Model Application Template for the Children’s Health Insurance Program

Effective Date: July 1, 2010

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OMB #: 0938-0707 Exp. Date:

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

Preamble

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

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

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

Form CMS-R-211

Model Application Template for the Children’s Health Insurance Program

Effective Date: July 1, 2010

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

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

State/Territory:

Kansas

(Name of State/Territory)

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

Andrew Allison, Ph.D.

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

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

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

Name: Barbara Langner, Ph.D.

Position/Title: Medicaid Director Name: Dr. Margaret Smith

Position/Title: Medical Director Name: Ron Smith

Position/Title: Fiscal Manager

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

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

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

1.1.1.

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

1.1.2.

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

1.1.3.

A combination of both of the above.

1.2.

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

1.3.

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

1.4.

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65): Effective date: July 1, 2010 Implementation date: July 1, 2010

Amendment #1 – Effective April 20, 2000 Amendment #2 – Effective May 1, 2001 Amendment #3 – Effective August 21, 2001 Amendment #4 – Effective January 1, 2003 Amendment #5 – Effective July 1, 2003 Amendment #6 – Effective July 1, 2005 Amendment #7 – Effective July 1, 2006 Amendment #8 – Effective January 1, 2010

Amendment #9 - Pending

Amendment #10-Pending

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

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

From 1997 to today, certain studies and reports have been promulgated regarding the uninsured in Kansas. In summary, those are:

September 1997 - The Kansas Health Foundation and the Kansas Department of Health and Environment funded a statewide survey and review of secondary data on insurance coverage. That survey found that 9.4% of the nonelderly population in Kansas was uninsured, and that 31% of the uninsured were children under age 18 (approximately 64,200 children, based on the 1994 Census figures) who were without insurance at the time of the survey. Another 29.9% of those uninsured at some point during the prior year (approximately 25,700) were in this age group. This results in a range of uninsurance for this age group of 64,200 at a point in time to 89,900 at any time over the past year. Adding children aged 18 to this review would, by interpolation, increase the range of uninsured to 67,800 to 91,500.

CPS data from 1993, 1994, 1995 - This data is the basis for the CHIP allocations in FFY 1998. While not statistically significant for Kansas, it showed that there were 60,000 uninsured children under age 19, plus or minus 12,300, for a range of 47,700 to 72,300 children.

March 2001 - Kansas Health Institute Issue Brief 11 - As part of the three-year evaluation of HealthWave 21, the dynamics of the Title 21 and Title 19 programs between July 1, 1998 and June 30, 2000 were evaluated. One of the findings was a majority (68%) of children entering HealthWave 21 had prior experience with Medicaid, and only 19% to 30% of enrollees were new to public insurance. This implies that while children “aging out” of the stair-step Medicaid eligibility ladder still have access to no-cost or low-cost insurance, the program is not reaching as many of the previously uninsured as was anticipated.

August 2001 - Kansas Health Insurance Study - This study, commissioned by the Kansas Insurance Department and funded by a grant from the Health Resources and Services Administration, Department of Health and Human Services, looked at insurance status by age, gender, marital status, education, employment status, and region. Questions about the reasons for uninsurance and health status were asked. This study found that 7.8% of children under age 19 were not insured at the time of the survey. While this percentage is lower than that found in the August 1997 survey for children under age 18 (9.4% versus 7.8%), it

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translates into approximately 55,600 children, based on the 2000 population figures for Kansas from the Census Bureau.

Other notable findings were that children were enrolled in Medicaid/HealthWave 21 at three times the rate of the general public, and that the main reason for uninsurance was the cost.

PROJECTED BASED ON 1997 CPS DATA Age 0-99% FPL 100 – 132% FPL 133- 149% FPL 150- 159% FPL 160- 169% FPL 170- 184% FPL 185- 199% FPL Total 0

10 10 15 15 50 1-5

1,150 783 783 1,174 1,221 5,111 6-14

12,097 6,212 4,230 4,230 6,347 6,597 39,713 15-18

4,608 2,365 1,612 1,612 2,417 2,513 15,126 Total

16,705 9,727 6,635 6,635 9,953 10,346 60,000

2.2. These studies in the aggregate imply that between 1997 and 2001, the reduction in the number of uninsured children under age 19 is somewhere between 12,200 and 35,900, with some enrolled in Medicaid and some enrolled in HealthWave 21.Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

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

Kansas House Substitute for Senate Bill 272, 2005 Session, transferred specific powers, duties and regulatory authority of the Secretary of Social and Rehabilitation Services on an interim basis to a new Division of Health Policy and Finance (DHPF) within the Department of Administration effective July 1, 2005. The Bill provides that DHPF will be the single state agency for Medicaid, Medikan and CHIP in Kansas. The Bill also establishes the Kansas Health Policy Authority (KHPA) effective July 1, 2006 which will eventually assume these programs as well as other medical programs for the State of Kansas.

Initially the program’s outreach focus was on a broad-based mass-marketing effort by the state’s outreach and marketing contractor to gain recognition for the program. Beginning July 1, 2001, the focus shifted to localized and targeted outreach by the SRS area offices and the RWJ/KCSL outreach partners.

Outreach and enrollment activities for Medicaid programs are administered through the Department of Social and Rehabilitation Services and the Kansas Health Policy Authority (KHPA). Education regarding the Medicaid program is provided to

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advocacy groups, schools, health care professionals, social service agencies, and other community organizations who may have contact with children requiring health insurance coverage in an effort to enlist the help of these organizations in identifying children without health insurance coverage and assisting the families in making application for Medicaid. There are also staff located in local field offices and in Central Office who conduct public awareness and education activities for the Medicaid program. In addition, local field staff have out stationing duties at disproportionate shared hospitals and the Federally Qualified Health Centers in the

State including Hunter Health Clinic (FQHC, IHS, & RHC) and United Methodist Health Clinic (FQHC) in Wichita. This provides additional opportunities for outreach and education as well as the initial processing of Medicaid applications.

Outreach activities for Maternal and Child Health and Title V programs are conducted through the Kansas Department of Health and Environment. Through an inter-agency agreement, SRS and KHPA staff refer consumers potentially eligible for these programs to the appropriate agency for eligibility determination. KDHE staff also refer potential Medicaid eligibles to SRS and KHPA.

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

Prior steps taken with the CARING program were completed in a very short time frame resulting in most of these children enrolled in CHIP or Medicaid. The state has enacted legislation to promote business partnerships and initial meetings for design and implementation are taking place in 2002.

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

The State’s CHIP program is marketed as a health insurance program. The marketing program includes coordination of efforts with state and local governmental entities and other child serving agencies, including the:

• Kansas Department of Education • Local Unified School Districts • Local Health Departments • Kansas Insurance Department • Community based organizations, including Indian Health Clinics, providing services

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to American Indian children, and other local community programs that deal with

families of potentially-eligible children including such traditional providers as: • Head Start • School-based clinics • Women Infant and Children (WIC) programs • Maternal Child Health (MCH) programs • Pre-schools • Child-care organizations • Parent-teacher associations • Religious organizations • Grass-root organizations • Other community-based organizations that deal with children.

The specific target audience of consumers are:

• Low-income, Kansas families, up to 241% of the federal poverty level

• Families with uninsured children, 0-18 years of age, who are potentially eligible for the CHIP or Medicaid Program • Families with children with special health care needs • Families without knowledge of, or access to, available health care coverage for their children • Potentially eligible youth, 16-18 years of age who may be living independently • Schools, Local Health Departments, other governmental and private service agencies that interface with low income families • Health care providers including hospitals, physicians, dentists, mental health providers and other providers of health care as directed by the KHPA staff.

A single application form for both Title XIX and CHIP is used and made widely available at numerous access points. In addition a toll free number (1-800-792-4884) is established where interested persons can call for information and to request an application form. Applications are self-addressed for return to a central processing unit. The family still has the option of submitting applications to the local SRS office. Once received, the application is reviewed for Tile XIX eligibility first, and then for Title XXI eligibility if Title XIX eligibility is not established. No reapplication is necessary by the consumer for CHIP determination.

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

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

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

By state statute, service delivery for the CHIP program is provided through capitated managed care arrangements. Limited benefits are carved out and paid fee-for-service. The benefits carved out are dental services, major organ transplants, antihemophiliac medications, and vaccine biologicals. All other health services are obtained through direct contracts with MCOs or MCEs chosen for participation as a result of a competitive Request for Proposal (RFP) process. The program is statewide, with coverage and access requirements contained in the contracts and monitored by the state. Children, through the physical health contractor, are enrolled with a primary care provider who coordinates their health care, including referrals to specialists, where appropriate.

Effective with Dates of Service on or after October 1, 2009, Kansas will ensure the Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) will receive a reimbursement equivalent to that received by those providers under the Medicaid Prospective Payment System (PPS).

For FQHC and RHC services, CHIP encounter claims are included in the clinic reimbursement method in the same manner as Medicaid encounter claims. Effective January 1, 2001, the State implemented the prospective payment system (PPS) to conform with the Benefits Improvements and Protections Act (BIPA) of 2000. There are no retroactive settlements under the PPS system. As an alternative to PPS, providers are offered the opportunity for reimbursement under the modified cost-based system. This method combines features of a cost-based system with the PPS system payment level mandated by BIPA. Under this system, clinics are paid the greater of cost-based or PPS-based reimbursement through retroactive settlements. To receive reimbursement under the alternative system, on a fiscal year basis, providers are required to submit a written request. The written request is required only once. By written request, providers may at any time, change their choice of reimbursement method.

The cost settlement is the difference between the amount paid to the clinic previously for the services through fee reimbursements, encounter reimbursements and wraparound payments and the determined cost-based amount under the alternative method.

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CHIP encounters in Indian Health Clinics are reimbursed by the managed care organizations at 100% of the Medicare Indian Health Service encounter rate negating the need for a wraparound payment. The managed care organizations reimburse all such managed care encounters provided for enrolled member by the Indian Health Clinic using 100% of the Medicare Indian Health Service encounter rate.

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

Utilization control mechanisms are in place for the CHIP program to ensure that children use only health care that is appropriate, medically necessary, and approved by the State or the participating health plan.

Before being approved for participation in the CHIP Program, health plans must develop and have in place utilization review policies and procedures that include protocols for prior approval and denial of services, hospital discharge planning, physician profiling, and retrospective review of both inpatient and ambulatory claims meeting pre-defined criteria. Plans also must develop procedures for identifying and correcting patterns of over and under utilization on the part of their enrollees.

More information can be found on utilization control in Section 7 – Quality and Appropriateness of Care.

Children who are determined presumptively eligible for Title XXI will receive the Title XIX benefit package until such time as eligibility for Title XXI is confirmed or denied. The State of Kansas provides Secretary Approved Coverage for Title XXI eligibles which includes The State Employee Health Plan as the benchmark coverage plus additional coverage that is medically necessary.

When formal determination of the PE application is complete, the child will be enrolled in the appropriate program, either Title XIX or Title XXI. Program placement will be based on established eligibility criteria.

Children who are found presumptively eligible will receive the Title XIX benefit package. Title XIX offers services to persons eligible for Medicaid through a fee-for-service delivery system. These services are available statewide. Medically necessary services are obtained by beneficiaries through Medicaid contracting providers. Children may obtain care from any Medicaid contracting provider of their choice.

