763-0001

Attn: Teresa Hursey

Dear Ms. Bellock:

The Centers for Medicare & Medicaid Services (CMS), has completed its review of Illinois State Plan Amendment (SPA) Transmittal Number (TN) 17-0014. This SPA implements Health Homes as authorized under Section 2703 of the Patient Protection and Affordable Care Act. The state plan pages for this SPA were submitted and approved through the Medicaid and CHIP Program System.

Enclosed for your records is an approved copy of the following State Plan Amendment.

TN #17-0014 – Authorizes the Medicaid Health Homes Benefit to cover certain physical and behavioral health conditions as outlined in the approved plan pages – Effective Date: October 1, 2018 –Approval Date: July 18, 2018

This approval is based on the state’s agreement to collect and report information required for the evaluation of the health home model. States are encourages to report on the CMS’ recommended core set of quality measures. In accordance with the statutory provisions at Section 1945 (c) (1) of the Social Security Act, for payments made to health home providers under this amendment, during the first eight fiscal quarters that the SPA is in effect, October 1, 2018 through September 30, 2020 the federal medical assistance percentage (FMAP) rate applicable to such payments shall be equal to 90 percent. The FMAP rate for payments made to health home providers will return to the state's published FMAP rate October 1, 2020. The Form CMS-64 has a designated category of service Line 43 for states to report health home services expenditures for enrollees with chronic conditions.

Page 2 Ms. Bellock

Please share with your staff my appreciation for their time and effort throughout the review process. If you have any questions regarding this Health Home State Plan Amendment, please have a member of your staff contact Courtenay Savage at 312-353-3721 or via email at Courtenay.Savage@cms.hhs.gov.

Sincerely,

/s/

Ruth A. Hughes

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

Enclosure

cc: Teresa Hursey, HFS Sara Barger, HFS

Kimberley Cox, HFS Mary Doran, HFS

CMS-10434 OMB 0938-1188 Package Information Package ID IL2016MH0001O Program Name Integrated Health Homes SPA ID IL-17-0014 Version Number 5 Submitted By Mary Doran Package Disposition Submission Type Official State IL Region Chicago, IL Package Status Approved Submission Date 12/5/2017 Approval Date 7/18/2018 11:31 AM EDT TN No: IL-17-0014 Supercedes: n/a Page 1 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Approval Notice DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850 Date: 07/18/2018 Head of Agency: Felicia Norwood Title/Dept : Director Address 1: 201 South Grand Avenue, East Address 2: City : Springfield State: IL Zip: 62763 MACPro Package ID: IL2016MH0001O SPA ID: IL-17-0014 Subject Approval Recommendation for IL-17-0014 Dear Felicia Norwood This is an informal communication that will be followed with an official communication to the State's Medicaid Director. The Centers for Medicare and Medicaid Services (CMS) is pleased to inform you that we are recommending approval for your request for SPA 17-0014 Reviewable Unit Effective Date Health Homes Intro 10/1/2018 Health Homes Geographic Limitations 10/1/2018 Health Homes Population and Enrollment Criteria 10/1/2018 Health Homes Providers 10/1/2018 Health Homes Service Delivery Systems 10/1/2018 Health Homes Payment Methodologies 10/1/2018 Health Homes Services 10/1/2018 Health Homes Monitoring, Quality Measurement and Evaluation 10/1/2018 Please indicate your acceptance of our recommendation. Sincerely, Alan Freund Acting ARA Approval Documentation Name Date Created IL-17-0014 7/18/2018 11:52 AM EDT TN No: IL-17-0014 Supercedes: n/a Page 2 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Name Date Created TN No: IL-17-0014 Supercedes: n/a Page 3 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018 DATE RECEIVED: December 5, 2017 DATE APPROVED: July 18, 2018 PLAN APPROVED – ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL: October 1, 2018 SIGNATURE OF REGIONAL OFFICIAL: /s/ TYPED NAME: Ruth A. Hughes TITLE: Associate Regional Administrator

Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date N/A State Information State/Territory Name: Illinois Medicaid Agency Name: Department of Healthcare and Family Services Submission Component State Plan Amendment Medicaid CHIP TN No: IL-17-0014 Supercedes: n/a Page 4 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date N/A SPA ID and Effective Date SPA ID IL-17-0014 Reviewable Unit Proposed Effective Date Health Homes Intro 10/1/2018 Health Homes Geographic Limitations 10/1/2018 Health Homes Population and Enrollment Criteria 10/1/2018 Health Homes Providers 10/1/2018 Health Homes Service Delivery Systems 10/1/2018 Health Homes Payment Methodologies 10/1/2018 Health Homes Services 10/1/2018 Health Homes Monitoring, Quality Measurement and Evaluation 10/1/2018 Page 5 of 49 TN No: IL-17-0014 Supercedes: n/a Page 5 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The Integrated Health Home (IHH) program is intended to be a new, fully-integrated form of care coordination, for all members of the Illinois Medicaid population with chronic conditions, with provision for high needs members covered through this SPA. 6 care delivery improvement goals have been identified for all IHH members: • Integrated Care Planning and Monitoring • Physical Health Provider Engagement • Behavioral Health Provider Engagement • Supportive Service Engagement • Member Engagement and Education • Population Health Management Each member in the Medicaid population would be linked to an Integrated Health Home provider, based on their level of need and the provider’s ability to meet these needs. The Integrated Health Home would be responsible for care coordination for members across their physical, behavioral, and social care needs. Integrated Health Homes would not, however, be responsible for provision for all services and treatment to members. The program is intended to launch statewide in October 2018. Members would be assigned to one of several tiers based on their level of need, and would be provided with a commensurate level of care coordination. This would be ascertained, first and foremost, with reference to their medical history and profile. Specific criteria for eligibility for each tier of membership would be defined, and members’ MCOs (or the State, for FFS populations) would be responsible for the review of their medical history for evidence of these criteria, and the assignment of the member to the appropriate tier of need. MCOs (or the State, for FFS populations) would also transfer them to different tiers of care as their needs change over time, following pre-defined reassignment criteria, and manage the manual assignment of members without available medical history data. After assignment to a tier of care, members would be attributed to an IHH provider best able to meet their needs, drawn from a broad pool of potential provider types, following a pre-determined attribution logic. The member would be notified of their place within the program and their prospective IHH provider, together with rights to opt out of the program or request a different provider. Likewise, the provider to which the member has been attributed would be alerted to this, to permit them to begin outreach. The members’ MCO, if they have one, would play a key supporting role in this process. Two main support streams are intended for IHHs. In order to deliver care coordination (as needed) from a pre-determined set of IHH activities, providers would receive from MCOs (or the State, for FFS populations) per member per month reimbursements. Submission of claims to generate a reimbursement will be required (as opposed to automatic, prospective off-claims transfers). The second stream to which providers would potentially be eligible is an outcomes-based stream, calibrated to incentivize value over volume. Provider performance against a set of quality and efficiency measures for their panel would be monitored for the duration of their membership in the program. Strong performance on these measures – without sacrificing quality in the pursuit of cost savings – would be used to determine both eligibility for this stream, and the extent of the value of the remuneration. Information on provider performance (together with actionable next steps as needed) may be provided to providers via a report card at regular intervals. The design of the Integrated Health Home model was led by HFS in collaboration with its sister agencies, including input from the Department of Mental Health, the Department of Alcoholism & Substance Abuse, and the Department of Children and Family Services among other agencies and departments. The Integrated Health Home model also has been informed by ongoing input from the Medicaid Waiver Advisory Group, which reflects input from the stakeholder community including providers. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $228000000 Second 2020 $228000000 TN No: IL-17-0014 Supercedes: n/a Page 6 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Federal Statute / Regulation Citation This document constitutes a proposed SPA for a Health Homes program, authorized under Section 2703 of the Affordable Care Act. FFY impact: FY19: $228,000,000; $223,000,000 (MC), $5,000,000 (FFS) FY20: $228,000,000; $223,000,000 (MC), $5,000,000 (FFS) TN No: IL-17-0014 Supercedes: n/a Page 7 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other TN No: IL-17-0014 Supercedes: n/a Page 8 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Submission - Public Comment MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date N/A Name of Health Homes Program Integrated Health Homes Indicate whether public comment was solicited with respect to this submission. Public notice was not required and comment was not solicited Public notice was not required, but comment was solicited Public notice was required and comment was solicited Indicate how public comment was solicited: Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism  Website Notice Select the type of website  Website of the State Medicaid Agency or Responsible Agency Date of Posting: Jun 14, 2018 Website URL: https://www.illinois.gov/hfs/info /legal/PublicNotices/Pages/defa ult.aspx Website for State Regulations Other Public Hearing or Meeting Other method Upload copies of public notices and other documents used Name Date Created 6.14.18_IHH_Public_Notice 6/14/2018 5:18 PM EDT Upload with this application a written summary of public comments received (optional) Name Date Created No items available Indicate the key issues raised during the public comment period (optional) Access Quality Cost TN No: IL-17-0014 Supercedes: n/a Page 9 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Payment methodology Eligibility Benefits Service delivery Other issue TN No: IL-17-0014 Supercedes: n/a Page 10 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Submission - Tribal Input MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date N/A Name of Health Homes Program Integrated Health Homes One or more Indian health programs or Urban Indian Organizations furnish health care services in this state Yes No This state plan amendment is likely to have a direct effect on Indians, Indian health programs or Urban Indian Organizations Yes No  The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, prior to submission of this SPA Complete the following information regarding any tribal consultation conducted with respect to this submission: Tribal consultation was conducted in the following manner  Indian Health Programs Name of Program Date of consultation: Method/Location of consultation: American Indian Health Services of Chicago 9/29/2016 Email Urban Indian Organizations States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Indian Tribes The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created AIHSC Notification 10/4/2016 10:38 AM EDT Indicate the key issues raised (optional) Access Quality Cost Payment methodology TN No: IL-17-0014 Supercedes: n/a Page 11 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Eligibility Benefits Service delivery Other issue TN No: IL-17-0014 Supercedes: n/a Page 12 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Submission - Other Comment MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date N/A SAMHSA Consultation Name of Health Homes Program Integrated Health Homes  The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions. Date of consultation 5/11/2017 TN No: IL-17-0014 Supercedes: n/a Page 13 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Intro MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Program Authority 1945 of the Social Security Act The state elects to implement the Health Homes state plan option under Section 1945 of the Social Security Act. Name of Health Homes Program Integrated Health Homes Executive Summary Provide an executive summary of this Health Homes program including the goals and objectives of the program, the population, providers, services and service delivery model used The Integrated Health Home (IHH) program is intended to be a new, fully-integrated form of care coordination, for all members of the Illinois Medicaid population with chronic conditions, with provision for high needs members covered through this SPA. 6 care delivery improvement goals have been identified for all IHH members: • Integrated Care Planning and Monitoring • Physical Health Provider Engagement • Behavioral Health Provider Engagement • Supportive Service Engagement • Member Engagement and Education • Population Health Management Each member in the Medicaid population would be linked to an Integrated Health Home provider, based on their level of need and the provider’s ability to meet these needs. The Integrated Health Home would be responsible for care coordination for members across their physical, behavioral, and social care needs. Integrated Health Homes would not, however, be responsible for provision for all services and treatment to members. The program is intended to launch statewide in October 2018. Members would be assigned to one of several tiers based on their level of need, and would be provided with a commensurate level of care coordination. This would be ascertained, first and foremost, with reference to their medical history and profile. Specific criteria for eligibility for each tier of membership would be defined, and members’ MCOs (or the State, for FFS populations) would be responsible for the review of their medical history for evidence of these criteria, and the assignment of the member to the appropriate tier of need. MCOs (or the State, for FFS populations) would also transfer them to different tiers of care as their needs change over time, following pre-defined reassignment criteria, and manage the manual assignment of members without available medical history data. After assignment to a tier of care, members would be attributed to an IHH provider best able to meet their needs, drawn from a broad pool of potential provider types, following a pre-determined attribution logic. The member would be notified of their place within the program and their prospective IHH provider, together with rights to opt out of the program or request a different provider. Likewise, the provider to which the member has been attributed would be alerted to this, to permit them to begin outreach. The members’ MCO, if they have one, would play a key supporting role in this process. Two main support streams are intended for IHHs. In order to deliver care coordination (as needed) from a pre-determined set of IHH activities, providers would receive from MCOs (or the State, for FFS populations) per member per month reimbursements. Submission of claims to generate a reimbursement will be required (as opposed to automatic, prospective off-claims transfers). The second stream to which providers would potentially be eligible is an outcomes-based stream, calibrated to incentivize value over volume. Provider performance against a set of quality and efficiency measures for their panel would be monitored for the duration of their membership in the program. Strong performance on these measures – without sacrificing quality in the pursuit of cost savings – would be used to determine both eligibility for this stream, and the extent of the value of the remuneration. Information on provider performance (together with actionable next steps as needed) may be provided to providers via a report card at regular intervals. The design of the Integrated Health Home model was led by HFS in collaboration with its sister agencies, including input from the Department of Mental Health, the Department of Alcoholism & Substance Abuse, and the Department of Children and Family Services among other agencies and departments. The Integrated Health Home model also has been informed by ongoing input from the Medicaid Waiver Advisory Group, which reflects input from the stakeholder community including providers. General Assurances  The state provides assurance that eligible individuals will be given a free choice of Health Homes providers.  The states provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from receiving Health Homes services. TN No: IL-17-0014 Supercedes: n/a Page 14 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