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Claims for services being provided to individuals found to be presumptively eligible for CHIP will be processed in accordance with the State Medicaid Manual, Option 1 (report all expenditures at Medicaid match rate). For applicants who qualify at 201 – 241% of Federal Poverty Level, they must not have any active health insurance for the time period of the application date minus 8 months.

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

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

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a)) 4.1.1.

Geographic area served by the Plan: The plan is available statewide. 4.1.2.

Age: Children from birth to age 19 are served. 4.1.3. Income: Income is at or below 241% FPL for the CHIP program. Current Medicaid definitions of family income and those income deductions, disregards, and budgeting methods specified in the State’s Title XIX State Plan is applicable to the CHIP population 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): No resource test is applied. 4.1.5.

Residency (so long as residency requirement is not based on length of time

in state): Children must be residents of Kansas. The citizenship and

immigration status requirements applicable to Title XIX shall also be

applicable to CHIP. 4.1.6.

Disability Status (so long as any standard relating to disability status does

not restrict eligibility): 4.1.7. Access to or coverage under other health coverage: Children up to 200%

Federal Poverty Level are ineligible for CHIP if currently covered by other

health insurance or eligible for Medicaid coverage. Children from 201 – 241%

Federal Poverty Level may not have had insurance coverage for the time

identified time period prior to the application date. The identified time period

is eight months. 4.1.8.

Duration of eligibility: Annual eligibility determination. Twelve months of

continuous eligibility is also applicable to both Title XIX and CHIP even if

family income increases above the income threshold. 4.1.9.

Other standards (identify and describe):

• To be eligible for CHIP coverage, families above 150% of the poverty level must agree to pay a monthly premium which does not exceed the limitations of section 2103(e).

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• Children are ineligible for CHIP coverage if they are eligible for health coverage under the Kansas Group Health Insurance Program, if they are an inmate in a public correctional institution, or if they are a patient in an institution for mental diseases.

• The state requires a social security number for all applicants in accordance with the provisions at 42 CFR 457.340(b).

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

4.2.1.

These standards do not discriminate on the basis of diagnosis.

4.2.2.

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

these standards do not cover children of higher income families without

covering children with a lower family income.

4.2.3.

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

condition.

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

A simplified application/enrollment form is used to access both Medicaid and CHIP coverage. The form is available through a number of access points including schools, churches, medical providers and Social and Rehabilitation Services (SRS). The form is mailed in along with supporting documentation such as wage information to a central clearinghouse. The clearinghouse is responsible for initial processing and eligibility determination for both Medicaid and CHIP and involves privately contracted staff. The Medicaid state agency administers the portion of the clearinghouse responsible for Medicaid determination and case maintenance. Contracted staff is responsible for all CHIP processing and determinations as well as ongoing case management.

The Income Eligibility Verification System (IEVS) is used to confirm income information on an ongoing basis and the Systematic Alien Verification for Entitlements (SAVE) program or an appropriate alternative is used to verify immigration status.

Eligibility is continuous for 12 months and re-established annually. The family must meet all eligibility criteria and have paid any applicable premiums from the prior year to be re-enrolled for a new 12-month period. The amendment effective 1/1/99 allows an infant born to a HealthWave enrolled mother will be retroactively enrolled in HealthWave starting with the month of birth, but will be subject to Medicaid screening and enrollment requirements no later than 90 days from the date the Agency has been notified of the birth of the infant.

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The application/enrollment form will be used to ascertain current health insurance coverage as well as access to state employee coverage. Children found to have current health coverage will be denied eligibility for CHIP coverage.

If application is made for medical assistance under Medicaid or CHIP, the applicant must provide approved documentation for verification of citizenship and identity.

In addition, access to state employee coverage will result in denial of benefits under the CHIP program.

The amendment effective 7/1/01 allows children who had health coverage within six months prior to application for the CHIP program to receive benefits. They will be denied benefits in the situation when other private health coverage is active on the day of application. Kansas does track those who had health coverage within 6 months prior to application. Premiums will be charged to families above 150% of FPL in the CHIP program. There are exceptions which are listed in section 4.4.4.2.

The agency will verify the applicant is not covered by any insurance at the time of application and will monitor any conditions that may contribute to crowd out on at least an annual basis for up to 200% of Federal Poverty Level. For those applicants between 201% - 241% of Federal Poverty Level, the agency will require that private insurance has not been voluntarily terminated within the previous eight months.

Presumptive Eligibility Process

Staff of designated entities selected and trained by the Medicaid state agency are authorized to determine presumptive eligibility. The determination will be completed using only the Kansas Presumptive Eligibility determination tool. The tool will be provided by the agency. If the income of the family group is at or below 241% of the appropriate federal poverty level, the child is presumptively eligible for medical coverage. Children within the CHIP income guidelines may be eligible for medical coverage if he or she has no other health coverage. Information on eligible children will be submitted by the qualified entity to the central clearinghouse within 5 working days. The staff at the designated entity will assist the family in completing a formal application for CHIP and submit it to the central clearinghouse.

Presumptive eligibility begins on the day the designated entity determines that the child appears eligible. If an application is filed on the child’s behalf by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on the day a final determination of eligibility is made. If an application is not filed by the last day of the month following the month the determination of presumptive eligibility was made, the presumptive period ends on that last day.

Each child is eligible for only one period of presumptive eligibility within a 12 month period.

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The 12 month period begins on the first day of presumptive eligibility determination.

Children who are determined presumptively eligible for Title XXI will receive the Title XIX benefit package until such time as eligibility for Title XXI is confirmed or denied. The State of Kansas provides Secretary Approved Coverage for Title XXI eligibles which includes The State Employee Health Plan as the benchmark coverage plus additional coverage that is medically necessary.

When formal determination of the PE application is complete, the child will be enrolled in the appropriate program, either Title XIX or Title XXI. Program placement will be based on established eligibility criteria.

Children who are found presumptively eligible will receive the Title XIX benefit package. Title XIX offers services to persons eligible for Medicaid through a fee-for-service delivery system. These services are available statewide. Medically necessary services are obtained by beneficiaries through Medicaid contracting providers. Children may obtain care from any Medicaid contracting provider of their choice.

Claims for services being provided to individuals found to be presumptively eligible for CHIP will be processed in accordance with the State Medicaid Manual, Option 1 (report all expenditures at Medicaid match rate). For applicants who qualify at 201% - 241% of Federal Poverty Level, they must not have any active health insurance for the time period of the application date minus eight months.

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

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

4.4. Describe the procedures that assure that:

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

Most current Medicaid financial and non-financial requirements as specified in the Title XIX State Plan are applicable to both the Medicaid and CHIP populations. The central clearinghouse described in section 4.3 determines initial eligibility for either Medicaid or CHIP by reviewing income and other information submitted by families. Families are provided coverage under either Medicaid or CHIP dependent upon total income available.

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

Through the use of a combined simplified application/enrollment form and the central clearinghouse, eligibility is determined for either Medicaid or CHIP coverage based on income and age level.

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

All applications are first reviewed for potential Medicaid eligibility, those found ineligible for Medicaid are immediately screened for CHIP eligibility. This process occurs at the same location, with the same workers, and no referral is required.

4.4.4. The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c)) 4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

The application/enrollment form is used to ascertain current health insurance coverage as well as access to state employee coverage. Children found to have current health coverage are denied eligibility for CHIP coverage.

In addition, access to state employee coverage results in denial of benefits under the CHIP program.

Premiums are charged to families above 150% of FPL in the CHIP program.

The central Clearinghouse application processing contractor monitors for substitution for coverage under group health plans through their application decisions software.

4.4.4.2.

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

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This provision is not applicable to coverage dropped by a non-custodial parent (such as a stepparent or absent parent) or by a caretaker relative. It is also no applicable to coverage which was terminated for the following reasons: • Loss of job from which health insurance was provided • Death of a policy holder • Termination of coverage by the policy holder’s employer • Termination of coverage due to financial hardship

Financial hardship exists when the monthly health insurance premium

exceeds 10% of the household gross monthly income. Verification of

the cost is required to establish a financial hardship exemption.

The application/enrollment form is used to ascertain current health insurance coverage as well as access to state employee coverage. Children found to have current health coverage or active health coverage from application date minus 8 months, are denied eligibility for CHIP coverage.

In addition, access to state employee coverage results in denial of benefits under the CHIP program.

Premiums are charged to families above 150% of FPL in the CHIP program.

The central Clearinghouse application processing contractor monitors for substitution for coverage under group health plans through their application decisions software.

Families will need to reapply after satisfactorily meeting the eight month waiting period.

4.4.4.3.

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

4.4.4.4.

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

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

The minimum employer contribution.

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The cost-effectiveness determination.

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

The State has undertaken the following actions:

• Including ethnic information on the application for tracking Indian numbers.

• Including in the outreach media campaign and other outreach activities, the names of the community based organizations that serve Indian children, to assure that families are aware of the program and assist in the enrollment process.

• Using the three Indian Health Clinics as access points to provide enrollment materials and assistance to potentially eligible children.

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

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

Kansas uses methods to reach families when parents are receptive to the consideration of obtaining health insurance for their children. School-based events, such as Kindergarten Round-ups, school enrollments, and program flyers sent home during the winter flu season are methods used to communicate the availability of public health insurance. School nurses assist outreach efforts by informing families of this insurance option.

Scheduled times at other public venues for families to complete an application are effective. Application assistance can take place in health departments during WIC pickup days, or at the state fair in September.

The business community is an effective partner in reaching parents. Many employers open their workforce and places of business to presentations and application assistance.

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

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

6.1. The state elects to provide the following forms of coverage to children:

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(Check all that apply.) (42CFR 457.410(a)) 6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions. 6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If “existing comprehensive state-based coverage” is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is

greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for “existing comprehensive state-based coverage.” 6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.

Coverage the same as the Medicaid State Plan.

This coverage is available to all Title XIX and Presumptively Eligible

CHIP children. Mental Health Services have parity with other covered

services, and are covered at the Medicaid State Plan level.

See Section 6, Attachment A for coverage information regarding

anti-hemophiliac medications and dental services.

Children who are found presumptively eligible will receive the Title

XIX benefit package. Title XIX offers services to persons eligible for

Medicaid through a fee-for-service delivery system. These services are

available statewide. Medically necessary services are obtained by

beneficiaries through Medicaid contracting providers. Children may

obtain care from any Medicaid contracting provider of their choice.

Claims for services being provided to individuals found to be

presumptively eligible for CHIP will be processed in accordance with

the State Medicaid Manual, Option 1 (report all expenditures at

Medicaid match rate). For applicants who qualify at 201% - 241% of

the Federal Poverty Level, they must not have any active health

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insurance for the time period of the application date minus eight

months.

After final determination of 12 months of continuous eligibility is made

for Title XXI, the State of Kansas provides Secretary Approved

Coverage for Title XXI eligibles, which includes The State Employee

Health Plan as the benchmark coverage plus additional coverage that is

medically necessary.

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population (EPSDT) 6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage. 6.1.4.5.

Coverage that is the same as defined by “existing comprehensive state- based coverage” 6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.

Other (Describe)

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

6.2.1.

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

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

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

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

Clinic services (including health center services) and other ambulatory

health care services. (Section 2110(a)(5)) 6.2.6.

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

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

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

Prenatal care and prepregnancy family services and supplies (Section

2110(a)(9)) 6.2.10.