 The state provides assurance that hospitals participating under the state plan or a waiver of such plan will be instructed to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Homes providers.  The state provides assurance that FMAP for Health Homes services shall be 90% for the first eight fiscal quarters from the effective date of the SPA. After the first eight quarters, expenditures will be claimed at the regular matching rate.  The state provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for each health homes enrollee will be claimed.  The state provides assurance that there will be no duplication of services and payment for similar services provided under other Medicaid authorities. TN No: IL-17-0014 Supercedes: n/a Page 15 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Geographic Limitations MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Health Homes services will be available statewide Health Homes services will be limited to the following geographic areas Health Homes services will be provided in a geographic phased-in approach TN No: IL-17-0014 Supercedes: n/a Page 16 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Categories of Individuals and Populations Provided Health Homes Services The state will make Health Homes services available to the following categories of Medicaid participants  Categorically Needy (Mandatory and Options for Coverage) Eligibility Groups  Medically Needy Eligibility Groups Mandatory Medically Needy  Medically Needy Pregnant Women  Medically Needy Children under Age 18 Optional Medically Needy (select the groups included in the population) Families and Adults  Medically Needy Children Age 18 through 20 Medically Needy Parents and Other Caretaker Relatives Aged, Blind and Disabled Medically Needy Aged, Blind or Disabled Medically Needy Blind or Disabled Individuals Eligible in 1973 TN No: IL-17-0014 Supercedes: n/a Page 17 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Population Criteria The state elects to offer Health Homes services to individuals with  Two or more chronic conditions Specify the conditions included  Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease BMI over 25  Other (specify) Name Description Diabetes and Heart Disease These two conditions were checked above in order to comply with the MACPro system requirements that two or more conditions must be checked. The chronic conditions that will apply to this IHH model are the 3M CRG categories listed above under "Catastrophic”, “Dominant/Metastatic” and “Dominant chronic diseases in 3 or more organ systems”. Catastrophic Dialysis with Diabetes Dialysis without Diabetes HIV Disease Total Parenteral Nutrition Dependence on a Mechanical Ventilator History of a Major Organ Transplant Congenital Quadriplegia, Diplegia or Hemiplegia Acquired Quadriplegia or Permanent Vegetative State Spina Bifida Progressive Muscular Dystrophy or Spinal Muscle Atrophy Cystic Fibrosis Dominant/Metastatic Multiple Dominant Primary Malignancies Multiple Non-Dominant Primary Malignancies Secondary Malignancy Brain and Central Nervous TN No: IL-17-0014 Supercedes: n/a Page 18 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Name Description System Malignancies Lung Malignancy Pancreatic Malignancy Kidney Malignancy Ovarian Malignancy Digestive Malignancy Chronic Lymphoid Leukemia Chronic Non-Lymphoid Leukemia Multiple Myeloma Acute Lymphoid Leukemia Acute Non-Lymphoid Leukemia Colon Malignancy Other Malignancies Hodgkins Lymphoma Plasma Protein Malignancy Breast Malignancy Prostate malignancy Genitourinary Malignancy Non-Hodgkins Lymphoma Dominant chronic disease in 3 or more organ systems Chronic Renal Failure - Diabetes - Other Dominant Chronic disease Chronic Renal Failure - 2 or more Other Dominant Chronic disease Congestive Heart Failure - Diabetes - Chronic Obstructive Pulmonary Disease Congestive Heart Failure - Diabetes - Cerebrovascular Disease Congestive Heart Failure - Diabetes - Other Dominant Chronic Disease Congestive Heart Failure - Chronic Obstructive Pulmonary Disease - Other Dominant Chronic Disease Congestive Heart Failure - Peripheral Vascular Disease - Other Dominant Chronic Disease Congestive Heart Failure - Cerebrovascular Disease - Other Dominant Chronic Disease Congestive Heart Failure - 2 or more Other Dominant Chronic Disease Diabetes - Advanced Coronary Artery Disease -Other Dominant Chronic Disease Diabetes - Cerebrovascular Disease - Other Dominant Chronic Disease Diabetes - Chronic Obstructive Pulmonary Disease - Other Dominant Chronic Disease Diabetes - 2 or More Other Dominant Chronic Diseases Chronic Obstructive Pulmonary Disease - Advanced Coronary Artery Disease - Other Dominant Chronic Disease Chronic Obstructive Pulmonary Disease - 2 or More Other Dominant Chronic Diseases TN No: IL-17-0014 Supercedes: n/a Page 19 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Name Description Advanced Coronary Artery Disease - Peripheral Vascular Disease - Other Dominant Chronic Disease Advanced Coronary Artery Disease - 2 or More Other Dominant Chronic Diseases Cerebrovascular Disease - 2 or More Other Dominant Chronic Diseases 3 or More Other Dominant Chronic Diseases Diabetes - Cerebrovascular Disease - Hypertension Diabetes - Hypertension - Other Dominant Chronic Disease  One chronic condition and the risk of developing another Specify the conditions included Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease BMI over 25  Other (specify) Name Description Catastrophic Dialysis with Diabetes Dialysis without Diabetes HIV Disease Total Parenteral Nutrition Dependence on a Mechanical Ventilator History of a Major Organ Transplant Congenital Quadriplegia, Diplegia or Hemiplegia Acquired Quadriplegia or Permanent Vegetative State Spina Bifida Progressive Muscular Dystrophy or Spinal Muscle Atrophy Cystic Fibrosis Dominant/Metastatic Multiple Dominant Primary Malignancies Multiple Non-Dominant Primary Malignancies Secondary Malignancy Brain and Central Nervous System Malignancies Lung Malignancy Pancreatic Malignancy Kidney Malignancy Ovarian Malignancy Digestive Malignancy Chronic Lymphoid Leukemia Chronic Non-Lymphoid Leukemia TN No: IL-17-0014 Supercedes: n/a Page 20 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Name Description Multiple Myeloma Acute Lymphoid Leukemia Acute Non-Lymphoid Leukemia Colon Malignancy Other Malignancies Hodgkins Lymphoma Plasma Protein Malignancy Breast Malignancy Prostate malignancy Genitourinary Malignancy Non-Hodgkins Lymphoma Specify the criteria for at risk of developing another chronic condition Character of specific chronic conditions within these two CRG risk groupings (“Catastrophic”, Dominant/Metastatic Malignancy”) are of such severity that, by their nature, they increase the likelihood that the member will develop further acute conditions and increase the risk of developing another chronic condition .  One serious and persistent mental health condition Specify the criteria for a serious and persistent mental health condition Members will be eligible for membership for the program should they have a condition (as evidenced by medical history over prior annual reference period) present within any multi-chronic condition subgroup within CRG categories “Catastrophic”, “Dominant/Metastatic Malignancy”, “Dominant chronic disease in 3 or more organ systems”, “Significant chronic diseases in multiple organ systems ” Group 1. Medicaid members with a diagnosis of one or more of the following conditions within the prior annual reference period (as evidenced by a qualifying claim) shall be eligible for the program: • Schizophrenia • Bipolar disorder Group 2. Medicaid members with a diagnosis of one or more of the following conditions AND one or more of the conditions set out within Group 3 within the prior annual reference period (as evidenced by a qualifying claim) shall be eligible for the program: • Attempted self-injury or suicide • Homicidal ideation Group 3. Medicaid members with one or more behavioral-health related inpatient / crisis-unit / residential treatment facility / rehab facility visits AND with a diagnosis of one or more of the following conditions shall be eligible for the program: • Diagnosed Substance use • Major depression • Other depression • Other mood disorders • Conduct disorder • ODD • Psychosis • PTSD • Personality disorders, including borderline personality disorder • Eating disorders In the absence of a claim for a condition qualifying a member for eligibility for the program, providers (including hospitals) may refer individuals they reasonably believe to have such a condition and level of need directly to an Integrated Health Home provider, who may enroll them on establishing contact. For the validity of this referral, and for the continuing membership of this individual, to be confirmed, a claim for a qualifying diagnosis must be received by the State or member’s MCO within [3] months of start of membership in the IHH. TN No: IL-17-0014 Supercedes: n/a Page 21 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Enrollment of Participants Participation in a Health Homes is voluntary. Indicate the method the state will use to enroll eligible Medicaid individuals into a Health Home Opt-In to Health Homes provider Referral and assignment to Health Homes provider with opt-out Other (describe) Describe the process used All members in Managed Care who meet the target population eligibility criteria will be informed of their eligibility for Integrated Health Home membership by the MCO. The State will inform those members who meet the population criteria and are not enrolled in Managed Care of their Integrated Health Home membership. Members will be attributed to an Integrated Health Home according to logic set out by the State, reflecting previously expressed member preference (or parental preference, in the case of children), level of member need, and any existing therapeutic relationship. This logic will be primarily claims-driven; for those members without the requisite medical history that would algorithmically allow attribution to a provider, the State and/or member’s MCO will attribute directly according to other criteria (e.g., geography, demonstrated provider capabilities). Eligible members of the IHH population will be assigned into one of three tiers reflecting members' underlying levels of physical and behavioral health needs, and with further sub-segmentation on the basis of age group. A fourth tier (Tier D) will be created separately as a Primary Care Case Management Services SPA for members with low underlying physical and behavioral health needs. The three tiers discussed in this SPA are labeled Tier A, Tier B, and Tier C, with Tier C representing members with low behavioral health needs but high physical health needs, Tier B representing members with low physical health needs but high behavioral health needs, and Tier A representing members with both high physical health needs and high behavioral health needs. For physical health, the level of need is determined by the specific combination of chronic conditions in a member’s claims history (or one chronic condition with risk of developing another). For high physical needs, a member must have a claims history relating the CRG categories “Catastrophic”, “Dominant/Metastatic”, or “Dominant chronic disease in 3 or more organ systems”. The specific condition combinations included in these CRG categories are listed in the section “Population Criteria”. For behavioral health, the State is mandating a diagnosis- and utilization-based approach for determining the level of behavioral health needs of members. High behavioral health needs are considered those outline in the subsection “One serious and persistent mental health condition” in the section “Population Criteria”. As noted, an individual with a claims-history of conditions considered high behavioral health needs and high physical health needs will be designated Tier A, and will receive the requisite care coordination services. HFS will provide IHH enrollment packets to eligible beneficiaries by direct mail. The enrollment packet will include information on the IHH choices, MCOs that the IHH is affiliated with, tips to assist an individual in selecting an IHH, switch/change periods and timeframes, how to work with their IHH, information on the IHH and an opt-out form. Eligible beneficiaries may request this material in alternate languages or formats. Members will retain the ability to request a different IHH or to opt out TN No: IL-17-0014 Supercedes: n/a Page 22 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

of the program on an ongoing basis . Integrated Health Homes will be alerted as regards to those members joining their panel, and will be provided a member roster, as appropriate. Once a member has been attributed to an IHH, the IHH will be responsible for engaging them and formally enrolling them, marking the commencement of health home services. Enrollment must be documented by the provider, and that documentation should at a minimum indicate that the individual has received required information explaining the health home program and has consented to receive the health home services noting the effective date of their enrollment .  The state provides assurance that it will clearly communicate the individual's right to opt out of the Health Homes benefit or to change Health Homes providers at any time and agrees to submit to CMS a copy of any letter or communication used to inform the individuals of the Health Homes benefit and their rights to choose or change Health Homes providers or to elect not to receive the benefit Name Date Created 20170719_Opt out letter draft 11/1/2017 11:00 AM EDT TN No: IL-17-0014 Supercedes: n/a Page 23 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Providers MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Types of Health Homes Providers  Designated Providers Indicate the Health Homes Designated Providers the state includes in its program and the provider qualifications and standards Physicians Clinical Practices or Clinical Group Practices Rural Health Clinics Community Health Centers Community Mental Health Centers Home Health Agencies Case Management Agencies Community/Behavioral Health Agencies Federally Qualified Health Centers (FQHC)  Other (Specify) Provider Type Description All qualifying Integrated Health Home providers Health homes will be required to be fully integrated. This can be achieved either through the existence of all relevant physical and behavioral health capabilities (including SUD) in a single organization, under one roof, or by a provider making use of collaborative agreement (s) with partner entities with complementary capabilities, to deliver the level of care required by their members. The State will use as a vehicle for the Integrated Health Home Program a range of providers including PCPs, clinical practices/clinical group practices, Rural Health Clinics, physicians and physicians groups employed by hospitals, community mental health centers, home health agencies, community/behavioral health agencies, FQHCs. In addition to these providers or practice types, all other Medicaid enrolled provider/practice TN No: IL-17-0014 Supercedes: n/a Page 24 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Provider Type Description types that meet the IHH eligibility standards outlined later in this document will be potentially eligible for the program . Teams of Health Care Professionals Health Teams TN No: IL-17-0014 Supercedes: n/a Page 25 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Providers MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Provider Infrastructure Describe the infrastructure of provider arrangements for Health Home Services The delivery of Illinois’s health home service model is based on an inter-disciplinary array of behavioral health care, medical care, and community-based services and supports for children and adult members with high needs. Taken together, this approach will enable the State to improve coordination of care for those members with the highest needs. The model is designed to cover the entire State of Illinois, and providers across the state will be engaged in the Integrated Health Homes model. Importantly, full integration of physical and behavioral health is required and may be achieved by either: - A single practice with physical and behavioral health (including SUD) capabilities housed under a single roof. If the lead entity is a fully integrated, responsible provider, the provider must attest to having necessary staff and capabilities and will receive full payment. - A practice not possessing the full set of physical and behavioral health (including SUD) capabilities housed under a single roof, but with collaborative agreement(s) with practices with complementary capabilities (e.g., a PCP with a collaborative agreement with a CMHC and SUD specialist). The collaborative agreement must contain explicit agreements in line with integration requirements laid out by the State. The lead entity will receive payment, with potential disbursement of funds to partner entity left up to lead provider’s discretion. The following guiding principles were used to determine eligibility of provider types: - Include provider types already capable of providing fully-integrated physical and behavioral health care - Ensure provider types can demonstrate capability to collaborate effectively with other providers whose abilities complement their own (e.g., CMHCs and Primary Care Physicians) - Select provider types whose institutional character ensures ability to maintain long-term relationship with members (e.g., rural health clinics, FQHCs) - Avoid excluding provider types where significant numbers of members have shown preference for establishing therapeutic and/or coordination relationships - Prioritize provider types catering to all age-groups, in order to ensure providers will be able to coordinate care for whole families (e.g., Primary Care Physicians who care for children and adults) - Consider more stringent provider requirements to serve members with the highest demonstrated needs (e.g., social support specialist as part of the care coordination team) Potential behavioral health providers include: - Community mental health centers - Other eligible specialty behavioral provider types as approved by the State (including SUD specialists, community/behavioral health agencies) Potential physical health providers include, but are not limited to: - Primary care physicians - Clinical practices or clinical group practices - Rural health clinics - Community health centers - Home health agencies - Federally Qualified Health Centers In addition to a lead entity with integrated physical and behavioral health, all Integrated Health Homes must additionally staff the following: - Health coordinators, including a lead nurse care manager, supporting nurse care manager(s), and clinical care coordinator(s) as employed by the lead entity - Clinical experts, including a physician and a psychiatrist (or other behavioral health specialist) Additional requirements for Integrated Health Homes serving members with high behavioral health needs include: - Health coordinators as above, with expectation of lower care coordination ratios - Clinical experts as above, and SUD specialist and psychologist - Social supports, including a social worker and a recovery support specialist Providers will be required to serve enrollees in Tiers A, B and C. Delivery of Health Home services will not vary depending on whether the member is enrolled with a Managed Care Organization or is a fee-for- service member. The State will be responsible for determining the appropriate tier for fee-for-service members and attributing them to Health Homes that meet their levels of need. Enrollees in fee-for-service will be notified of their Health Home provider by the State. The State will be responsible for sharing lists of attributed members with providers. The team structure, eligibility requirements, services provided, standards, and rate structure will not differ for Health Home providers under managed care or fee-for-service. TN No: IL-17-0014 Supercedes: n/a Page 26 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Providers MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Supports for Health Homes Providers Describe the methods by which the state will support providers of Health Homes services in addressing the following components 1. Provide quality-driven, cost-effective, culturally appropriate, and person- and family- centered Health Homes services 2. Coordinate and provide access to high quality health care services informed by evidence-based clinical practice guidelines 3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders 4. Coordinate and provide access to mental health and substance abuse services 5. Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care 6. Coordinate and provide access to chronic disease management, including self-management support to individuals and their families 7. Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services 8. Coordinate and provide access to long-term care supports and services 9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health- care related needs and services 10. Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate 11. Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level Description The State and Illinois MCOs will support providers of Health Homes services with regards to the above listed components in the following ways : State: • Identifying providers with the potential to become health homes and supporting them through the application process to ensure that all eligibility criteria are met via provision of required evidence • Supporting the required adoption of EHR capabilities (in line with State-set timeline) with access to relevant information (e.g. on types available and on grants/funding available to facilitate adoption) and exchange of best practice on usage and training at the Learning Collaborative • Developing stakeholder material outlining roles, responsibilities, and opportunities set out for Health Home providers, including via the creation of a provider manual outlining key aspects of the program (e.g., approach to reimbursement ) • Using transition support funds (as applied for through the current 1115 Waiver package) to enhance provider education and integration efforts - especially by setting up a Learning collaborative and by offering of training on relevant topics (e.g., via webinars, in-person coaching) • Potentially requiring and rolling-out use of a single provider notification system (e.g., ADT feeds) to enable health homes more easily to track their members • Aligning on a set State-defined and mandated functional assessment(s) and screening tools (e.g., IM-CANS, SBIRT) to be made available to help health homes track their members’ progress over time and their evolving needs State/MCOs: • Setting up provider portals through which providers will be able to access relevant information to support members of their panel and to contact relevant support staff • Monitoring the coordination of care by health homes to ensure that it meets all required standards and is provided in a high-quality, cost effective manner • Deploying tools for risk stratification and analysis of member-level data to support assignment to tiers • Providing reports showing provider performance on key quality and efficiency measures (aligned on following stakeholder input and reference to national standards), including actionable next steps and areas of concern • Maintaining relationship with agency partners with a view to resolving any barriers to care delivery (e.g., communication/administrative blockages), and making available examples of best practice, information, and resources these partner agencies have at their disposal MCOs: • Abiding by all contractual responsibilities as articulated through the managed Medicaid reprocurement process to support providers (including provision of technical support, building awareness and knowledge of the program, maintaining a network of providers for referral purposes, etc.) TN No: IL-17-0014 Supercedes: n/a Page 27 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Providers MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Other Health Homes Provider Standards The state's requirements and expectations for Health Homes providers are as follows In order for a practice to be eligible to participate in the program, they must abide by the following standards: • (Unless they are fully capable of providing physical and behavioral health services, including SUD, within the bounds of their organization) Possess and demonstrate to the state the existence of a collaborative agreement with a practice whose abilities would complement their own that provides for intensive integration to fully meet the needs of the target population • Commit to employ or have regular access to the following personnel as part of the care coordination team (maintaining appropriate staffing ratios with respect to each, as indicated through state guidelines ): o One lead nurse care manager per practice, with further nurse care managers as needed. Lead nurse care manager must be a qualified RN, with other nurse care managers needing to be either a qualified RD, a qualified LPN, or a qualified APN. o Clinical care coordinator, possessing at minimum a bachelor’s degree in a relevant subject and demonstrated experience of care coordination/case management o Physician, possessing appropriate clinical licenses and/or professional certifications o Psychiatrist or other behavioral health specialist, possessing appropriate clinical licenses and/or professional certifications o SUD specialist, possessing appropriate clinical licenses and/or professional certifications o Psychologist, possessing appropriate clinical licenses and/or professional certifications o Social worker, possessing at minimum a bachelor’s degree in a relevant subject o Recovery support specialist, possessing at minimum the appropriate certification for the role Each personnel member must be IMPACT-enrolled • Be a recognized Medicaid provider in good standing • Demonstrate ability before joining program to meet the following activity requirements (drawn from the broader set articulated from the Health Home service definitions) to: o Maintain following appointment standards for members (stricter requirements for high behavioral health tier members in brackets): • Routine, preventive care available within 5 [3] weeks from request, but within 2 [1] weeks for infants less than 6 months, from the date of request for such care • Urgent care appointments not deemed emergency medical conditions triaged and, if deemed necessary, provided within 24 hours • Appointments for member problems or complaints not deemed serious available within 3 [2] weeks from the date of request for such care • Initial prenatal appointments without expressed problems: 1st trimester within 2 [1] weeks, 2nd trimester within 1 week [5 days], 3rd trimester within 3 days [2 days ] o Provide direct access to members for coverage 24 hours a day, seven days a week, at the very least through an answering service/direct notification mechanism or other approved arrangement , e.g., secure electronic messaging system and/or video conferencing system to offer interactive clinical advice to members. In addition, providers must develop emergency contact protocols for members to establish contact with clinical personnel directly during crisis situations, and protocols for timely sharing of information with other providers relevant to members’ care o Facilitate and participate in regular interdisciplinary care team meetings, including clinicians from the members’ primary behavioral and physical care providers when possible o Establish relationships with hospitals, residential settings, rehabilitation settings, other treatment settings, LTSS, and support providers to facilitate transitions as member moves between levels of care or back into community. This includes developing protocols for prompt notification and ongoing communication o Have ability to receive notifications on member status from rendering providers (e.g., via ADT feeds) • Be able to maintain a minimum panel size of 500, as determined by the State/MCO attribution algorithm (this may be relaxed for specific provider types, e.g., acute specialists, and in rural areas) • Be able to conduct bi-directional, multimodal outreach and engagement (e.g., via telephone, secure messaging • Use an EHR or commit to adopt or demonstrate progression towards adoption of EHR by State-set adoption timetable • Commit to ensure staff receive appropriate training to support highest need members, as defined by the state • Commit to participate in and contribute to the IHH learning collaborative • Commit to supply all relevant data to state/MCOs as needed for reporting purposes, e.g., for annual program evaluations and required transmittal of data to CMS • Commit to support continuous improvement efforts (e.g., supply of data for compilation of practice performance reports as needed and to use such reports once issued to guide own improvement efforts) • Commit to maintain all documentation and records supporting the care of members (including consent to such care), making them available for monitoring efforts as needed while ensuring member confidentiality as required by law • Commit – as applicable to location – to assist State in implementation of 1115 Waiver pilots through reporting as required relevant information on panel members receiving services via these pilots Ongoing participation in the program will be contingent on health homes providing consistent, high quality care coordination for their members, with exceptions made on some quality measures for particular provider types. In addition to maintaining the ability to comply with the initial eligibility requirements, IHHs are expected to maintain the ability to provide for members as needed any of the activities and capabilities which, taken together, both comprise the 6 Health Home services outlined above in this document. TN No: IL-17-0014 Supercedes: n/a Page 28 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Name Date Created 092517 Staffing ratios one-page 9/25/2017 3:09 PM EDT TN No: IL-17-0014 Supercedes: n/a Page 29 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Service Delivery Systems MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Identify the service delivery system(s) that will be used for individuals receiving Health Homes services  Fee for Service PCCM  Risk Based Managed Care The Health Plans will be a Designated Provider or part of a Team of Health Care Professionals Yes No Indicate how duplication of payment for care coordination in the Health Plans' current capitation rate will be avoided The current capitation rate will be reduced  The State will impose additional contract requirements on the plans for Health Homes enrollees Provide a summary of the contract language for the additional requirements MCOs will be providing technical support of the IHH, building awareness and knowledge of the program and maintaining a network of providers for referral. Other Other Service Delivery System TN No: IL-17-0014 Supercedes: n/a Page 30 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Payment Methodology The State's Health Homes payment methodology will contain the following features  Fee for Service Individual Rates Per Service  Per Member, Per Month Rates  Fee for Service Rates based on  Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other Comprehensive Methodology Included in the Plan Incentive Payment Reimbursement Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided Delivery of Health Home services will not vary depending on whether the member is enrolled with a Managed Care Organization or is a fee-for-service member. The State will be responsible for determining the appropriate tier and the initial attribution of all eligible members into an IHH. After the initial attribution, MCOs will be responsible for the tier assignment and IHH attribution of members with the State's review. The State will be responsible for fee-for-service members and attributing them to Health Homes that meet their levels of need. Enrollees in fee-for-service will be notified of their Health Home provider by the State. The State will be responsible for sharing lists of attributed members with providers. The team structure, eligibility requirements, services provided, standards, and rate structure will not differ for Health Home providers under managed care or fee-for-service. PCCM (description included in Service Delivery section) Risk Based Managed Care (description included in Service Delivery section) Alternative models of payment, other than Fee for Service or PMPM payments (describe below) Page 31 of 49 TN No: IL-17-0014 Supercedes: n/a Page 31 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Agency Rates Describe the rates used FFS Rates included in plan Comprehensive methodology included in plan The agency rates are set as of the following date and are effective for services provided on or after that date TN No: IL-17-0014 Supercedes: n/a Page 32 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Rate Development Provide a comprehensive description in the SPA of the manner in which rates were set 1. In the SPA please provide the cost data and assumptions that were used to develop each of the rates 2. Please identify the reimbursable unit(s) of service 3. Please describe the minimum level of activities that the state agency requires for providers to receive payment per the defined unit 4. Please describe the state's standards and process required for service documentation, and 5. Please describe in the SPA the procedures for reviewing and rebasing the rates, including • the frequency with which the state will review the rates, and • the factors that will be reviewed by the state in order to understand if the rates are economic and efficient and sufficient to ensure quality services. Comprehensive Description IHH providers will be reimbursed following the submission of a qualifying care coordination claim (listed below) for a member on their panel. The member must be attributed to the IHH submitting this claim and only one claim may be paid for each member, each month. Any additional qualifying claim submissions will pay at $0. IHH provider claims submission will be through the department's MMIS system. Qualifying care coordination codes: • CPT/HCPCS G9004 – Comprehensive Care Management • CPT/HCPCS G9005 – Care Coordination and Health Promotion • CPT/HCPCS G9007 – Transitional Care • CPT/HCPCS G9010 – Patient and Family Support • CPT/HCPCS G9011 – Referral to Social Services As appropriate (and subject to final guidelines issued by the State) completed activities may merit a claim not only via direct in-person provision to the member, but also: • if appropriate, telephonically (or through other means of electronic communication) • if appropriate, to the member's immediate collaterals and caregivers As covered by this SPA, the IHH population will be assigned into three tiers reflecting members' underlying levels of physical and behavioral health needs, and with further sub-segmentation on the basis of age group. Consequently, PMPM payments will be tiered, with the value calculated to reflect the anticipated level of care coordination support IHH personnel will be expected to provide members. Levels of support are understood in terms of time that can be potentially spent by care coordination team personnel with a given member as funded by the PMPM (yielding guideline ratios for providers). Illinois-specific labor cost data from the Bureau of Labor Statistics were used for these calculations, which were made with reference to staffing ratios in similar population health management programs. The three tiers A-C are divided into three age groups (children, transition and adults). Each tier with PMPM is as follows. Tier A children (0-18) = $240 Tier A transition (18-21) = $240 Tier A adults (21+) = $120 Tier B children (0-18) = $80 Tier B transition (18-21+) = $60 Tier B adults (21+) = $48 Tier C children (0-18) = $48 Tier C transition (18-21) = $48 Tier C adults (21+) = $48 Separately from the IHH activities and rates, providers will be able to continue to bill, on a FFS basis, for treatments and services provided to members. The following services, which closely support but are not part of the care planning and coordination process, may be billed for separately on a FFS basis, and are consequently not folded into the IHH PMPM rates: • Administration of a functional assessment to a member (e.g., IM-CANS ) • MCO care management • Other Waiver services and transition support Beyond the submission of care coordination claims for activities provided to the member, the IHH must also document these services within the members' medical records, in compliance with the State's broader TN No: IL-17-0014 Supercedes: n/a Page 33 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