Inpatient mental health services, other than services described in

6.2.18, but including services furnished in a state-operated mental

hospital and including residential or other 24-hour therapeutically

planned structural services (Section 2110(a)(10))

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6.2.11.

Outpatient mental health services, other than services described in

6.2.19, but including services furnished in a state-operated mental

hospital and including community-based services (Section 2110(a)(11) 6.2.12.

Durable medical equipment and other medically-related or remedial

devices (such as prosthetic devices, implants, eyeglasses, hearing aids,

dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

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

Home and community-based health care services (See instructions)

(Section 2110(a)(14)) 6.2.15.

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

Abortion only if necessary to save the life of the mother or if the

pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

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

Inpatient substance abuse treatment services and residential substance

abuse treatment services (Section 2110(a)(18)) 6.2.19.

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

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

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

Physical therapy, occupational therapy, and services for individuals

with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

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

Any other medical, diagnostic, screening, preventive, restorative,

remedial, therapeutic, or rehabilitative services. (See instructions)

(Section 2110(a)(24)) 6.2.25.

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

6.2.26.

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

Enabling services (such as transportation, translation, and outreach

services (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and

not included under this section (Section 2110(a)(28))

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

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

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

6.4. Additional Purchase Options. If the state wishes to provide services under the plan through

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cost effective alternatives or the purchase of family coverage, it must request the

appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010) N/A

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess

of the 10% limitation on use of funds for payments for: 1) other child

health assistance for targeted low-income children; 2) expenditures for

health services initiatives under the plan for improving the health of

children (including targeted low-income children and other low-income

children); 3) expenditures for outreach activities as provided in section

2102(c)(1) under the plan; and 4) other reasonable costs incurred by

the state to administer the plan, if it demonstrates the following (42CFR

457.1005(a)):

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

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

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

6.4.2.

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

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the

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associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for

health insurance coverage that would be provided to such children but for the

purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI

requirements. (42CFR 457.1010(c))

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Section 6 Attachment A OVERVIEW OF THE BENEFITS SCHEDULE 1999 Managed Care Benefits Schedule

The Kansas Children’s Health Plan is known as HealthWave.

Copayments and Deductibles

No copayments or deductibles may be charged to HealthWave members for any of the three service categories, Physical Health Services, Behavioral Health and Substance Abuse Services, and Dental Services listed below. HealthWave members may be liable for the cost of services not covered under this contract, or for the cost of services obtained without following approved prior authorization procedures.

PHYSICAL HEALTH SERVICES

Physician Services

Physician services shall include: Diagnostic and treatment services by participating physicians and other participating health professionals; including office visits; periodic health assessments including school and camp physicals; hospital care; consultation; manipulation; surgical and non-surgical office procedures and injectable medications administered by the physician or medical staff under direction of the physician

Outpatient Services

Outpatient services shall consist of all services requested or directed by the Contractor, or primary care physicians to be provided on an outpatient basis, including diagnostic and/or treatment services; health evaluations, well-child care and routine immunizations according to Centers for Disease Control (CDC) guidelines; drugs administered in an outpatient setting, prescription medications, biologicals, and fluids; inhalation therapy; and procedures which can be appropriately provided on an outpatient basis, including certain surgical procedures, anesthesia, the administration of blood and blood products, recovery room services, ambulatory surgical centers, and hospital outpatient surgical centers.

Inpatient Hospital Services

Inpatient Hospital Services are provided upon prior approval of the Contractor, for evaluation or treatment of conditions that cannot be adequately treated on an ambulatory basis or on an outpatient basis. Hospital Services shall include semi-private room and board; care and services in an

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Section 6 Attachment A

intensive care unit; administered drugs, prescribed medications, biologicals, fluids and chemotherapy; special diets; dressings and casts; general nursing care; use of operating room and related facilities; the administration of blood and blood products; x-rays, laboratory and other diagnostic services; anesthesia and oxygen services; inhalation therapy, radiation therapy; and such other services customarily provided in acute care hospitals.

Inpatient Services at Other Participating Health Care Facilities

A Participant shall be entitled to inpatient services at Other Participating Health Care Facilities for a minimum of sixty (60) days per Contract Year, when medically appropriate as determined by the Contractor. Services shall include semi-private room and board; care and services in an intensive care unit; administered drugs, medications, biologicals, fluids and chemotherapy; special diets; dressings and casts; general nursing care; use of operating room and related facilities; the administration of blood and blood products; x-rays, laboratory and other diagnostic services; anesthesia and oxygen services; inhalation therapy, radiation therapy; and such other services customarily provided in acute care hospitals.

Short-Term Rehabilitative Therapy

Short-term rehabilitative therapy, including physical, speech and occupational therapy, are provided on an inpatient or outpatient basis. Services provided on an outpatient basis are at a minimum of one hundred eighty (180) consecutive days per condition if significant improvement can be expected within sixty (60) days of the first treatment, as determined by the Contractor. Contractor may conduct periodic evaluations as required to assure continued medical necessity. Such coverage is available only for rehabilitation following injuries, surgery or acute medical conditions.

Home Health Services

Home health services are provided for a participant who requires skilled care and is home bound due to a disabling condition, is unable to receive medical care on an ambulatory outpatient basis, and does not require confinement in a hospital or other participating health care facility. Home health services shall be provided by an accredited home health agency which is a participating provider. Home health services include visits by professional nurses and home health aides, medical supplies and durable medical equipment administered or used by such persons in the course of services rendered during such visits and drugs administered in the home setting which are prescribed by a participating provider and which are covered under the plan. Physical, occupational and speech therapy provided in the Home are subject to the benefit limitations described under “Short-Term Rehabilitative Therapy.

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Section 6 Attachment A

Diagnostic Laboratory and Diagnostic and Therapeutic Radiology Services

Diagnostic laboratory and diagnostic and therapeutic radiology services shall include electrocardiograms; electroencephalograms; radiation therapy; Computer Aided Tomography (CAT) scans, Magnetic Resonance Imaging (MRI) procedures, and other diagnostic and therapeutic procedures.

Maternity Care

Maternity care shall include medical, surgical and hospital care during the term of pregnancy, upon delivery and during the postpartum period for normal delivery, spontaneous abortion (miscarriage) and complications of pregnancy.

Family Planning Service Access and Confidentiality

Family Planning Services are a covered benefit. Examples of family planning and reproductive health services are: contraception management, insertion and removal of Norplant, insertion and removal of IUD, Depo Provera Injections, Pap test, pelvic exams, sexually transmitted disease testing, family planning counseling/education or various methods of birth control.

Services for Infertility

Infertility services are covered as determined by the Contractor. These include diagnostic services to establish cause or reason for infertility. Artificial Insemination is covered subject to a maximum of three billable attempts per year of eligibility subject to prior authorization by the Contractor. There is no coverage for donor fees, collection and/or storage of sperm or any other related services.

Vision Services

Vision Services are covered. These services include one complete eye exam, eyeglasses including frames and lenses (limited to three pair per year), and repairs as needed, for members. Eye exams for post-cataract surgery patients up to one year following the surgery and eyeglasses for post-cataract surgery members are covered when provided within one year following surgery. Contact lenses and replacements are covered when ordered by a qualified Contractor provider and when such lenses provide better management of some visual or ocular conditions than can be achieved with eyeglass lenses.

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Section 6 Attachment A

Eye prosthesis includes postsurgical lenses customarily used during convalescence from eye surgery, are covered when ordered by a qualified Contractor provider.

Ambulance Service

A Participant is entitled to ambulance service, provided such ambulance service is Medically Necessary and authorized by the Contractor, or the use of such ambulance service is determined to have been an Emergency Service, as defined in the "Emergency Services" provision below.

Prescribed Drugs

A Participant is entitled to prescribed drugs as defined below. Bidders must propose their Prior Authorization (PA) List. Future PA additions must be prior approved by KHPA.

Plan Design:

Formulary: Open

Quantity/Days Supply: 34-day supply or less (one standard quantity)

Refills: available after 75% of the original supply has been consumed

Prior Authorization may include, but is not limited to: growth hormone, amphetamines/amphetamine mixtures, Accutane, Retin-A

Maximum allowable quantity list: -- must be included in the Vendor’s Proposal.

EXCLUSIONS:

• Drugs for cosmetic purposes

• Drugs available without a prescription, except insulin, acetaminophen, ibuprofen, multivitamins, oral electrolyte solutions (such as Pedialyte), cough and cold preparations. • Appetite suppressants, anorexiants or diet aids • Experimental or investigational drugs • Drugs not registered with the FDA or that do not have FDA approved indications • Drugs furnished by local, state or federal government and any drug to the extent payment of benefits are provided or available from local, state or federal government whether or not that payment or benefit is received, except as otherwise provided by law. • Replacement prescription drugs resulting from loss or theft.

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Section 6 Attachment A Emergency Services

1. Definition of Emergency Services. Services which would be considered emergent by a prudent layperson must be covered under the Contract as required by the Federal Balanced Budget Act of 1997.

2. Emergency Services Within the Service Area. Emergency Services within the Service Area must be obtained from the Primary Care Physician or other Participating Providers. Participating Providers must be available on call twenty-four (24) hours a day, seven (7) days a week, to assist Participants needing Emergency Services. Emergency Services obtained other than as set forth above are covered only if the Contractor, on review, determines that the Participant had no control over where or by whom the Emergency Services were rendered.

3. Emergency Services Outside the Service Area. Participants are covered for Emergency or urgent care services outside the Service Area. Participants must contact the Contractor covering the required emergency service immediately for direction and authorization; however, this requirement shall not cause denial of an otherwise valid claim if the Participant could not reasonably comply, provided that notification is given to the Contractor as soon as reasonably possible. The Contractor, at its option, may arrange to transfer a Participant to a Participating Provider for continued care when medically prudent to do so.

4. Continuing or Follow-up Treatment. Continuing or follow-up treatment, whether in or out of the Service Area, are covered unless authorized in advance by the Primary Care Physician or the Contractor.

Internal Prosthetic/Medical Appliances

Coverage for Internal Prosthetic/Medical Appliances authorized by the Primary Care Physician consists of permanent or temporary internal aids and supports for defective body parts. Repair or maintenance of a covered appliance is covered. Prosthetic devices are limited to the first surgically implanted device and the first ocular or prosthesis required as a result of accidental injury. The plan covers artificial limbs only to the extent of the first such artificial limb required. Special braces required to maintain the function of a disabled limb or required to support a functionally impaired body part. Penile implants only when required as a result of diabetes or other medical conditions. There is a maximum of one implant per lifetime which is a covered benefit unless the prosthetic device or appliance is no longer suitable due to continued growth and/or development, providing the original prosthetic device or appliance was originally provided to a child.

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Section 6 Attachment A Breast Reconstruction and Breast Prostheses

Incidental to a mastectomy, the Participant shall be provided surgical services for breast reconstruction and up to two (2) external post-operative breast prostheses.

Durable Medical Equipment

Durable Medical Equipment, including medical supplies and equipment, which include those necessary for the administration of insulin; and asthma supplies such as, but not limited to, spacers, nebulizers, peak flow meters are covered when deemed necessary and ordered by the primary care physician.

Organ Transplant Services

A Participant is entitled to receive benefits for human organ and tissue transplant services , at limited facilities throughout the United States, as designated by the Contractor, subject to the conditions and limitations below.