requirements with service documentation. In addition to the PMPM payment, IHHs may potentially be eligible for separate outcomes-based payments (paid out in annual lump sums). Outcomes-based payments will be issued according to performance against state benchmarks. These benchmarks will be used to set thresholds based on the previous calendar year's measurement period. For the bonus payment period from 10/1/2019 through 9/30/2020, the measurement year (MY) will be 10/1/2018 through 9/30/2019. The measures, performance level thresholds and benchmarks will be posted on the agency's website at www.illinois.gov/hfs by the first day of the month preceding the start of the performance year which begins October 1, 2018. From the first year of operation, each IHH will be able to earn a bonus payment, i.e., outcomes-based payment, equal to the value of either 10% or 25% of the amount of their total annual care coordination reimbursement. The percentages were developed by the Department based on the withhold and the allocation thereof. The Department will create a pool of funds dedicated to outcomes-based payments. Outcomes-based payments are determined for an individual IHH in three stages: • Determination of eligibility for outcomes-based payment • Level of performance on selected measures • Determination of payment There are 18 quality measures in year 1 of the program. Providers will report on all 18 measures. Ten of these measures will be used for outcomes-based payments. Determine IHH’s eligibility for outcomes-based payment To be eligible for any outcomes-based payment, an IHH must report on all 18 measures. For any measures with sub-metrics, reporting must be performed on each sub-metric. All Integrated Health Homes – intensive and non-intensive – can be eligible for payment. Determine IHH’s level of performance for outcomes-based payment Each IHH eligible to receive outcomes-based payments will be split into a performance level. Performance levels are determined based on two factors equally weighed: average percentile performance across all 10 selected measures and lowest performance on any given measure, in comparison with all other IHHs throughout the state. An IHH must achieve a minimum of a Bronze level of performance across 10 selected measures to receive any outcomes-based payment. The average percentile performance will only be calculated across those measures with 30 or more observations in the measure’s denominator, i.e., a practice will only be assessed on any given measure if it has seen at least 30 members eligible for that measure. Similarly, the thresholds for lowest performance on any given measure do not apply for those measures that do not have the minimum of 30 or more observations. Calculate amount of outcomes-based payment due to each IHH IHHs eligible for payment will receive ascending payment amounts based on performance across 10 selected measures: Bronze: 10% of total amount equal to the IHH’s care coordination Per Member, Per Year (PMPY) payment Silver: 25% of total amount equal to the IHH’s care coordination PMPY payment Gold: Silver-level bonus plus additional bonus including all funding remaining in outcomes-based payment pool If there are no remaining funds in the outcomes-based pool, the additional gold bonus is $0. The State will disburse payment within one year of the end of the performance year. For instance, for an outcomes-based payment period from 10/1/2019 through 6/30/2020, the measurement year (MY) would be 10/1/2018 through 9/30/2019. Total pool of funding for outcomes-based payment across all providers The total pool of funding for outcomes-based payment across all providers will consist of funds allocated from the total funds available for the Integrated Health Homes program. The PMPYs distributed to IHHs will be 80% of the previously determined rate.The 20% excluded will be pooled to create the funding for the outcomes based payments. The State reserves the right to review and rebase PMPM rates at least annually, in order to ensure that these rates enable providers to coordinate care for their members to the degree that their needs require. For purposes of this review, the State will consider both the quality and efficiency of care delivered to members, as determined by consideration in aggregate of IHH program members' medical data for the given year against state-selected performance measures, in addition to an assessment of program cost savings as data quality permits. The State will align the review process, as far as is possible, with existing rate review processes, incorporating as appropriate feedback from MCOs and providers. The care coordination per-member-per-month reimbursement rate is posted at TN No: IL-17-0014 Supercedes: n/a Page 34 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

https://www.illinois.gov/hfs/MedicalProviders/cc/Pages/defaultnew.aspx and is effective for dates of services provided on or after October 1, 2018. TN No: IL-17-0014 Supercedes: n/a Page 35 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Assurances  The State provides assurance that it will ensure non-duplication of payment for services similar to Health Homes services that are offered/covered under a different statutory authority, such as 1915(c) waivers or targeted case management. Describe below how non- duplication of payment will be achieved Health Homes are responsible for coordinating all care and therfore providers may not claim for both integrated health home services and TCM services for Medicaid beneficiaries at the same time. The State has determined that: • dually eligible individuals participating in the Medicare-Medicaid Alignment initiative • individuals with third-party liabilities • partially-eligible individuals will not, for the duration of this statuses, be eligible for IHH membership, due to the elevated potential for duplication in care coordination services associated with said individuals. In addition, members entering LTC facilities will, after 90 days within these facilities, have their membership of their IHH suspended for the duration of their stay, in order to avoid duplication and to ensure that IHHs are reimbursed for care coordination only when they can affect delivery of care for their members.  The State meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6), 1902(a)(30)(A), and 1903 with respect to non-payment for provider-preventable conditions.  The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule, unless otherwise described above.  The State provides assurance that it shall reimburse providers directly, except when there are employment or contractual arrangements consistent with section 1902(a)(32). TN No: IL-17-0014 Supercedes: n/a Page 36 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Services MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Service Definitions Provide the state's definitions of the following Health Homes services and the specific activities performed under each service Comprehensive Care Management Definition The State defines comprehensive care management as comprising the following activities. Providers will need to deliver from the set of following activities as reflects member needs (i.e. with greater scope and provision for members in higher needs tiers): • Co-ordinate screenings and assessment as necessary of members by functional assessments by relevant professionals to understand members’ strengths and levels of functional need, thus identifying members with high needs which may not have previously manifested themselves in claims data • Initiate, complete, update, and monitor the progress of a comprehensive, culturally-competent, person-centered, goal-oriented care plan, following a comprehensive assessment of the member’s behavioral and physical health needs within 30 days of member enrollment. Plan should be updated at least twice a year and address the member’s overall health treatment and care coordination needs, including protocols for treatment adherence and crisis management. Input should be incorporated from: o The member, the member’s caregiver, and the member’s social supports (if applicable) o The member’s MCO (if applicable). The IHH should give particular attention in engaging with the MCO on care planning particularly to achieving the requisite prior authorizations for treatment, and, if necessary, making appeals on the member’s behalf o The member’s primary behavioral and physical health providers as well as specialty care providers (within 90 days of enrollment with the Integrated Health Home) • Carry out the member’s comprehensive integrated care plan, through collaboration with a behavioral health provider if the Integrated Health Home is a physical health provider or through collaboration with a physical health provider if the lead entity is a behavioral health provider • Track and make improvements based on quality outcomes • Identify highest risk members on a continuous basis, supported by appropriate stratification tools, aligning within the organization (and, where necessary, with MCOs) to focus resources and interventions Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum • Providers will be supplied by MCOs/State of attributed panel list electronically and will use the list to identify their members • Providers will use analysis and insights from stratification and population health management tools to focus resources and interventions in the care planning process • Providers will have electronic access to – and help coordinate access/usage of – screening and functional assessment data as appropriate to inform the care planning process • Providers will be able to use online/electronic means to refer their members and set up appointments, in order to carry out the members’ integrated care plan • Where appropriate, providers will be able to use members’ EHRs to undertake care planning • Provider focus on this service may be informed by supply by MCOs/State of reports on panel outlining performance on key indicators of care delivery quality and efficiency, with indicators for how to improve performance • Training on relevant topics may be provided via webinars to providers (in addition to via Learning collaboratives) • Transition assistance funding (as applied for through the current 1115 Waiver package) for relevant HIT infrastructure support for delivery of this service may be available for selected providers Scope of service The service can be provided by the following provider types  Behavioral Health Professionals or Specialists Description Same as defined in the Medicaid state plan.  Nurse Practitioner Description Same as defined in the Medicaid state plan. Nurse Care Coordinators  Nurses Description TN No: IL-17-0014 Supercedes: n/a Page 37 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Same as defined in the Medicaid state plan. Medical Specialists  Physicians Description Same as defined in the Medicaid state plan.  Physician's Assistants Description As defined by the Illinois Physician Assistant Practice Act (225 ILCS 95). Pharmacists  Social Workers Description Same as defined in the Medicaid state plan. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists  Other (specify) Provider Type Description Clinical Care Coordinator Clinical care coordinators (further information on qualifications included in provider standards section) will be responsible for the majority of the day-to-day interaction with members and the provision of support to them as needed, particularly with regard to enacting smooth transitions from settings of care, ensuring completion of necessary follow-up, ensuring scheduling and attendance at appointments, engaging in outreach, and coordinating member/family education and support etc.. In this they will consult as necessary with the nurse care manager and specialists (as detailed in the provider standards section). Nurse Care Manager Nurse care managers (further information on qualifications included in the provider standards section) will be responsible in particular for establishing and maintaining linkages and with specialists (e.g., convening interdisciplinary care team meetings), ensuring that specialist input is reconciled and reflected within the care planning process, providing supervisory support for clinical care coordinators (including ensuring that best practices are followed with regards to population health management and the promotion of wellness across the practice) etc. Key specialists with whom the nurse care manager will interact for planning and consultation purposes are detailed in the provider standards section). Care Coordination Definition The State defines care coordination as comprising the following activities. Providers will need to deliver from the set of following activities as reflects member needs (i.e. with greater scope and provision for members in higher needs tiers): • Proactively outreach to partner entities regarding specific gaps in care • Facilitate and participate in regular interdisciplinary care team meetings, including clinicians from the members’ primary behavioral and physical care providers when possible • Communicate with partner entities and other providers (including MCOs) to understand significant changes in members’ medical status, and translate into care plan • Follow up with other providers or clinical staff, including specialists, as needed to understand additional behavioral and physical health needs, incorporating these in the care plan • Maintain following appointment standards for members (stricter requirements for high behavioral health tier members in brackets): o Routine, preventive care available within 5 [3] weeks from request, but within 2 [1] weeks for infants less than 6 months, from the date of request for such care o Urgent care appointments not deemed emergency medical conditions triaged and, if deemed necessary, provided within 24 hours o Appointments for member problems or complaints not deemed serious available within 3 [2] weeks from the date of request for such care o Initial prenatal appointments without expressed problems: 1st trimester within 2 [1] weeks, 2nd trimester within 1 week [5 days], 3rd trimester within 3 days [2 days ] • Provide direct access to members for coverage 24 hours a day, seven days a week, at the very least through an answering service/direct TN No: IL-17-0014 Supercedes: n/a Page 38 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

notification mechanism or other approved arrangement , e.g., secure electronic messaging system and/or video conferencing system to offer interactive clinical advice to members. In addition, providers must develop emergency contact protocols for members to establish contact with clinical personnel directly during crisis situations, and protocols for timely sharing of information with other providers relevant to members’ care • Support scheduling and reduce barriers to adherence for medical and behavioral health appointments, including in-person accompaniment to some appointments • Engage in outreach to establish and renew relationship with member Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum • Providers will be required to be able to receive notifications on members status (e.g., via ADT feeds) • Providers will be able to use online/electronic means to schedule appointments and make referrals for members • Providers will be required to make available direct access to members on a 24/7 basis, potentially through use of a secure electronic messaging system and/or video conferencing system to offer interactive clinical advice to members • Provider focus on this service may be informed by supply by MCOs/State of reports on panel outlining performance on key indicators of care delivery quality and efficiency, with indicators for how to improve performance • Training on relevant topics may be provided via webinars to providers (in addition to via Learning collaboratives) • Transition assistance funding (as applied for through the current 1115 Waiver package) for relevant HIT infrastructure support for delivery of this service may be available for selected providers Scope of service The service can be provided by the following provider types  Behavioral Health Professionals or Specialists Description Same as defined in the Medicaid state plan.  Nurse Practitioner Description Same as defined in the Medicaid state plan. Nurse Care Coordinators  Nurses Description Same as defined in the Medicaid state plan. Medical Specialists  Physicians Description Same as defined in the Medicaid state plan.  Physician's Assistants Description As defined by the Illinois Physician Assistant Practice Act (225 ILCS 95). Pharmacists  Social Workers Description Same as defined in the Medicaid state plan. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists  Other (specify) Provider Type Description Nurse Care Manager Nurse care managers (further information on qualifications included in the provider standards section) will be responsible in particular for establishing and maintaining linkages and with specialists (e.g., convening interdisciplinary care team meetings), ensuring that specialist input is reconciled and reflected within the care planning process, providing supervisory support for clinical care coordinators (including ensuring that best practices are followed with regards to population health management and the promotion of wellness across the practice) etc. Key specialists with whom the nurse care manager will interact for planning and consultation purposes are detailed in the provider standards section). TN No: IL-17-0014 Supercedes: n/a Page 39 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Provider Type Description Clinical Care Coordinator Clinical care coordinators (further information on qualifications included in provider standards section) will be responsible for the majority of the day-to-day interaction with members and the provision of support to them as needed, particularly with regard to enacting smooth transitions from settings of care, ensuring completion of necessary follow-up, ensuring scheduling and attendance at appointments, engaging in outreach, and coordinating member/family education and support etc.. In this they will consult as necessary with the nurse care manager and specialists (as detailed in the provider standards section). Health Promotion Definition The State defines health promotion as comprising the following activities. Providers will need to deliver from the set of following activities as reflects member needs (i.e. with greater scope and provision for members in higher needs tiers): • Coordinate access for members and families to independent living skill and wellness/prevention education, respite care, and peer support • Give information, where relevant, to members and caregivers on pathway to becoming a Recovery Support Specialist • Participate in transition assistance training and learning collaboratives at which best practice on a variety of topics, including health promotion, will be disseminated • Make available settings of care and methods of interaction outside of physical clinics (e.g., telehealth) to accommodate the needs of those members who would prefer a non-clinical setting Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum • Providers may be able to record or plan as appropriate any wellness or education initiatives for the member in their EHR • Providers may be able to use electronic means to refer members or set up appointments for them with specialists on wellness topics • Providers will be encouraged to make settings of care and methods of interaction available that most fit members’ preferences, including via telemedicine and electronic communication Scope of service The service can be provided by the following provider types  Behavioral Health Professionals or Specialists Description Same as defined in the Medicaid state plan.  Nurse Practitioner Description Same as defined in the Medicaid state plan. Nurse Care Coordinators  Nurses Description Same as defined in the Medicaid state plan. Medical Specialists  Physicians Description Same as defined in the Medicaid state plan.  Physician's Assistants Description As defined by the Illinois Physician Assistant Practice Act (225 ILCS 95). Pharmacists  Social Workers Description Same as defined in the Medicaid state plan. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists  Other (specify) TN No: IL-17-0014 Supercedes: n/a Page 40 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Provider Type Description Clinical Care Coordinator Clinical care coordinators (further information on qualifications included in provider standards section) will be responsible for the majority of the day-to-day interaction with members and the provision of support to them as needed, particularly with regard to enacting smooth transitions from settings of care, ensuring completion of necessary follow-up, ensuring scheduling and attendance at appointments, engaging in outreach, and coordinating member/family education and support etc.. In this they will consult as necessary with the nurse care manager and specialists (as detailed in the provider standards section). Nurse Care Manager Nurse care managers (further information on qualifications included in the provider standards section) will be responsible in particular for establishing and maintaining linkages and with specialists (e.g., convening interdisciplinary care team meetings), ensuring that specialist input is reconciled and reflected within the care planning process, providing supervisory support for clinical care coordinators (including ensuring that best practices are followed with regards to population health management and the promotion of wellness across the practice) etc. Key specialists with whom the nurse care manager will interact for planning and consultation purposes are detailed in the provider standards section). Comprehensive Transitional Care from Inpatient to Other Settings (including appropriate follow-up) Definition The State defines comprehensive transitional care as comprising the following activities. Providers will need to deliver from the set of following activities as reflects member needs (i.e. with greater scope and provision for members in higher needs tiers): • Have ability to receive notifications on member status from rendering providers (e.g., via ADT feeds) • Develop a systemic protocol to assure timely access to follow-up care post discharge, reflecting all relevant agency protocols that includes at a minimum all of the following: o Receipt of a summary of care record from the discharging entity o Medication reconciliation o Reevaluation of the care plan to include and provide access to needed community support services o A plan to ensure timely scheduled appointments • Establish relationships with hospitals, residential settings, rehabilitation settings, other treatment settings, LTSS, and support providers to facilitate transitions as member moves between levels of care or back into community. This includes developing protocols for prompt notification and ongoing communication • Communicate and provide education to the member, the member’s supports, the providers located at the setting from which the member is transitioning, and those at the setting to which the member is transitioning • Participate in implementation of discharge plan for each hospitalization to support member’s transition, particularly to ensure all relevant follow-up after discharge takes place (including with partner agencies and member’s MCO). This includes discharges from ERs, inpatient residential, rehabilitative, and other treatment settings. • Coordinate access to additional high touch support in crisis situations when other resources unavailable, or as alternative to ED/CSU (including developing with member crisis self-support plan in advance) Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum • Providers will be required to be able to receive notifications on members status (e.g., via ADT feeds) • Providers will be able to use online/electronic means to supply new settings of care with information as needed in order to plan member care for duration and to prepare for discharge (EHR data may also be used to support providers offering crisis support ) • Provider focus on this service may be informed by supply by MCOs/State of reports on panel outlining performance on key indicators of care delivery quality and efficiency, with indicators for how to improve performance • Training on relevant topics may be provided via webinars to providers (in addition to via Learning collaboratives) • Transition assistance funding (as applied for through the current 1115 Waiver package) for relevant HIT infrastructure support for delivery of this service may be available for selected providers Scope of service The service can be provided by the following provider types  Behavioral Health Professionals or Specialists Description Same as defined in the Medicaid state plan.  Nurse Practitioner Description Same as defined in the Medicaid state plan. TN No: IL-17-0014 Supercedes: n/a Page 41 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Nurse Care Coordinators  Nurses Description Same as defined in the Medicaid state plan. Medical Specialists  Physicians Description Same as defined in the Medicaid state plan.  Physician's Assistants Description As defined by the Illinois Physician Assistant Practice Act (225 ILCS 95). Pharmacists  Social Workers Description Same as defined in the Medicaid state plan. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists  Other (specify) Provider Type Description Nurse Care Manager Nurse care managers (further information on qualifications included in the provider standards section) will be responsible in particular for establishing and maintaining linkages and with specialists (e.g., convening interdisciplinary care team meetings), ensuring that specialist input is reconciled and reflected within the care planning process, providing supervisory support for clinical care coordinators (including ensuring that best practices are followed with regards to population health management and the promotion of wellness across the practice) etc. Key specialists with whom the nurse care manager will interact for planning and consultation purposes are detailed in the provider standards section). Clinical Care Coordinator Clinical care coordinators (further information on qualifications included in provider standards section) will be responsible for the majority of the day-to-day interaction with members and the provision of support to them as needed, particularly with regard to enacting smooth transitions from settings of care, ensuring completion of necessary follow-up, ensuring scheduling and attendance at appointments, engaging in outreach, and coordinating member/family education and support etc.. In this they will consult as necessary with the nurse care manager and specialists (as detailed in the provider standards section). Individual and Family Support (which includes authorized representatives) Definition The State defines individual support as comprising the following activities. Providers will need to deliver from the set of following activities as reflects member needs (i.e. with greater scope and provision for members in higher needs tiers): • Coordinate access to high-touch in-person support to ensure treatment and medication adherence (including medication reconciliation, medication management for specialty medications, medication drop-off, and help arranging transportation to appointments) • Check-in with member to support treatment adherence • Identify and communicate resources to assist individuals and family supporters in acquiring and improving self-help/advocacy, socialization, and adaptive skills • Coordinate access (via MCO if applicable) to caregiver counseling or training including skill development to help members improve function, understand information on their condition, and navigate service system • Seek out and integrate member feedback on all relevant elements of their experience Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum TN No: IL-17-0014 Supercedes: n/a Page 42 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