1. Definition of Transplant Services. Transplant services are the recipient's medical, surgical and hospital services, inpatient immunosuppressive medications, and organ procurement required to perform the following human to human organ or tissue transplants: kidney, cornea. Other tissue or organ transplants; bone marrow, heart, heart/lung, liver or pancreas, shall be reimbursed on a fee-for- service basis (inpatient hospital service costs only) with prior approval of KHPA. The Contractor shall cover all non-inpatient costs associated with these transplantation services.

2. Preauthorization. Coverage for transplant services must be authorized by the Contractor based on the medical criteria and methodology employed by a transplant facility designated by the Contractor.

Nutritional Evaluation

Initial nutritional evaluation and counseling from a Participating Provider is provided when diet is part of the medical management of a documented disease, including morbid obesity.

Hospice Services

Hospice Care Services when provided, due to Terminal Illness, under a Hospice Care Program is covered. Hospice Care Services shall include inpatient care; outpatient services; professional services of a Physician; services of a psychologist, social worker or family counselor for individual and family counseling; bereavement counseling once every six weeks, and Home Health Services.

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Section 6 Attachment A

Hospice Care Services do not include the following: • services or supplies not listed in the Hospice Care Program; • services for curative or life prolonging procedures; • services for which any other benefits are payable under the Contract; • services or supplies that are primarily to aid the Participant in daily living in excess of 10 days per month; • services for respite care; • nutritional supplements, non-prescription drugs or substances, medical supplies vitamins or minerals.

Oral Surgery Benefits

Benefits for Oral Surgical Procedures of the jaw or gums are covered for;

1. Removal of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth; 2. Removal of exostoses (bony growths) of the jaw and hard palate; 3. Treatment of fractures and dislocations of the jaw and facial bones; 4. Intra-oral X-rays in connection with covered oral surgery if treatment begins within 30 days. 5. General anesthetic for covered oral surgery.

Anti-hemophiliac factors: Providers are directly reimbursed on a Fee-For-Service basis with prior approval of KHPA .

Vaccine Purchases: MCOs are encouraged to coordinate with Kansas Immunization Program Providers in MCO covered regions to facilitate the Immunization Program. MCOs should encourage their network providers not currently participating in the Vaccines for Children program to apply to become Kansas Immunization Program Providers by completing the “Vaccines For Children” (VFC) Program 1998 Provider Enrollment Form.

The State of Kansas deemed our CHIP children as state eligible children for immunizations. The Kansas Health Policy Authority entered into an agreement with the Kansas Department of Health and Environment to buy vaccines for children off of their federal contract. Providers in the CHIP program have their vaccines provided to them off of this contract.

The following vaccines are available in the Vaccines for Children Program. Contractors are notified of any changes to this list of available vaccines.

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Section 6 Attachment A

Vaccines included in the CDC Recommended Childhood Immunization Schedule

Kansas adjusts to meet the CDC immunization schedule when changes are made.

The following vaccines if indicated: Hepatitis A (Hep A) Influenza Virus (Flu) Pneumococcal (Pneumo)

BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES

Inpatient and Outpatient Behavioral Health Services

Coverage of medically necessary inpatient and outpatient mental health/behavioral health services for “biologically based” mental illnesses is a requirement under this Contract. For the purpose of this Contract “biologically based” means the following:

a. Schizophrenia, schizo affective disorder, schizophreniform disorder, brief reactive psychosis, paranoid or delusional disorder, atypical psychosis; b. major affective disorders (bipolar and major depression), cyclothymic and dysthymic disorders;

c. obsessive compulsive disorder;

d. panic disorder

e. pervasive developmental disorder, including autism;

f. other childhood mental illnesses, including attention deficit disorder and attention deficit hyperactive disorder; or

g. borderline personality disorder.

Substance Abuse Services

Inpatient:

Coverage is provided for up to sixty (60) days per plan year, when medically necessary, for rehabilitation when required for diagnosis and treatment of abuse or addiction to alcohol or drugs upon authorization by the Contractor or its designee. Inpatient services are covered only if provided by a facility designated by the Contractor.

The benefits may be exchangeable with partial hospitalization sessions, if medically necessary and appropriate, of not less than three (3) hours and not more then twelve (12) hours in any twenty-four (24) hour period, based upon the following exchange formula: If the charge for one partial hospitalization session does not exceed fifty (50) percent of the allowable charges for one inpatient

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Section 6 Attachment A

day of the average semi-private rate at the Participating Hospital where the session is conducted, the benefit exchange shall be two (2) partial hospitalization sessions equal to one day of inpatient care. If the charge for one partial hospitalization session does not exceed fifty (50) percent of the allowable charges for one inpatient day for the average semi-private rate at the Participating Hospital where the session is conducted, the benefit exchange is one partial hospitalization session equal to one day of inpatient care.

Outpatient:

The following explanation and limitations apply to all rehabilitation services, which are the following: • Community Psychiatric Support and Treatment • Psychosocial Rehabilitation • Peer Support • Crisis Intervention • Outpatient Substance Abuse Services

These rehabilitation services are provided as part of a comprehensive specialized psychiatric program available to all CHIP eligibles with significant functional impairments resulting from an identified mental health diagnosis or substance abuse diagnosis. The medical necessity for these rehabilitative service must be determined by a licensed mental health practitioner or physician who is acting within the scope of his/her professional license and applicable state law, and furnished by or under the direction of a physician, to promote the maximum reduction of symptoms and/or restoration of a recipient to his/her best possible functional level.

Limitations: Services are subject to prior approval, must be medically necessary, must be recommended by a licensed mental health practitioner or physician according to an individualized treatment plan, and must be furnished under the direction of a physician. The activities included in the service must be intended to achieve identified treatment plan goals or objectives. Anyone providing substance abuse treatment services must be licensed under K.S.A. 65-4601, in addition to their scope of practice license.

Medical necessity of the services is determined by a licensed mental health practitioner or physician conducting an assessment consistent with state law, regulation and policy.

Services provided at a work site must not be job tasks oriented. Any services or components of services the basic nature of which are to supplant housekeeping, homemaking, or basic services for the convenience of a person receiving covered services (including housekeeping, shopping, child care, and laundry services) are non-covered. Services cannot be provided in an institute for mental disease (IMD).

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A unit of service is defined according to the HCPCS approved code set unless otherwise specified. Definitions:

The services are defined as follows:

1. Community Psychiatric Support and Treatment (CPST) are goal directed supports and solution-focused interventions intended to achieve identified goals or objectives as set forth in the consumer’s individualized treatment plan. CPST is a face-to-face intervention with the consumer present; however, family or other collaterals may also be involved. The majority of CPST contacts must occur in community locations where the person lives, works, attends school, and/or socializes.

This service may include the following components: A. Assist the consumer and family members or other collaterals to identify strategies or treatment options associated with the consumer’s mental illness, with the goal of minimizing the negative effects of mental illness symptoms or emotional disturbances or associated environmental stressors which interfere with the consumer’s daily living, financial management, housing, academic and/or employment progress, personal recovery or resilience, family and/or interpersonal relationships, and community integration. B. Individual supportive counseling, solution focused interventions, emotional and behavioral management, and problem behavior analysis with the consumer, with the goal of assisting the consumer with developing and implementing social, interpersonal, self care, daily living and independent living skills to restore stability, to support functional gains, and to adapt to community living. C. Participation in and utilization of strengths based planning and treatments which include assisting the consumer and family members or other collaterals with identifying strengths and needs, resources, natural supports and developing goals and objectives to utilize personal strengths, resources, and natural supports to address functional deficits associated with their mental illness. D. Assist the consumer with effectively responding to or avoiding identified precursors or triggers that would risk their remaining in a natural community location, including assisting the consumer and family members or other collaterals with identifying a potential psychiatric or personal crisis, developing a crisis management plan and/or as appropriate, seeking other supports to restore stability and functioning.

Provider qualifications: Must have a BA/BS degree or four years of equivalent education and/or experience working in the human services field. Certification in the State of Kansas to provide the service, which includes criminal, abuse/neglect registry and professional background checks, and completion of a standardized basic training program.

2. Psychosocial Rehabilitation (PSR) services are designed to assist the consumer with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their mental illness. Activities included must be intended to achieve identified goals or objectives as set forth in the consumer’s individualized treatment plan. The intent of psychosocial

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rehabilitation is to restore the fullest possible integration of the consumer as an active and productive member of his or her family, community, and/or culture with the least amount of ongoing professional intervention. PSR is a face-to-face intervention with the consumer present. Services may be provided individually or in a group setting. The majority of PSR contacts must occur in community locations where the person lives, works, attends school, and/or socializes.

This service may include the following components: A. Restoration and support with the development of social and interpersonal skills to increase community tenure, enhance personal relationships, establish support networks, increase community awareness, develop coping strategies, and effective functioning in the consumer’s social environment including home, work and school. B. Restoration and support with the development of daily living skills to improve self management of the negative effects of psychiatric or emotional symptoms that interfere with a person’s daily living. Supporting the consumer with development and implementation of daily living skills and daily routines critical to remaining in home, school, work, and community. C. Implementing learned skills so the person can remain in a natural community location. D. Assisting the consumer with effectively responding to or avoiding identified precursors or triggers that result in functional impairments.

Provider qualifications: Must be at least 18 years old, and have an high school diploma or equivalent. Certification in the State of Kansas to provide the service, which includes criminal, abuse/neglect registry and professional background checks, and completion of a standardized basic training program.

3. Peer Support (PS) services are consumer centered services with a rehabilitation and recovery focus designed to promote skills for coping with and managing psychiatric symptoms while facilitating the utilization of natural resources and the enhancement of community living skills. Activities included must be intended to achieve the identified goals or objectives as set forth in the consumer’s individualized treatment plan. The structured, scheduled activities provided by this service emphasize the opportunity for consumers to support each other in the restoration and expansion of the skills and strategies necessary to move forward in recovery. PS is a face-to-face intervention with the consumer present. Services can be provided individually or in a group setting. The majority of PS contacts must occur in community locations where the person lives, works, attends school, and/or socializes. This service may include the following components:

A. Helping the consumer to develop a network for information and support from others who have been through similar experiences. B. Assisting the consumers with regaining the ability to make independent choices and to take a proactive role in treatment including discussing questions or concerns about medications, diagnoses or treating with their treating clinician. C. Assisting the consumer with the identifying and effectively responding to or avoiding identified precursors or triggers that result in functional impairments.

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Provider qualifications: Must be at least 18 years old, and have a high school diploma or equivalent. Certification in the State of Kansas to provide the service, which includes criminal, abuse/neglect registry and professional background checks, and completion of a standardized basic training program. Self identify as a present or former consumer of mental health services.

4. Crisis Intervention (CI) services are provided to a person who is experiencing a psychiatric crisis, designed to interrupt and/or ameliorate a crisis experience including a preliminary assessment, immediate crisis resolution and de-escalation, and referral and linkage to appropriate community services to avoid more restrictive levels of treatment. The goals of Crisis Interventions are symptom reduction, stabilization, and restoration to a previous level of functioning. All activities must occur within the context of a potential or actual psychiatric crisis. Crisis intervention is a face- to-face intervention and can occur in a variety of locations, including an emergency room or clinic setting, in addition to other community locations where the person lives, works, attends school, and/or socializes. This service may include the following components: A. A preliminary assessment of risk, mental status, and medical stability; and the need for further evaluation or other mental health services. Includes contact with the client, family members or other collateral sources (e.g. caregiver, school personnel) with pertinent information for the purpose of a preliminary assessment and/or referral to other alternative mental health services at an appropriate level. B. Short-term crisis interventions including crisis resolution and de-briefing and follow-up with the individual, and as necessary, with the individual’s caretaker and/or family members. C. Consultation with a physician or with other providers to assist with the individual’s specific crisis.

Provider qualifications: Must be at least 18 years old, and have an AA/AS degree or two years of equivalent education and/or experience working in the human services field. Certification in the State of Kansas to provide the service, which includes criminal, abuse/neglect registry and professional background checks, and completion of a standardized basic training program.

5. Outpatient substance abuse services include an array of consumer centered outpatient and intensive outpatient services consistent with the individual’s assessed treatment needs, with a rehabilitation and recovery focus designed to promote skills for coping with and managing substance abuse symptoms and behaviors. These services are delivered in a wide variety of settings and are nonresidential services designed to help individuals achieve changes in their substance abuse behaviors. Services should address an individual’s major lifestyle, attitudinal and behavioral problems that have the potential to undermine the goals of treatment. Outpatient services may be indicated as an initial modality of service for an individual whose severity of illness warrants this level of treatment, or when an individual’s progress warrants a less intensive modality of service than they are currently receiving. Intensive outpatient treatment is provided any time during the day or week and provides essential skill restoration and counseling services.

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Provider qualifications: Must be licensed under K.S.A. 65-4601.

Detoxification Services: Coverage is provided for detoxification and related medical ancillary services when required for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs. The Contractor decides, based upon medical necessity, whether such services are provided in an inpatient or outpatient setting.

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Section 6 Attachment A DENTAL SERVICES

Coverage for preventative and necessary dental benefits is a requirement under this Contract. Kansas shall cover the following dental care services:

Diagnostic: Includes procedures necessary to assist the dentist in evaluating existing conditions and the dental care required.

Oral examinations twice per plan year not to exceed one every four months

Diagnostic x-rays; bitewings twice per plan year not to exceed one every four months for dependents under age 18 and once every twelve months for adults age 18 and over.

Full mouth x-rays once every five years.

Preventive: Provides for the following:

Prophylaxis/cleaning (including periodontal maintenance) twice per plan year not to exceed one every four months

Topical fluoride twice per plan year not to exceed one every four months

Space maintainers only if under age 9 for premature loss of primary molars

Sealants one per four years for children under age 17 for permanent molars with no decay or restorations.

Ancillary: Provides for visits to the dentist for the emergency relief of pain

Oral-surgery: Provides for extractions and other oral surgery including pre- and post-operative care.

Regular Restorative Dentistry: Provides amalgam, synthetic porcelain and composite white resin restorations on front teeth.

Endodontics: Includes necessary procedures for root canal treatments and root canal fillings.

Periodontics: Includes procedures necessary for the treatment of diseases of the gums and bone

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supporting the teeth.

Section 6 Attachment A

Special Restorative Dentistry: When teeth cannot be restored with a filling material listed under Regular Restorative Dentistry, provides for gold restorations and individual crowns. Buildup and pins covered if tooth had a previous root canal treatment.

TMJ: Limited to specific non-surgical procedures involving Temporomandibular Joint Dysfunction.

Prosthodontics: Includes bridges, partial and complete denture, including repairs and adjustments.

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Section 7. Quality and Appropriateness of Care

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

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

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

Tools to assure quality will include:

 Written provider credential standards.

 Written descriptions of quality standards  Annual audits of plan compliance  Process to survey consumers and providers  HEDIS

7.1.2. Performance measurement Tools to measure performance will include:

 Well-child screening rates  Immunization rates  Responses to satisfaction surveys  Prenatal care compliance  Primary care visit rates

7.1.3. Information strategies

Tools to measure information strategies will include:

 Review of enrollment materials  Survey results  Grievance results

7.1.4. Quality improvement strategies

Tools to monitor quality improvement strategies will include:

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 Corrective action plans  Compliance audits  Review of utilization rates  Review and approval of quality studies

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

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

The state assures access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations by monitoring reports received by the fiscal agent through the analysis of encounter data.

The state uses quality standards, performance measurements, information strategies, and quality improvement strategies to achieve the goals established with the implementation of managed care as a delivery system for CHIP. The following definition of quality of care guides quality management.

“Quality care achieves the best possible health outcomes and functional health status by delivering the most appropriate level of care in a safe environment, with the least possible risk. Quality care is accessible and efficient, provided in the appropriate setting, according to professionally accepted standards, in a coordinated and continuous rather than episodic, manner.”

Goals underlying the implementation of this quality care are:

To improve the quality of services provided to the CHIP population. A central component of the quality management program is the ongoing evaluation of the provision of care and the measurement of key outcomes related to specific conditions or diagnoses important to the CHIP population.

To improve consumer access to health care. The quality management program includes specific access standards which address access to providers, appointments, maximum distance and other structural measures of access to care. Evaluation of outcomes focus on access to primary care services.

Ensure and protect consumer rights and dignity. Consumers are provided a written copy of specific program rights and responsibilities upon enrollment. A consumer survey is sent one time per year to assess consumer satisfaction.

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EXTERNAL MONITORING

External Quality Review Organization (EQRO)

The EQRO does perform on a periodic basis, a review of the quality of services furnished by each managed care contractor. External quality review includes three types of activities: focused studies of patterns of care; individual case review in specific situations; and follow-up activities on previous pattern of care study findings and individual case review findings. This provides KHPA and federal government with an independent assessment of the quality of health care delivered to CHIP beneficiaries enrolled in contracting HMOs. The EQRO works to resolve identified problems in health care and contributes to improving the care of all CHIP beneficiaries. The EQRO works closely with the State and contracting HMOs to insure workable implementation of external review.

INTERNAL MONITORING

Contract Compliance Review

Each of the contracts between KHPA and participating MCO plans contain specific performance objectives. KHPA monitors contracting HMOs, on a periodic basis, to determine compliance with these performance objectives. Areas to be monitored include, but are not limited to:

 The HMO’s complaint/grievance policies and procedures  The policies and procedures used by the HMO to safeguard confidential information  The contents and scope of HMO contract with practitioners  Coordination and continuity of care  The HMO’s credentialing process  The HMO’s denial policies  The scope of the HMO’s member service effort, including health education and prevention programs  Enrollment/disenrollment policies and procedures  Medical records policies and procedures, accessibility and availability  Provider network and access to covered services  The HMO’s organizational structure and administration to monitor and evaluate the care delivered to enrollees  The HMO’s process to survey members and providers

Grievance Review

A grievance is defined as an expression of dissatisfaction about any matter including a denial of or limited authorization of requested service(s).

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A grievance requires formal written documentation. A thorough investigation is made and appropriate resolution presented to the consumer. All calls and letters from members are received in the customer service unit. Every inquiry (calls or letters) are logged. Once the inquiry is logged, it is evaluated to determine if the inquiry should be handled by professional medical staff.

Professional medical staff receives grievances regarding utilization, quality of care, and access. Each inquiry is researched thoroughly and responded to. Clinical education is given to members by this staff.

At any time a consumer may request a fair hearing from the state in conjunction with a grievance.

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

Methods to ensure access include, but are not limited to the following:

 Monitoring of numbers of various providers in each county.  Study of twenty four hour seven days a week accessibility on a random basis.  Studies of waiting times - offices, hospital ER, and clinics.  Monitoring of enrollment, and disenrollment reports.  Monitoring of grievances.  Study of distance and travel time between providers and consumers  Consumer satisfaction surveys.  Study of emergent and non-emergent patterns of ER usage.  Study of appointment time (office, urgent, emergent) scheduling.

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

Contracts with the MCOs require the following:

• Access Standards which is inclusive of specialty networks; • Assignment of beneficiaries; and • Referral Standards

The Title V Director sends medical care plans for children with special health care (Title V) needs to the MCO. The MCO Medical Director and the Title V Director send a letter to the child’s primary care provider that includes the child’s medical

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care plan asking the primary care provider’s cooperation in providing the necessary referrals for the child to continue to receive services from current specialists.

The provider network is sent electronically to the EQRO who, in turn, monitors access through GEO mapping. If gaps are noted, recruitment efforts are initiated on the part of the MCO and an exception mapping occurs in six (6) months.

Beneficiaries are automatically assigned to a primary care provider in the MCO in order to assure immediate access to care. The beneficiary may choose to change providers after enrollment by notifying the MCO. This is monitored through complaints and grievances.

These issues are monitored through the EQRO by their annual audit of the MCO. In the annual audit the EQRO obtains a list of all denied claims. From this list a sample is taken and the areas that are reviewed are: timeliness of filing, referral standards, provider’s in or out-of-network, and appropriateness of denial. The findings are reported to the State, the State then works with the MCO to address any issues that arise.

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

The contracts with the MCOs require that decisions regarding all covered services be made no longer than 48 hours after the request.

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Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

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

8.2.1. Premiums: $20 per month per family where family income is between 151% and 175% of FPL $30 per month per family where family income is between 176% and 200% of FPL $50 per month per family where family income is between 201% and 225% of FPL $75 per month per family where family income is between 226% and 241% of FPL

8.2.2. Deductibles: None

8.2.3. Coinsurance or copayments: None

8.2.4. Other: None

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

Information regarding premiums is provided with the application and upon eligibility determination and redetermination if the family is in premium paying status. The HealthWave website (www.kansashealthwave.org), brochure, provider’s offices, all have premium information.

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

8.4.1.

Cost-sharing does not favor children from higher income families over

lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including

age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

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8.4.3

No additional cost-sharing applies to the costs of emergency medical

services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR

457.515(f))

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

Premium limits were established to insure that the aggregate cost-sharing for a family did not exceed 5% of the family’s annual income. Families have the option of paying monthly, quarterly, or on any other basis convenient to the family. The only requirement is that the full amount of the premium requirement be paid before renewal.

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

An ethnicity designator is collected at the time of application. This is a self-declaration field on the application. If the indicator for a family is marked American Indian or Alaskan Native and they are eligible for Title XXI, no premium is charged.

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

An enrollee family has a full year to meet their premium obligation. Notices are sent monthly outlining the amounts due, or paid. At 45 days before the end of the eligibility period, a final notice is sent informing the enrollee that if the premium is not paid in full coverage ends. An enrollee must pay all delinquent premiums, or provide information that they are no longer in a premium paying status, before eligibility is redetermined.

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

State has established a process that gives enrollees reasonable

notice of and an opportunity to pay past due premiums,

copayments, coinsurance, deductibles or similar fees prior to

disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to

show that the enrollee’s family income has declined prior to

disenrollment for non payment of cost-sharing charges. (42CFR

457.570(b))

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In the instance mentioned above, that the state facilitates

enrolling the child in Medicaid or adjust the child’s cost-sharing

category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an

impartial review to address disenrollment from the program.

(42CFR 457.570(c))

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

8.8.1.

No Federal funds are used toward state matching requirements. (Section

2105(c)(4)) (42CFR 457.220) 8.8.2.