• Providers will be supplied by MCOs/State of attributed panel list electronically and will use the list to identify their members • Providers will be able to use online/electronic means to engage their members as appropriate, and as reflects member preferences (this will also include telemedicine) • Where appropriate, providers will be able to use members’ EHR records to record further specifications, by their members, of their preferred means of engagement and of any ad-hoc feedback on care delivery • Providers may use online surveys to elicit, where appropriate, members’ feedback on a regular basis • Providers will be able to use online/electronic means to refer their members to other providers or supply these providers with information as needed in order to deliver this service (e.g., providing members’ EHR data to pharmacist) • Provider focus on this service may be informed by supply by MCOs/State of reports on panel outlining performance on key indicators of care delivery quality and efficiency, with indicators for how to improve performance • Training on relevant topics may be provided via webinars to providers (in addition to via Learning collaboratives) • Transition assistance funding (as applied for through the current 1115 Waiver package) for relevant HIT infrastructure support for delivery of this service may be available for selected providers Scope of service The service can be provided by the following provider types  Behavioral Health Professionals or Specialists Description Same as defined in the Medicaid state plan.  Nurse Practitioner Description Same as defined in the Medicaid state plan. Nurse Care Coordinators  Nurses Description Same as defined in the Medicaid state plan. Medical Specialists  Physicians Description Same as defined in the Medicaid state plan.  Physician's Assistants Description As defined by the Illinois Physician Assistant Practice Act (225 ILCS 95). Pharmacists  Social Workers Description Same as defined in the Medicaid state plan. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists  Other (specify) Provider Type Description Clinical Care Coordinator Clinical care coordinators (further information on qualifications included in provider standards section) will be responsible for the majority of the day-to-day interaction with members and the provision of support to them as needed, particularly with regard to enacting smooth transitions from settings of care, ensuring completion of necessary follow-up, ensuring scheduling and attendance at appointments, engaging in outreach, and coordinating member/family education and support etc.. In this they will consult as necessary with the nurse care manager and specialists (as detailed in the provider standards section). Nurse Care Manager Nurse care managers (further information on qualifications included in the provider standards section) will be responsible in particular for establishing and maintaining linkages and with specialists (e.g., convening interdisciplinary care team meetings), ensuring that TN No: IL-17-0014 Supercedes: n/a Page 43 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Provider Type Description specialist input is reconciled and reflected within the care planning process, providing supervisory support for clinical care coordinators (including ensuring that best practices are followed with regards to population health management and the promotion of wellness across the practice) etc. Key specialists with whom the nurse care manager will interact for planning and consultation purposes are detailed in the provider standards section). Referral to Community and Social Support Services Definition The State defines referral to community and social support services as comprising the following activities. Providers will need to deliver from the set of following activities as reflects member needs (i.e. with greater scope and provision for members in higher needs tiers): • Identify community supports where applicable that would facilitate members in achieving their highest level of function, social skill development, independence, and wellness/self-management • Provide information, assistance, and referrals where applicable to members and their caregivers to enhance access to social support services, and undertake follow-up • Attend Integrated Regional Meetings to alert agency partners of gaps in supportive service provision in locality • Engage community partners to support the member outreach process (e.g., to ascertain location, optimal means of communication and approach) • Communicate member needs to community partners and incorporate information from community partners into care planning process, ensuring social determinants of health are addressed within this (e.g., housing situation) • Communicate via MCOs (if applicable) with partner agencies (e.g., DCFS) to involve social supports (e.g., caseworkers) and incorporate appropriate legal guidance • Coordinate consolidation of information on member held by social supports and community partners, with member’s consent, in order to improve care planning and delivery process Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum • Providers will be able to use online/electronic means to refer their members to community and social supports where possible • Where appropriate, providers will be able to use members’ EHR data to provide community and social supports with relevant information on the members’ needs • Where appropriate, providers (and the State/member’s MCO) will be able to share analysis and insights derived from the members’ medical history (including any risk scoring or tier status) and screening/assessment data to give evidence of social functioning and needs • Providers will be expected to engage community and social support services, as applicable, during their attempts to locate and engage members, which may involve usage of secure electronic communications • Provider focus on this service may be informed by supply by MCOs/State of reports on panel outlining performance on key indicators of care delivery quality and efficiency, with indicators for how to improve performance • Training on relevant topics may be provided via webinars to providers (in addition to via Learning collaboratives) • Transition assistance funding (as applied for through the current 1115 Waiver package) for relevant HIT infrastructure support for delivery of this service may be available for selected providers Scope of service The service can be provided by the following provider types  Behavioral Health Professionals or Specialists Description Same as defined in the Medicaid state plan.  Nurse Practitioner Description Same as defined in the Medicaid state plan. Nurse Care Coordinators  Nurses Description Same as defined in the Medicaid state plan. Medical Specialists  Physicians Description Same as defined in the Medicaid state plan.  Physician's Assistants Description As defined by the Illinois Physician Assistant Practice Act (225 ILCS 95). Pharmacists  Social Workers Description TN No: IL-17-0014 Supercedes: n/a Page 44 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Same as defined in the Medicaid state plan. Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists  Other (specify) Provider Type Description Nurse Care Manager Nurse care managers (further information on qualifications included in the provider standards section) will be responsible in particular for establishing and maintaining linkages and with specialists (e.g., convening interdisciplinary care team meetings), ensuring that specialist input is reconciled and reflected within the care planning process, providing supervisory support for clinical care coordinators (including ensuring that best practices are followed with regards to population health management and the promotion of wellness across the practice) etc. Key specialists with whom the nurse care manager will interact for planning and consultation purposes are detailed in the provider standards section). Clinical Care Coordinator Clinical care coordinators (further information on qualifications included in provider standards section) will be responsible for the majority of the day-to-day interaction with members and the provision of support to them as needed, particularly with regard to enacting smooth transitions from settings of care, ensuring completion of necessary follow-up, ensuring scheduling and attendance at appointments, engaging in outreach, and coordinating member/family education and support etc.. In this they will consult as necessary with the nurse care manager and specialists (as detailed in the provider standards section). TN No: IL-17-0014 Supercedes: n/a Page 45 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Services MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Health Homes Patient Flow Describe the patient flow through the state's Health Homes system. Submit with the state plan amendment flow-charts of the typical process a Health Homes individual would encounter Slide showing flow in order: • How eligibility assessed (claims, referrals + claims), • Attribution determination according to pre-set hierarchy • Notification of member/IHH • Conditions for service suspension/end (member switch, opt out, entry into LTC/duplicative care coordination arrangement, decrease in level of need to tier D, i.e. out of population covered by Health Home SPA) Name Date Created 20170426 2000 Member flow vF 4/27/2017 5:04 PM EDT TN No: IL-17-0014 Supercedes: n/a Page 46 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Monitoring Describe the state's methodology for calculating cost saving (and report cost savings annually in Quality Measure Report). Include savings that result from improved coordination of care and chronic disease management achieved through the Health Homes Program, including data sources and measurement specifications, as well as any savings associated with dual eligibles, and if Medicare data was available to the state to utilize in arriving at its cost-savings estimates The state will annually perform analyses of total cost of care per member per month (TCOC PMPM) figures for the IHH target population belonging to each practice, for each member tier. Historic Medicaid claims data using a three-year base period will be employed to determine the average TCOC PMPM for each member tier before program launch. A growth rate will be trended forward on this baseline figure to permit comparison between projected PMPM costs in absence of the program and the actual PMPM costs following program launch. The growth rate will be specific to each tier . The TCOC PMPM will be calculated based on the total Medicaid membership net of the following members to ensure data completeness, consistent service coverage, comparability of pricing, as well as to avoid excessive influence of outliers: • Dual eligible members • Members with third party liabilities • Partially eligible members • Members with fewer than 6 months of attribution period with the attributed practice • Members with extended stay in long-term care facilities (>90 days) • Members whose spend are outliers given their health profile, based on 3M CRG tool In addition, the TCOC PMPM will be calculated making the following spend exclusion: • Spend for vision, dental, and transportation services • NICU spend • Spend for care coordination, including IHH or legacy programs such as targeted case management Describe how the state will use health information technology in providing Health Homes services and to improve service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider) Health information technology will be used in the following ways to support the provision of health home service delivery and coordination across the care continuum. State • Requiring providers seeking to become IHHs either to already possess an EHR at the time of application, or committing to adopt or make measurable progress towards adopting an EHR following the state’s adoption timetable • Reserving the right to select and roll out an ADT system, use of which would be required of all IHH providers • Requiring providers to be capable of engaging in multimodal outreach and engagement with members (including via secure electronic communication) • Supporting IHH providers with potential grants from waiver development funds • (For providers supporting FFS members) Supporting provider population health management through supplying providers with information from applicable risk stratification and member tiering tools • Organizing learning collaborative and training to share best practice for e.g., selection and use of EHR and use of wireless patient technology MCO • (For members in managed care) Supporting provider population health management through supplying providers with information from applicable risk stratification and member tiering tools State/MCO • Providing reports on an ongoing basis to IHHs indicating their performance against key quality and efficiency measures and potential actions that could be taken to improve performance further • Generating and updating member lists/rosters with appropriate privacy safeguards for use by members’ IHHs TN No: IL-17-0014 Supercedes: n/a Page 47 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID | Medicaid State Plan | Health Homes | IL2016MH0001O | IL-17-0014 | Integrated Health Homes Package Header Package ID IL2016MH0001O Submission Type Official Approval Date 7/18/2018 Superseded SPA ID N/A SPA ID IL-17-0014 Initial Submission Date 12/5/2017 Effective Date 10/1/2018 Quality Measurement and Evaluation  The state provides assurance that all Health Homes providers report to the state on all applicable quality measures as a condition of receiving payment from the state  The state provides assurance that it will identify measureable goals for its Health Homes model and intervention and also identify quality measures related to each goal to measure its success in achieving the goals  The state provides assurance that it will report to CMS information submitted by Health Homes providers to inform evaluations, as well as Reports to Congress as described in Section 2703(b) of the Affordable Care Act and as described by CMS  The state provides assurance that it will track avoidable hospital readmissions and report annually in the Quality Measures report TN No: IL-17-0014 Supercedes: n/a Page 48 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/20/2018 6:17 PM EDT TN No: IL-17-0014 Supercedes: n/a Page 49 of 49 Approval Date: July 18, 2018 Effective Date: October 1, 2018

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 19-0012 This file contains the following documents in the order listed: 1) Approval Letter

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

Department of Health & Human Services

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop $2-26-12 « RA &,

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

Financial Management Group November 25, 2019

Theresa Eagleson, Director

Illinois Department of Healthcare and Family Services 201 South Grand Avenue East, 3rd Floor

Springfield, IL 62763-0001

RE: State Plan Amendment (SPA) 19-0012 Dear Ms. Eagleson:

We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number 19-0012. This amendment proposes to increase its rates for facilities licensed by the Department of Public Health under the ID/DD Community Care Act, as well as, facilities licensed under the MC/DD Act and developmental training rates for intermediate care facilities for persons with intellectual disabilities (ICF/ID).

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We have found that the proposed reimbursement methodology complies with applicable requirements and therefore have approved them with an effective date of August, 1, 2019. We are enclosing the CMS-179 and the amended

approved plan pages.

If you have any questions, please contact Fredrick Sebree at Fredrick.sebree@cms.hhs. gov.

Sincerely,

istin Fan Director

ce: Fredrick Sebree Tom Caughey

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTER FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0193 1. TRANSMITTAL NUMBER | 2, STATE: TRANSMITTAL AND NOTICE OF APPROVAL 19-0012 ILLINOIS OF STATE PLAN MATERIAL 3. PROGRAM IDENTIFICATION:

FOR: CENTER FOR MEDICARE AND MEDICAID SERVICES

Title XIX of the Social Security Act (Medicaid)

TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE: CENTERS FOR MEDICARE AND MEDICAID SERVICES August 1, 2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One)

[ ] NEWSTATE PLAN [ ] AMENDMENT TO BE CONSIDERED AS NEW PLAN [X] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT Section 1902 of th i ity Act a. FFY 2019 - $1,084,000 ction 190: e Social Security A © PEV Oued -é:coe ion 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 4.19-D, page 839A OR ATTACHMENT (If Applicable):

Attachment 4.12-D, page 120A Attachment 4.19-D, page 839A

Attachment 4.19-D, page 120A

40. SUBJECT OF AMENDMENT: {D/DD and MC/DD rate increase

11. GOVERNOR'S REVIEW (Check One}

[] GOVERNOR'S OFFICE REPORTED NO COMMENT

[ ] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

[] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[DQ OTHER, AS SPECIFIED: Not submitted for review by prior approval.

16. RETURN TO: Department of Healthcare and Family Services Bureau of Program and Reimbursement Analysis Attn: Mary Doran 201 South Grand Avenue East Springfield, IL 62763-0001

13. TYPED NAME:

14. TITLE: Director of Healthcare and Family Services

18.DATESUBMITTED 9-23 -/G

FOR REGIONAL OFFICE USE ONLY . 17. DATE RECEIVED: 18. DATE APPROVED: NOV 25 2019

PLAN APPROVED—ONE COPY ATTACHED

419. EFFECTIVE DATE OF APPROVED MATERIAL: p FR AUG 0 1 2019

ZITYPEDNAME Kerichin Fin

23. REMARKS:

FORM CMS-179 (07/92) instructions on Back

State: Minols

Attachment 4.19-D Page 894

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES—

REIMBURSEMENT TO LONG TERM CARE FACILITIES

04/19

11. Exceptional Care Rate methodology for persons with complex or extensive medical needs in MC/DD Facilities

a.

Effective for dates of service on or after April 1, 2019, the conditions and services used for the purposes of this Section have the same meanings as ascribed to those conditions and services under the Federal Resident Assessment Instrument (RAD) and specified in the most recent Federal manual.

Effective for dates of service on or after April 1, 2019, for purposes of this Section., a person is considered complex or with extensive medical needs for exceptional care if the person is receiving one of the following medical services:

i. Tier 1 is for residents who are receiving at least 51% of their caloric intake via a feeding tube. ii. Tier 2 is for residents who are receiving tracheostomy care without a

Effective April 1, 2019 through July 31, 2019, medically complex for the developmentally disabled facilities must be reimbursed an exceptional care per diem rate, instead of the base rate, for services to residents with complex or extensive medical needs. Exceptional care per diem rates must be paid for the conditions or services specified under subsection (b) at the following per diem rates: Tier 1 ni Tier 2 $546, and Tier 3 $735. Effective August 1, 2019, the exceptional c: er diem rates for the conditions or servi

subsection (b)} at be reimbursed at the following per diem rates: Tier 1 $337.41, Tier 2 $565.11, and Tier 3 $760.73

Payments are subject to an adjustment if the medical documentation required in subsection 12.c. does not support the resident is receiving the medical services as specified under subsection (b). The reimbursement rate will be adjusted to the appropriate tier for services that are documented pursuant to section 12, If exceptional care services cannot be documented, the facility shall receive their base per diem rate.

TN# 19-0012

Supersedes TN# 19-0001

Approval REV 9g 5 2019 Effective date: 08/01/2019

State: Mlinois

Attachment 4.19-D Page 120A

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES— REIMBURSEMENT TO LONG TERM CARE FACILITIES

097

07/8

08/19

Notwithstanding the provisions set forth in this Section, effective for services beginning September 1, 2017, facilities licensed by the Department of Public Health under the ID/DD Community Care Act as an ID/DD [210 ILCS 47] facility and medically complex for the developmentally disabled facilities licensed under the MC/DD Act [210 ILCS 46] will receive an increase to their reimbursement rate sufficient to provide a $0.75 per hour wage increase for non-executive staff. ,

Notwithstanding the provisions set forth in this Section, effective for services beginning Fuly 1, 2018, facilities licensed by the Department of Public Health under the ID/DD

. Community Care Act [210 ILCS 47] or MC/DD Act [210 ILCS 46] will receive an

increase to the facility per diem rates and developmental training rates as follows:

1. Facilities outside the geographic boundaries of the City of Chicago, will receive an increase to their reimbursement rates sufficient to provide a $0.50 per hour wage increase for non-executive staff.

2. Facilities inside the geographic boundaries of the City of Chicago, will receive an increase to their reimbursement rates sufficient to provide a $0.54 per hour wage increase for non-executive staff.

Notwithstanding the provisi in thi i tive for services beginnin August 1, 2019, facilities licensed by the Department of Public Health under the 1D/DD Community Care Act as an ID/DD [210 ILCS 47] facility and medically complex for the developmentally disabled facilities licensed under the MC/DD Act [210 TLCS 461 will receive a 3.5% increase to the facility per diem rates and developmental training rates

TN # 19-0012

Supersedes TN# 18-0010

Effective date: 08/01/2019

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 19-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 233 N. Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

Regional Operations Group

November 5, 2019

Theresa Eagleson, Director Illinois Department of Healthcare and Family Services 201 South Grand Avenue East, 3rd Floor Springfield, IL 62763-0001

Attn: Douglas Elwell

Dear Ms. Eagleson:

Enclosed for your records is an approved copy of the following State Plan Amendment.

Transmittal #19-0015 -Eliminates Cost Sharing -Effective Date: September 1, 2019 -Approval Date: November 1, 2019 If you have any questions, please have a member of your staff contact Courtenay Savage at 312-353-3721 or via email at Courtenay.Savage@cms.hhs.gov.

Sincerely,

/s/ Ruth A. Hughes Deputy Director Center for Medicaid and CHIP Services Regional Operations Group

Enclosure

cc: Sara Barger, HFS

Mary Doran, HFS Jane Eckert, HFS

Submitted By: Mary Doran Last Revision Date: Oct 29, 2019 Submit Date: Sep 27, 2019 State/Territory name: Illinois Medicaid Premiums and Cost Sharing: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IL-19-0015 Proposed Effective Date 09/01/2019 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 1902 of the Social Security Act Federal Budget Impact Federal Fiscal Year Amount First Year 2019 $2000000.00 Second Year 2020 $24000000.00 Subject of Amendment Elimination of Title XIX copayments Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official TN # 19-0015 Approval Date: Effective Date: 9/1/2019 11/1/19

Page 54 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] 42 CFR 447.51 4.18 Recipient Cost Sharing and Similar Charges through 447.58 (a) Unless a waiver under 42 CFR 431.55(g) applies, deductibles, coinsurance rates, and co-payments do not exceed the maximum allowable charges under 42 CFR 447.54. 1916(a) and (b) (b) Except as specified in items 4.18(b)(4), (5), and (6) below, with respect to of the Act individuals covered as categorically needy or as qualified Medicare beneficiaries (as defined in section 1905(p)(1) of the Act) under the plan: (1) No enrollment fee, premium, or similar charge is imposed under the plan. (2) No deductible, coinsurance, co-payment, or similar charge is imposed under the plan for the following: (i) Services to individuals under age 18, or under—  Age 19  Age 20  Age 21 Reasonable categories of individuals who are age 18 or older, but under age 21, to whom charges apply are listed below, if applicable. (ii) Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy. 11/1/19

Page 55 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 03-10 [Page Left Blank Intentionally] 4.18 (b) (2) (Continued) 42 CFR 447.51 (iii) All services furnished to pregnant women. through 447.58  Not applicable. Charges apply for services to pregnant women unrelated to the pregnancy. (iv) Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution to spend for medical care costs all but a minimal amount of his or her income required for personal needs. (v) Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4). (vi) Family planning services and supplies furnished to individuals of childbearing age. (vii) Services furnished by a managed care organization, health insuring organization, prepaid inpatient health plan, or prepaid ambulatory health plan in which the individual is enrolled, unless they meet the requirements of 42 CFR 447.60. 42 CFR 438.108  Managed care enrollees may be charged deductibles, 42 CFR 447.60 coinsurance rates, and co-payments in an amount equal to the State Plan service cost-sharing.  Managed care enrollees are not charged deductibles, coinsurance rates, and co-payments. 1916 of the Act, (viii) Services furnished to an individual receiving hospice care, as defined Pub.L. 99-272, in section 1905(o) of the Act. (Section 9505) 11/1/19

Page 56 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] 4.18 (b) (Continued) 42 CFR 447.51 (3) Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, through 447.58 coinsurance, co-payment, or similar charges are imposed for services that are not excluded from such charges under item (b)(2) above.  Not applicable. No such charges are imposed. (i) For any service, no more than one type of charge is imposed. (ii) Charges apply to services furnished to the following age groups:  18 or older  19 or older  20 or older  21 or older  Charges apply to services furnished to the following reasonable categories of individuals listed below who are 18 years of age or older but under age 21. 11/1/19

Page 56A STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] 4.18 (b) (3) (Continued) 42 CFR 447.51 (iii) For the categorically needy and qualified Medicare beneficiaries, through 447.58 Attachment 4.18-A specifies the: (A) Service(s) for which a charge(s) is applied; (B) Nature of the charge imposed on each service; (C) Amount(s) of and basis for determining the charge(s); (D) Method used to collect the charge(s); (E) Basis for determining whether an individual is unable to pay the charge and the means by which such an individual is identified to providers; (F) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b); and (G) Cumulative maximum that applies to all deductible, coinsurance or co-payment charges imposed on a specified time period.  Not applicable. There is no maximum. 11/1/19

Page 56B STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] 1916(c)  4.18 (b) (4) A monthly premium is imposed on pregnant women and infants who are of the Act covered under section 1902(a)(10)(A)(ii)(IX) of the Act and whose income equals or exceeds 150 percent of the federal poverty level applicable to a family of the size involved. The requirements of section 1916(c) of the Act are met. Attachment 4.18-D specifies the method the State uses for determining the premium and the criteria for determining what constitutes undue hardship for waiving payment of premiums by recipients. 1902(a)(52)  4.18 (b) (5) For families receiving extended benefits during a second 6-month period and 1925(b) under section 1925 of the Act, a monthly premium is imposed in of the Act accordance with sections 1925(b)(4) and (5) of the Act. 1916(d)  4.18 (b) (6) A monthly premium, set on a sliding scale, imposed on qualified of the Act disabled and working individuals who are covered under section 1902(a)(10)(E)(ii) of the Act and whose income exceeds 150 percent (but does not exceed 200 percent) of the federal poverty level applicable to a family of the size involved. The requirements of section 1916(d) of the Act are met. Attachment 4.18-E specifies the method and standards the State uses for determining the premium. 11/1/19

Page 56C STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] 42 CFR 447.51 4.18 (c) Individuals are covered as medically needy under the plan. through 447.58  (1) An enrollment fee, premium or similar charge is imposed. Attachment 4.18-B specifies the amount of and liability period for such charges subject to the maximum allowable charges in 42 CFR 447.52(b) and defines the State’s policy regarding the effect on recipients of non- payment of the enrollment fee, premium, or similar charge. (2) No deductible, coinsurance, co-payment or similar charge is imposed under the plan for the following: (i) Services to individuals under age 18, or under—  Age 19  Age 20  Age 21 Reasonable categories of individuals who are age 18, but under age 21, to whom charges apply are listed below, if applicable: 11/1/19