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

and all other types) is used toward state matching requirements. (Section

2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title are used for coverage if a private insurer

would have been obligated to provide such assistance except for a

provision limiting this obligation because the child is eligible under the

this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining

Medicaid eligibility are not more restrictive than those applied as of

June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title

includes coverage of abortion except if necessary to save the life of the

mother or if the pregnancy is the result of an act of rape or incest.

(Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.

No funds provided under this title are used to pay for any abortion or to

assist in the purchase, in whole or in part, for coverage that includes

abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

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Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

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

1. Reduce the number of uninsured non-Medicaid eligible children under 19 years of age and below 241% FPL in the State of Kansas.

2. Assure that the enrolled children with significant health needs have access to appropriate care.

3. Assure that the enrolled children receive high quality health care services.

4. Increase the percentage of enrolled children with regular preventive care.

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

Strategic Objective #1

Performance Goal: To reduce the number of children eligible for HealthWave XXI coverage within the State of Kansas without insurance to less than 5% of the total number of children of all income levels.

Performance Measure: We are measuring what percentage of the total number of children below 19 years of age and eligible for Medicaid or CHIP are uninsured.

Strategic Objective #2

Performance Goal: Enrollment in HealthWave XXI continues to increase by a rate of 3% as indicated by an increase of coverage of children eligible for CHIP.

Performance Measure: The number of children who qualify for medical benefits in the State of Kansas is constantly changing. With our ability to educate the public and potential members, Kansas has reached a capacity and is no longer to meet the numerical expectations of a new plan when it comes to growth. Kansas will take a new approach to reach and increase enrollment based on achieving enrollment of a percentage of the potential members.

This will be measured by subtracting the sum of the previous year’s final number of eligible members (PY elig) from the current year’s final number of eligible members (CY elig) and then dividing the sum by the previous year’s final number of eligible members ((CY elig. – PY elig.)/PY elig.).

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Strategic Objective #3

Performance Goal: Annually, a minimum of 80% of children enrolled in CHIP report overall satisfaction with their health plan.

Performance Measure: The Consumer Assessment of Health Plan Study (CAHPS) survey will reflect that 80% of the surveyed children/families express satisfaction with the health plan.

Strategic Objective #4

Performance Goal: Eighty percent of enrolled children receive one or more Early and Periodic Screening Diagnostic and Treatment (EPSDT) services.

Performance Measure: The State’s contracts require reporting quarterly to KHPA through the CMS 416 format over a rolling 12 month period. KHPA will review these quarterly reports to assess compliance, and discuss MCOs improvements where necessary.

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

The State contracts with an External Quality Review Organization (EQRO) to verify performance goals and identify needed areas of improvement.

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

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

Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

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

The extent to which outcome measures show progress on one or more

of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger

than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which

measures will be collected, such as: 9.3.7.1.

Immunizations 9.3.7.2.

Well child care

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9.3.7.3.

Adolescent well visits 9.3.7.4.

Satisfaction with care 9.3.7.5.

Mental health 9.3.7.6.

Dental care 9.3.7.7.

Other, please list: 9.3.8.

Performance measures for special targeted populations.

9.4.

The state assures it will collect all data, maintain records and furnish reports to

the Secretary at the times and in the standardized format that the Secretary

requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation

required under Section 10. Briefly describe the state’s plan for these annual

assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

The State of Kansas currently follows, and plans to continue to follow, the

template for the annual report provided by NASHP.

9.6.

The state assures it will provide the Secretary with access to any records or

information relating to the plan for purposes of review of audit. (Section

2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify

those measures to meet national requirements when such requirements are

developed. (42CFR 457.710(e))

9.8.

The state assures, to the extent they apply, that the following provisions of the

Social Security Act will apply under Title XXI, to the same extent they apply

to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

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

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to

limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations

and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be

filed)

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

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The conception of the CHIP program in Kansas occurred through multiple stakeholder meetings during 1997 and 1998. These meetings included members of the Kansas Legislature, Kansas Insurance Department, Kansas Medical Society, The Kansas Department of Health and Environment, local pediatricians and pharmacists, physical health providers, health care professional associations, SRS employees and advocacy groups. Their input was used in the design of Senate Bill 424, which authorized the CHIP plan for the State of Kansas.

The Medicaid Director chairs a committee, Medical Care Advisory Council (MCAC) which represents beneficiaries and various health care professionals. The purpose is to provide input into the current processes of the CHIP program. Community advocates and provider boards are both utilized when appropriate and unhindered by HIPAA regulations.

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

Kansas Health Policy Authority will establish and maintain periodic meetings to consult and obtain feedback specifically with the Indian Tribe Medical Directors and/or designees, prior to implementation of any plan amendments, waiver requests, and proposal for demonstration projects likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations. A process for written notice and feedback from Tribal leaders regarding changes in the CHIP program is in place.

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

Prior public notice was published in the Kansas Register on December 19, 2002, in relationship to CHIP State Plan Amendment #4 which increases premiums for HealthWave.

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9.10 Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

Actual and Projected Budget for Kansas CHIP Program - as of November 2010

Federal Fiscal Year 2010 total costs

Federal Fiscal Year 2011 premium change, PPS payments, and mental health parity

Change between 2010 to 2011

Benefit Costs

Insurance payments

Managed care 58,310,000 63,010,500 4,700,500

per member/per month rate X # of member months 116.62 X 500,000 120.02 X 525,000 *3.40 X 25,000

* Fee for Service (FFS) FFS increase for RHC and FQHC wrap payments and cost settlements 13,262,600

0.00 13,262,600

1,200,000 0.00

1,200,000

Total Benefit Costs 71,572,600 77,473,100 5,900,500

(Offsetting beneficiary cost sharing payments) (2,932,000) (3,078,600) (146,600)

Net Benefit Costs

68,640,600

74,394,500

5,753,900

Administration Costs

Personnel

General administration

Contractors/Brokers (e.g., enrollment contractors)

6,520,900

6,520,900 0.00

Claims Processing

Outreach/marketing costs

Other

Total Administration Costs 6,520,900 6,520,900 0.00

10% Administrative Cost Ceiling

6,864,060

7,439,450

575,390

Federal Share (multiplied by enhanced FMAP rate)

54,319,216

57,725,046

3,405,830

State Share

20,842,284

23,190,354

2,348,070

TOTAL PROGRAM COSTS

75,161,500

80,915,400

5,753,900

Enhanced FMAP eff. 10-1-09

0.7227

0.7134

(0.0093) *Note: Source of State Share - State General Fund and $2,000,000 Tobacco settlement funds . *Note: Contractor includes payment for applications, processing, enrollment, marketing, and fiscal agent functions. *Note: The RHC/FQHC wrap increase is included. *Note: The PMPM amount is increased by 3.40 for MH parity.

 Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.  Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

Model Application Template for the Children’s Health Insurance Program

Effective Date: July 1, 2010

51 Approval Date:

Section 10. Annual Reports and Evaluations (Section 2108)

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

10.1.1.

The progress made in reducing the number of uncovered low-income

children and report to the Secretary by January 1 following the end of

the fiscal year on the result of the assessment, and

10.2.

The state assures it will comply with future reporting requirements as they are

developed. (42CFR 457.710(e))

10.3.

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

Section 11. Program Integrity (Section 2101(a))

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

11.1.

The state assures that services are provided in an effective and efficient manner

through free and open competition or through basing rates on other public and private

rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

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

42 CFR Part 455 Subpart B (relating to disclosure of information by

providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related

information) 11.2.3.

Section 1126 (relating to disclosure of information about certain

convicted individuals) 11.2.4.

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

Section 1128B (relating to criminal penalties for certain additional

charges) 11.2.6.

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

collection program)

Model Application Template for the Children’s Health Insurance Program

Effective Date: July 1, 2010

52 Approval Date:

Section 12. Applicant and enrollee protections (Sections 2101(a))

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

Eligibility and Enrollment Matters

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

The state contracts with a private entity to manage, determine and redetermine eligibility and to collect premium fees. The State of Kansas follows the Kansas Medicaid Fair Hearing and Appeal process for CHIP.

Health Services Matters

12.2. Please describe the review process for health services matters that complies with 42 CFR §457.1120.

The state contracts with an External Quality Review Organization (EQRO) to perform an annual audit of the Title 21 Service Delivery Program. The State of Kansas follows the Kansas Medicaid Fair Hearing and Appeal process for CHIP.

Premium Assistance Programs

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

N/A

KANSAS TITLE XXI PROGRAM FACT SHEET

Name of Plan: HealthWave

Date Plan Submitted: July 14, 1998 Date Plan Approved: September 1, 1998 Plan Effective Date: July 1, 1998

Date Amendment #1 Submitted: March 30, 1999 Date Amendment #1 Approved:

April 20, 2000 Date Amendment #1 Effective:

April 20, 2000

Date Amendment #2 Submitted: March 21, 2001 Date Amendment #2 Approved:

June 22, 2001 Date Amendment #2 Effective:

May 1, 2001

Date Amendment #3 Submitted:

June 20, 2002 Date Amendment #3 Approved:

September 18, 2002

Date Amendment #4 Submitted:

December 5, 2002

Date Amendment #4 Approved:

March 5, 2003 Date Amendment #4 Effective:

January 1, 2003

Date Amendment #5 Submitted:

June 11, 2003 Date Amendment #5 Approved:

September 8, 2003 Date Amendment #5 Effective:

July 1, 2003

Date Amendment #6 Submitted:

August 3, 2005

Date Amendment #6 Approved:

October 17, 2005 Date Amendment #6 Effective:

July 1, 2005

Date Amendment #7 Submitted:

March 31, 2006

Date Amendment #7 Approved:

July 31, 2006 Date Amendment #7 Effective:

July 1, 2006

Date Amendment #8 Submitted:

November 6, 2009 Date Amendment #8 Approved:

February 4, 2010 Date Amendment #8 Effective:

January 1, 2010

Background

• On September 1, 1998, Kansas received approval for its initial Title XXI State plan, HealthWave, a separate child health program, to expand coverage to low-income children in families with incomes up to 200 percent of the Federal Poverty Level (FPL), who are not eligible for Medicaid.

Amendments

• On March 30, 1999, Kansas submitted its first State plan amendment to allow an infant born to a mother, who is under age 19 and enrolled in HealthWave, to retroactively enroll in HealthWave starting with the month of birth as a means of ensuring continuity of care for the newborn. However, the infant must be screened for Medicaid eligibility and enrolled in Medicaid, if appropriate, no later than 90 days from the date the Agency was notified of the infant’s birth. The mother of the infant will already be screened for Medicaid eligibility as a pregnant woman, with a family size that includes the unborn child. This amendment also specifies that the clearinghouse contractor is responsible for enrollment of HealthWave eligibles into participating health plans.

• On March 21, 2001, Kansas submitted its second State plan amendment to eliminate the requirement that a child be uninsured for a 6-month period prior to application to its separate child health insurance program, HealthWave.

• On June 28, 2002, Kansas submitted its third amendment to update and amend the CHIP State plan to indicate the State’s compliance with the final CHIP regulations.

• On December 5, 2002, Kansas submitted its fourth amendment to increase premiums from $10 to $30 per month per family where family income is between 151 and 175 percent of the FPL and from $15 to $45 per month per family where family income is between 176 percent and 200 percent of the FPL.