Page 56D STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] 42 CFR 447.51 4.18 (c) (2) (Continued) through 447.58 (ii) Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy. (iii) All services furnished to pregnant women.  Not applicable. Charges apply for services to pregnant women unrelated to the pregnancy. (iv) Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution, to spend for medical care costs all but a minimal amount of his income required for personal needs. (v) Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4). (vi) Family planning services and supplies furnished to individuals of childbearing age. 1916 of the Act, (vii) Services furnished to an individual receiving hospice care, as defined Pub.L. 99-272 in section 1905(o) of the Act. (Section 9505) 447.51 through (viii) Services provided by a health maintenance organization (HMO) to 447.58 enrolled individuals.  Not applicable. No such charges are imposed. 11/1/19

Page 56E STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] 4.18 (c) (3) Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, coinsurance, co-payment, or similar charges are imposed on services that are not excluded from such charges under item (b)(2) above.  Not applicable. No such charges are imposed. (i) For any service, no more than one type of charge is imposed. (ii) Charges apply to services furnished to the following age group.  18 or older  19 or older  20 or older  21 or older  Reasonable categories of individuals who are 18 years of age, but under 21, to whom charges apply are listed below, if applicable. 11/1/19

Page 56F STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois MEDICAL ASSISTANCE PROGRAM Citation Condition or Requirement TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] 42 CFR 447.51 4.18 (c) (2) (Continued) through 447.58 (iii) For the medically needy, and other optional groups, Attachment 4.18-C specifies the: (A) Service(s) for which charges(s) is applied; (B) Nature of the charge imposed on each service; (C) Amount(s) of and basis for determining the charges(s); (D) Method used to collect the charge(s); (E) Basis for determining whether an individual is unable to pay the charge(s) and the means by which such an individual is identified to providers (F) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b); and (G) Cumulative maximum that applies to all deductible, coinsurance, or co-payment charges imposed on a family during a specified time period.  Not applicable. There is no maximum. 11/1/19

Attachment 4.18-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois CO-PAYMENTS TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 12-023 [Page Left Blank Intentionally] A. Hospitals 07/12 1. Effective for dates of service July 1, 2012, a co-payment is required for all inpatient days with the exception of those classes of individuals identified in Section B.3. of this attachment. 2. The co-payment is a deduction from the hospital per diem. 07/12 3. The co-payment amount is determined as follows: Inpatient hospital services: a daily copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the copayment amount is $3.90. Copayments for hospital admissions will not exceed a total amount of $75.00. Non-emergency services rendered in an emergency room: a copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the copayment amount is $3.90. 4. The co-payment amounts are automatically deducted from the Department’s per diem payment to the hospital. 5. No provider may deny care or services on account of an individual’s inability to pay a co- payment. (This requirement, however, does not extinguish the liability for payment of the co-payment.) 07/03 6. The exclusions for children and long-term care residents are enforced by MMIS edits using patient age and resident’s information. Those exclusions are enforced based upon indicators entered into the Department’s computer system. Indicators exist for pregnancy, hospice selection and long term care residency upon admission to the Long Term Care facility. Family planning services are uniquely identified by procedure code and drug therapeutic class code. 7. The hospital is required to identify days of care for pregnant women in coding. B. Non-institutional providers 1. The provider is responsible for collecting the co-payment from the patient. The co- payment amount owed by the patient is automatically deducted from the department’s payment, regardless of the provider’s ability to collect from the patient. 11/1/19

Attachment 4.18-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois CO-PAYMENTS TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 12-023 [Page Left Blank Intentionally] 07/12 2. Effective for dates of service July 1, 2012, a co-payment will be assessed to participants based on the following rate: a. A $2.00 co-payment for each over the counter and generic drug billed to the Department. b. For dates of service beginning July 1, 2012 through March 31, 2013, a $3.65 co- payment for each brand name drug billed to the Department. Beginning April 1, 2013, the copayment amount is $3.90. c. For dates of service beginning July 1, 2012 through March 31, 2013, a $3.65 co- payment for each office visit and encounter visit billed to the Department. Beginning April 1, 2013, the copayment amount is $3.90. Except, no co-payment will be assessed for emergency services, as defined in 42 CFR 447.53(b)(4), or for pharmacy products that are so identified in the Department’s point of sale system for pharmacies and listed in notices to providers, available to the public on the Department’s Internet website. 07/12 3. Co-payments will not apply to: a. persons residing in hospitals, nursing facilities, intermediate care facilities for the mentally retarded; b. pregnant women (including a postpartum period of 60 days) ;, c. children under 19 years of age; d. all non institutionalized individuals whose care is subsidized by the Department of Children and Family Services or the Department of Corrections; e. hospice patients; and f. residents of a State-certified, State-licensed, or State-contracted residential care program where residents, as a condition of receiving care in that program, are required to pay all of their income, except an authorized protected amount for personal use, to the cost of their residential care program. For the purpose of this subsection, the protected amount shall be no greater than the protected amount authorized for personal use by the Department. 07/12 4. Co-payments will not be assessed for services paid by Medicare, family planning services, certain medications, cancer chemotherapy, radiation therapy and renal dialysis treatment. 5. Except for those services and drugs excluded, the Department will automatically deduct the appropriate co-payment from the provider. 6. No provider may deny services to an eligible individual due to the individual’s inability to pay the co- payment. However, this does not remove the individual’s liability for the co-payment. The patient will self-declare inability to pay at the time of service. 11/1/19

Attachment 4.18-C Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois CO-PAYMENTS TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 12-023 [Page Left Blank Intentionally] A. Hospitals 07/12 1. Effective for dates of service July 1, 2012, a co-payment is required for all inpatient days with the exception of those classes of individuals identified in Section B.3. of this attachment. 2. The co-payment is a deduction from the hospital per diem. 07/12 3. The co-payment amount is as follows: Inpatient hospital services: a daily copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the copayment amount is $3.90. Copayments for hospital admissions will not exceed a total amount of $75.00. Non-emergency services rendered in an emergency room: a copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the copayment amount is $3.90. 4. The co-payment amounts are automatically deducted from the Department’s per diem payment to the hospital. 5. No provider may deny care or services on account of an individual’s inability to pay a co- payment. (This requirement, however, does not extinguish the liability for payment of the co-payment.) 07/03 6. The exclusions for children and long-term care residents are enforced by MMIS edits using patient age and resident’s information. Those exclusions are enforced based upon indicators entered into the Department’s computer system. Indicators exist for pregnancy, hospice selection and long term care residency upon admission to the Long Term Care facility. Family planning services are uniquely identified by procedure code and drug therapeutic class code. 7. The hospital is required to identify days of care for pregnant women in coding. B. Non-institutional providers 1. The provider is responsible for collecting the co-payment from the patient. The co- payment amount owed by the patient is automatically deducted from the department’s payment, regardless of the provider’s ability to collect from the patient. 11/1/19

Attachment 4.18-C Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois CO-PAYMENTS TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 12-023 [Page Left Blank Intentionally] 07/12 2. Effective for dates of service July 1, 2012 through August 31, 2019, a co-payment will be assessed to participants based on the following rate: a. A $2.00 co-payment for each over the counter and generic drug billed to the Department. b. For dates of service beginning July 1, 2012 through March 31, 2013, a $3.65 co- payment for each brand name drug billed to the Department. Beginning April 1, 2013, the copayment amount is $3.90. c. For dates of service beginning July 1, 2012 through March 31, 2013, a $3.65 co- payment for each office visit and encounter visit billed to the Department. Beginning April 1, 2013, the copayment amount is $3.90. Except, no co-payment will be assessed for emergency services, as defined in 42 CFR 447.53(b)(4), or for pharmacy products that are so identified in the Department’s point of sale system for pharmacies and listed in notices to providers, available to the public on the Department’s Internet website. 07/12 3. Co-payments will not apply to: a. persons residing in hospitals, nursing facilities, intermediate care facilities for the mentally retarded; b. pregnant women (including a postpartum period of 60 days) ;, c. children under 19 years of age; d. all non institutionalized individuals whose care is subsidized by the Department of Children and Family Services or the Department of Corrections; e. hospice patients; and. f. residents of a State-certified, State-licensed, or State-contracted residential care program where residents, as a condition of receiving care in that program, are required to pay all of their income, except an authorized protected amount for personal use, to the cost of their residential care program. For the purpose of this subsection, the protected amount shall be no greater than the protected amount authorized for personal use by the Department. 07/12 4. Co-payments will not be assessed for services paid by Medicare, family planning services, certain medications, cancer chemotherapy, radiation therapy and renal dialysis treatment. 5. Except for those services and drugs excluded, the Department will automatically deduct the appropriate co-payment from the provider. 6. No provider may deny services to an eligible individual due to the individual’s inability to pay the co- payment. However, this does not remove the individual’s liability for the co-payment. The patient will self-declare inability to pay at the time of service. 11/1/19

Attachment 4.18-D Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois PREMIUMS IMPOSED ON LOW INCOME PREGNANT WOMEN AND INFANTS TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] A. The following method is used to determine the monthly premium imposed on optional categorically needy pregnant women and infants covered under section 1902 (a)(10)(A)(ii)(IX)(A) and (B) of the Act: B. A description of the billing method used is as follows (include due date for premium payment, notification of the consequences of non-payment, and notice of procedures for requesting waiver of premium payment); *Description provided on attachment. 11/1/19

Attachment 4.18-D Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois PREMIUMS IMPOSED ON LOW INCOME PREGNANT WOMEN AND INFANTS TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] C. State or local funds under other programs are used to pay for premiums:  Yes  No D. The criteria used for determining whether the agency will waive payment of a premium because it would cause an undue hardship on an individual are described below: *Description provided on attachment. 11/1/19

Attachment 4.18-E Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois OPTIONAL SLIDING SCALE PREMIUMS IMPOSED ON QUALIFIED DISABLED AND WORKING INDIVIDUALS TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] A. The following method is used to determine the monthly premium imposed on qualified disabled and working individuals covered under section 1902(a)(10)(E)(ii) of the Act: Not Applicable B. A description of the billing method used is as follows (include due date for premium payments, notification of the consequences of nonpayment, and notice of procedures for requesting waiver of premium payment): Not Applicable *Description provided on attachment. 11/1/19

Attachment 4.18-E Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Illinois OPTIONAL SLIDING SCALE PREMIUMS IMPOSED ON QUALIFIED DISABLED AND WORKING INDIVIDUALS TN # 19-0015 Approval date: Effective date: 09/01/2019 Supersedes TN # 91-25 [Page Left Blank Intentionally] C. State or local funds under other programs are used to pay for premiums:  Yes  No Not Applicable D. The criteria used for determining whether the agency will waive payment of a premium because it would cause an undue hardship on an individual are described below: Not Applicable 11/1/19

TN # 19-0015 Approval Date: Effective Date: 9/1/2019 Medicaid Premiums and Cost Sharing State Name: Illinois OMB Control Number: 0938‐1148 Transmittal Number: IL - 19 - 0015 Expiration date: 10/31/2014 Cost Sharing Requirements G1 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20140415 11/1/19

Table of Contents State/Territory Name: IL State Plan Amendment (SPA) #: 19-0020 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group

February 6, 2020

Theresa Eagleson, Director Illinois Department of Healthcare and Family Services 201 South Grand Avenue East, 3rd Floor Springfield, IL 62763-0001

Attn: Douglas Elwell

Dear Ms. Eagleson:

Enclosed for your records is an approved copy of the following State Plan Amendment:

Transmittal #19-0020 -Medicare-Medicaid Alignment Initiative End Date Extension -Effective Date: January 1, 2020 -Approval Date: January 31, 2020 If you have any questions, please have a member of your staff contact Courtenay Savage at 312-353-3721 or via email at Courtenay.Savage@cms.hhs.gov.

Sincerely,

/s/ James G. Scott Division Director Division of Program Operations

Enclosure

cc: Kimberley Cox, HFS

Mary Doran, HFS Jane Eckert, HFS

12/31/2019 01/31/2020 01/01/2020 James G. Scott Director, Division of Program Operations

01/31/2020

01/31/2020