• On June 11, 2003, Kansas submitted its fifth amendment to decrease premiums from $30 to $20 per month per family where family income is between 151 percent and 175 percent of the FPL and from $45 to $30 per month per family where family income is between 176 percent and 200 percent of the FPL.

• On August 3, 2005, Kansas submitted its sixth amendment to reflect changes made by the Kansas Legislature to transfer the authority to administer the State’s CHIP program from the Secretary of Social and Rehabilitation Services on an interim basis to a new Division of Health Policy and Finance within the Department of Administration. This amendment also reflects the establishment of the Kansas Health Policy Authority, which will permanently assume administration of CHIP in Kansas.

• On March 31, 2006, Kansas submitted its seventh amendment to add presumptive eligibility (PE) for children ages 0 through 18 who appear to be eligible for the State’s Title XXI State plan until a final eligibility determination is made. It also streamlines the administrative processing of dental claims for the Kansas Medical Assistance Program (KMAP) by having one entity responsible for claims payment of both Title XIX and Title XXI dental claims. In addition, the amendment removes the $1,500 stop loss (annual dental limit) for managed care organizations.

• On November 6, 2009, Kansas submitted its eighth CHIP amendment which expands eligibility for children from 200 up to 241 percent of the Federal poverty level (FPL).

3

It also added HEDIS as one of the State’s quality tools and updates several performance goals and measures with existing goals to enhance its monitoring of CHIP. It also updated Kansas’ consultation practices with the Native American population. Lastly, the amendment changes the name of the State Agency from the Division of Health Policy and Finance to the Kansas Health Policy Authority.

Children Covered Under Program

• The State reports that there were 48,090 children were ever enrolled in Kansas’ CHIP program for Federal fiscal year (FFY) 2009.

Administration

• Effective July 1, 2005, the authority to administer CHIP is transferred from the Secretary of Social and Rehabilitation Services on an interim basis to a new Division of Health Policy and Finance within the Department of Administration. Effective July 1, 2006, the Kansas Health Policy Authority was established and assumed administration of CHIP in Kansas.

• Effective January 1, 2010, the name of the State Agency changed from the Division of Health Policy and Finance to the Kansas Health Policy Authority.

• Eligibility is continuous for 12 months and re-established annually.

• Presumptive eligibility is provided for children who appear to be eligible for the State’s Title XXI State plan.

Health Care Delivery System

• The State contracts with entities that include insurance companies, health maintenance organizations, non-profit dental service corporations, or non-profit hospital and medical insurance corporations.

Benefit Package

• Children who are determined presumptively eligible for the Title XXI will receive the Title XIX benefit package until such time as eligibility for Title XXI is confirmed or denied. Title XIX offers services to persons eligible for Medicaid through a fee for service delivery system. These services are available statewide. Medically necessary services are obtained through Medicaid contracting providers. Children may obtain care from any Medicaid contracting provider of their choice.

• The State provides a Secretary-approved benefit package for CHIP eligible children which includes the State Employee Health Plan as the benchmark coverage plus additional coverage that is medically necessary.

4 Crowd-Out Strategy

The State does not have a waiting period below 200 percent of the FPL. For those applicants above 200 up to and including 241 percent of the FPL, the State will require that group health insurance has not been voluntarily terminated within the previous 8 months prior to the application date for CHIP. This 8-month period of uninsurance was mandated by the State legislature. Exceptions to the waiting list include the loss of a job from which health insurance was provided or the termination of coverage by the employer; death of a policy holder; termination of coverage by anon-custodial parent or caretaker relative; and termination of coverage due to financial hardship. The State has defined financial hardship as existing when the monthly health insurance premium exceeds 10 percent of the household gross monthly income. Verification of the cost is required to establish a financial hardship exemption.

Cost Sharing

• No coinsurance, copayments or deductibles are charged.

• No copayments or premiums are charged for children with family incomes at or below 150 percent of the FPL, or for any American Indian and Alaskan Native children, regardless of income level.

• The HealthWave Program has enrollee cost-sharing responsibilities in the form of premiums for children with family incomes above 150 percent of the FPL. They are as follows:

 Premiums of $20 per month per family are charged to families with incomes from 151 percent through 175 percent of the FPL.  Premiums of $30 per month per family are charged to families with incomes from 176 percent through 200 percent of the FPL.  Premiums of $50 per month per family are charged to families with incomes from 201 percent through 225 percent of the FPL.  Premiums of $75 per month per family are charged to families with incomes from 226 percent through 241 percent of the FPL.

• The State established premium limits to insure that the aggregate cost sharing for a family does not exceed 5 percent of the family’s annual income. Families have the option of paying monthly, quarterly or on any other basis convenient to the family. The only requirement is that the full amount of the premium be paid before renewal.

State Outreach and Enrollment Activities

• Kansas uses methods to reach families when parents are most receptive to the consideration of obtaining health insurance for their children. School-based events, such as Kindergarten Round-ups, school enrollments, and program flyers sent home during the winter flu season are methods used to communicate the availability of public health assistance. School nurses assist outreach efforts by informing families of this insurance option.

5

• The State scheduled times at other public venues for families to complete an application are effective. Application assistance can take place in health departments during WIC pick-up days, or at the State Fair in September.

• The business community is an effective partner in reaching parents. Many employers open their workplaces to presentations and application assistance to their workforce.

• Kansas’ State Medicaid Director chairs a Committee, Medical Care Advisory Council (MCAC) which represents beneficiaries and various health care professionals. The purpose is to provide input into the current CHHIP processes. Community advocates and provider boards are both utilized when appropriate and unhindered by HIPAA regulations.

• The State has process for written notice and feedback from Tribal leaders regarding changes in CHIP. It establishes and maintains periodic meetings to consult and obtain feedback with the Indian Tribe Medical Directors prior to implementation of any SPAs, waiver requests, and proposals for demonstration projects that are likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations.

Coordination between CHIP and Medicaid

• Through the use of combined simplified application/enrollment form and the central clearinghouse, eligibility is determined for either Medicaid or CHIP coverage based on income and age level.

Financial Information

Total Federal Fiscal Year 2010 CHIP Allotment – $60,287,325 FFY '10 Enhanced Federal Matching Rate – 72.27%

Date last updated: CMS, CMSO, Division of State Children’s Health Insurance, March 12, 2010

_____________________________________________________________________________

Table of Contents

State/Territory Name: Kansas

State Plan Amendment (SPA) #: KS-14-0009

This file contains the following documents in the order listed:

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

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

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

7500 Security Boulevard, Mail Stop: $2-26-12 Baltimore, Maryland 21244-1850

CCMs

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

Children and Adults Health Programs Group JUN 25 2014

Susan Mosier, MD

State Medicaid Director

Kansas Department of Health and Environment Division of Health Care Finance

Landon State Office Building

900 SW Jackson Street, Suite 900-N

Topeka, KS 66612-1220

Dear Dr. Mosier:

Tam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number KS-14-0009, submitted on March 27, 2014. This SPA is related to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

In SPA number KS-14-0009, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. The supporting document to CS7 describes the methodology the state uses annually to update the upper income standard for CHIP. And on page CS13 the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP. A copy of the approved CS15 is attached and should be incorporated within a separate ° subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 and the supporting document are attached and together supersede the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS13 is attached and should be incorporated within a separate subsection under section 4.3 of the state’s approved CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

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

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Page 2 — Dr. Susan Mosier

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12™ St, Room 355

Kansas City, MO 64103-2808

If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs, at (410) 786-5920. We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman Director Enclosures cc:

James G. Scott, Associate Regional Administrator, CMS Region VII

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility KS.0840.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Kansas State Funds: $ Federal Funds: $ Submitted By: Bobbie Graff-Hendrixson Last Revision Date: Jun 20, 2014 Submit Date: Mar 27, 2014 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0009 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.310, 315 and 320; 42 CFR 457.360; 42 CFR 457.315; 42 CFR 457.320(a)(5) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:55 out of 2000 MAGI Eligibility & Methods - CHIP State Plan Amendment. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Bb Abe CHIP Eligibility

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

CSI5

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

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

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

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

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

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

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

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. 9

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

An attachment is submitted.

PRA Disclosure Statement

JUN 25 2014

SPA# KS-14-0009 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

coms CHIP Eligibility

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

V.20130917

JUN 25 2014

SPA# KS-14-0009 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

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

CS7

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

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

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

Income Standards

Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) + lo 1 166 245 x + 1 6 149 245 x + |\o 19 133 245 xX

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

The above is applicable to all ages 0-19.

Special Program for Children with Disabilities

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

JUN 25 2014

SPA# KS-14-0009 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CMs. CHIP Eligibility

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

V.20130917

SPA# KS-14-0009 Approval Date: JUN 2 5 2014 Effective Date: January 1, 2014 Page 2 of 2

Upper Income Limit Methodology for Targeted Low-Income Children

TRANSMITTAL NUMBER: STATE:

CHIP SPA KS-14-0009 Kansas

Kansas state law requires that the maximum family income for eligibility as a targeted low- income child in CHIP is 250 percent of the 2008 federal poverty level (FPL). In order to express the equivalent income standard in terms of the current year FPL, the state uses a simple ratio for each household size, expresses the limit as percentage of the current FPL and adopts the highest resulting percentage. This percentage is used for the entire CHIP population for the year. The revision is effective on April | of each year.

The income standard equivalent to 250 percent of the 2008 FPL was 225 percent of the FPL in 2013. This amount was converted for use with MAGI-based methodology to 245 percent of the FPL. Each year the state will update the CHIP upper income table below with the current year income standard and submit it to CMS as a state plan amendment.

Year (Beginning April 1) Upper Income Standard in Current Year FPL 2013 245% 2014 242% 2015 2016 JUN 25 2014

SPA# KS-14-0009 Approval Date: Effective Date: January 1, 2014

CHIP Eligibility

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

Sep:

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

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

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

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

The state elects the following option(s):

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

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

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

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

V.20130917

JUN 25 2014

SPA# KS-14-0009 Approval Date: Effective Date: January 1, 2014

Page 1 of 1

_____________________________________________________________________________

Table of Contents

State/Territory Name: Kansas

State Plan Amendment (SPA) #: KS-14-0010

This file contains the following documents in the order listed:

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

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

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

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

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

Children and Adults Health Programs Group

JUL 2.3 2016

Susan Mosier, MD

State Medicaid Director

Kansas Department of Health and Environment Division of Health Care Finance

Landon State Office Building

900 SW Jackson Street, Suite 900-N

Topeka, KS 66612-1220

Dear Dr. Mosier:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number KS-14-0010, submitted on March 27, 2014, with additional information provided on June 24, 2014. This SPA relates to the Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number KS-14-0010 converts the state’s existing income eligibility standards to MAGI-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

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

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid and Children’s Health Operations

Page 2 — Dr. Susan Mosier

Richard Bolling Federal Building 601 East 12 St, Room 355 Kansas City, MO 64103-2808

Congratulations on the approval. If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs, at (410) 786-0719. We look forward to

continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerel Eliot Fishman Director Enclosure ce:

James G. Scott, Associate Regional Administrator, CMS Region VII

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility KS.0844.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Kansas State Funds: $ Federal Funds: $ Submitted By: Bobbie Graff-Hendrixson Last Revision Date: May 30, 2014 Submit Date: Mar 27, 2014 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0010 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.360; 42 CFR 457.315; 42 CFR 457.320(a)(5) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:52 out of 2000 KS XXI MAGI Medicaid Expansion State Plan Amendment. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

coms CHIP Eligibility

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

Eligibility for Medicaid Expansion Program : CS3

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

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

Age and Household Income Ranges

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

+ Ilo 19 113 133 xX

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

JUL 2.3 2014

SPA# KS-14-0010 Approval Date: Effective Date: January 1, 2014 Page 1 of |

_____________________________________________________________________________

Table of Contents

State/Territory Name: Kansas

State Plan Amendment (SPA) #: KS-14-0011

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES a, Centers for Medicare & Medicaid Services q

7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss Baltimore, Maryland 21244-1850 ATER FOR MEIC aucaln SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

JUN 17 2014

Susan Mosier, M.D.

State Medicaid Director

Kansas Department of Health and Environment Division of Health Care Finance

900 SW Jackson ;

Suite 900-N Landon State Office Building Topeka, KS 66612-1220

Dear Dr. Mosier:

Tam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number KS-14-0011 submitted on March 27, 2014. This SPA relates Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number KS-14-0011 describes the state’s plan to provide coverage in its separate CHIP, for children subject to section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS$14 is attached, and should be incorporated within a separate subsection under section 4.1 of Kansas’ approved CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows:

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

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hbhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator (ARA) in our Kansas City Regional Office. Mr. Scott’s address is:

Page 2 — Dr. Susan Mosier

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12" Street, Room 355

Kansas City, MO 64103-2808

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920.

Sincerely, Eliot Fishman Director Enclosure cc:

James G. Scott, ARA, CMS Region VII, Kansas City

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility KS.0843.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Kansas State Funds: $ Federal Funds: $ Submitted By: Bobbie Graff-Hendrixson Last Revision Date: Mar 27, 2014 Submit Date: Mar 27, 2014 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0011 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:60 out of 2000 KS CHIP MAGI Establish 2101 (f) Group State Plan Amendment. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

coms. CHIP Eligibility

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

Section 2101(f) of the ACA and 42 CFR 457,310(d)

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

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

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

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

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

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

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

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

% FPL

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

JUN L U 2014 Effective Date: January 1, 2014

Page | of 2

SPA# KS-14-0011 Approval Date:

cems CHIP Eligibility

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

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. 1f 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

JUN 17 2014

SPA# KS-14-0011 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Kansas

State Plan Amendment (SPA) #: KS-14-0012

This file contains the following documents in the order listed:

1) Approval Letter/ Companion Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

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

7500 Security Boulevard, Mail Stop: $2-26-12 Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Dr. Susan Mosier, M.D.

State Medicaid Director pec 22 2014 Kansas Department of Health and Environment

Division of Health Care Finance

900 SW Jackson

Suite 900-N Landon State Office Building

Topeka, Kansas 66612-1220

Dear Dr. Mosier:

lam pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved Kansas’ Children’s Health Insurance Program (CHIP) state plan amendment (SPA), KS-14-0012-MC4 submitted on March 27, 2014. This SPA incorporates the Modified Adjusted Gross Income (MAGI)-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of KS-14-0012-MC4 includes full approval of your state’s alternative single streamlined paper application. The state is using an interim alternative single streamlined online application and by October 31, 2015, will implement a revised alternative single streamlined online application that addresses CMS concems outlined in the companion letter issued with this SPA approval.

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

e C824

e Attachment 1 —Alternative single, streamlined paper application

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

This approval and the enclosures supercede the following sections of the current CHIP state plan:

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

Page 2 — Dr. Susan Mosier

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows: .

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hbhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and Mr. James Scott, Associate Regional Administrator, in our Kansas City Regional Office. Mr. Scott’s address is:

Mr. James Scott

Office of the Regional Administrator 601 E. 12" Street, Suite 355

Kansas City, MO 64106

If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at 410-786-0719.

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

Sincerely, Eliot Fishman Director Enclosure ce:

Mr. James Scott, ARA, CMS Kansas City Region

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

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

Children and Adults Health Programs Group

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

Dr. Susan Mosier, M.D.

State Medicaid Director

Kansas Department of Health and Environment Division of Health Care Finance

900 SW Jackson

Suite 900-N Landon State Office Building Topeka, Kansas 66612-1220

Dear Dr. Mosier:

DEC 2 2 2014

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Children’s Health Insurance Program (CHIP) state plan amendment (SPA) transmittal KS-14-0012-MC4, which was submitted to CMS on March 27, 2014. Our review of this submission included a review of the alternative single streamlined online 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.

Necessary changes to online application Date by which changes will be completed:

The state agrees to add logic to ask questions October 31, 2015

about access to employer sponsored coverage only for applicants who appear ineligible for Medicaid and CHIP.

Pensions and retirement income is generally June 30, 2015

taxable and should be included as a MAGI income type rather than a non-MAGI income

type.

Page 2 — Dr. Susan Mosier

The CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Ms. Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167. We look forward to continuing to

work with you and your staff. =

Kelly Whitener Director Division of State Coverage Programs

ce: Mr. James Scott, ARA, CMS Kansas City Region

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility KS.0842.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Kansas State Funds: $ 113000.00 Federal Funds: $ 262000.00 Submitted By: Bobbie Graff-Hendrixson Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0012 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:57 out of 2000 KS MAGI CHIP Eligibility Processing State Plan Amendment. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Last Revision Date: Dec 23, 2014 Submit Date: Mar 27, 2014 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Cems. CHIP Eligibility

OMB Control Number: 0938-1148 irati : 10/31/2014

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

enrollment.

Application Processing modified adjusted gross income standard:

O Care Act.

Other electronic means:

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

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable

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

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the (C1 agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

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

The agency accepts applications in the following other electronic means.

Name of method

Description

Fax

Through facsimile machine

Screen and Enroll Process

other insurance affordability programs.

Procedures include:

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low- income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for

SPA# KS-14-0012 Approval Date:

DEC 2 2 2014

Effective Date: October 1, 2013

Page | of 2

cems CHIP Eligibility

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

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

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

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

premium tax credits in accordance with section 1943(b)(2) of the SSA. No

Redetermination Processing

wl Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[Mf] Once every 12 months.

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

Screening by Other Insurance Affordability Programs

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

screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

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

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

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

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

V.20130917

SPA# KS-14-0012 Approval Date:, DEC 2 2 2014 Effective Date: October 1, 2013 Page 2 of 2

KC1100 Revised 09/30/14

Application for Medical Assistance

anCare for Families with Children

This application is for families, children, and pregnant women. You

can use this application to apply for anyone in your family, even if

Who can use this application? they have insurance now.

If you are a childless adult, you may qualify for coverage through the

Federal Health Insurance Marketplace at www.healthcare.gov

e Free or low-cost medical assistance from Medicaid or the Children’s Health Insurance Program (CHIP)

e If you are not approved for KanCare, your information may be sent to the Federal Health Insurance Marketplace. They will see if you can get other help paying for medical assistance.

Use this application to see what choices you have

GO! Would you rather apply online?

Apply faster online Apply faster online at www.applyforKanCare.ks.gov

Important! E> Is anyone who is requesting medical assistance pregnant?

LJ Yes L] No

Questions about you and the people in your household... Questions about your job and household incOMe......csscsssssessersssssseesessesscesesreessneessereeseesens 9

Questions about other health insurance.....csssecsssscssessssessssssseasssecnsssesssessesesseesessensees 11

| Section: —Questions about Native Americans and Alaska Natives...ccecnnesnseneeneemnnneeed 8 Choosing someone to help you with your medical assistance CaS ....sssssesssestesesseees 14

SIQNATULE PAGE... sccerersssseesssrersssssvsesseseescsescensesesessesecsssssesseasseeserssseeeseenseseeceneseseesenseseeeeeenee 15

Agency Use Only

Outstationed Worker

For help completing this application, call toll free: 1-800-792-4884

DEC 2 2 2014

1 SPA# KS-14-0012 Approval Date: Effective Date: October 1, 2013

KC1100 Revised 09/30/14

A. Tell us about Yourself and the People in Your Home

Your Name: (First, Middle, Last) Other names used:

Home Address: Mailing Address (If different):

City: State: City: State: County: Zip: County: Zip: C1 Check here if you don’t have a home address. You still need to give a mailing address.

Home Phone: ( ) aad Work Phone: ( ) _

| would like to get information about this application by:

Email: 1 No O yes | Email Address: text: C0 no CO yes | cell Phone Number: ( ) -

What language do you speak at home? What language do you read at home?

Your income and family size help us decide what programs you qualify for. With this information, we can make sure everyone gets the most coverage possible.

Here’s who you need to include on this application: e Yourself e Your spouse e Your children under 21 who live with you e Your partner who lives with you (but only if you have children together who need medical assistance) e Anyone you include on your tax return, even if they don’t live with you e Anyone else under 21 who you take care of and lives with you

Anyone else who lives with you that is not listed above will need to file their own application if they want medical assistance. You don’t need to file taxes to apply for medical assistance.

Complete the questions on the next few pages for each person in your family. Start with yourself! If you have more than 6 people in your family, please attach another sheet of paper.

Your information is private.

e We'll keep your information private as required by law.

e We'll use the information on this form only to see if you qualify for medical assistance. For help completing this application, call toll free: 1-800-792-4884

2 SPA# KS-14-0012 Approval Date: DEC 2 2 2014 Effective Date: October 1, 2013

Persons 1, 2, and 3

KC1100 Revised 09/30/14

Please tell us about all the people in your household. See page 2 for more information about who to include.

Start with yourself! 4 Person 3 _ U _ First Name Middle Name Last Name Maiden Name : What is this person’s relationship to __ Self you? Gender O Male C Female OO mate O Female OO male C1 Female Date of Birth (mm/dd/yyyy) : / / / / / / {C1 Never Married C1 never Married O Never Married Oo Married O Married Oo Married oO Common-Law O Common-Law O Common-Law Marital Status O divorced 0 pivorced D1 bivorced O Separated O Separated oO Separated O widowed O widowed CO widowed i ive at th Does this person live at the same Ono O yes C1 no O yes address as you? If no, list address. Does this person have income? Ono 0 Yes O No OI yes Ono O yes (oO Change jobs oO Change jobs O Change jobs In the past year did this person O Stop working | Stop working oO Stop working Check all that appl (Check all that apply) O Start working less hours oO Start working less hours oO Start working less hours C1 None of these (1 None of these [1 None of these We need Social Security Numbers (SSNs) for everyone applying for medical assistance. A SSN is optional for people not applying for medical

assistance, but providing a SSN can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with medical assistance. If someone doesn’t have a SSN, call 1-800-772-1213 or visit www.socialsecurity. gov

Social Security #

Is this person applying for medical Ono O Yes O no OI yes C1 No O Yes assistance? [f no, skip to Section D on page 9. Has this person lived in a state other Ono C ves OC wo CO yes Cl No C yes than Kansas in the last 3 months? If yes, when and where? Pregnant? OO No O Yes OC no O yes O No C1 Yes What is the expected due date? / / / / / / How many babies are expected? For help completing this application, call toll free: 1-800-792-4884 2 2 3 DEC 2014 Effective Date: October 1, 2013

SPA# KS-14-0012

Approval Date:

Persons 1, 2, and 3 (continued)

KC1100

Revised 09/30/14

Please continue to answer questions about Yourself, Person 2 and Person 3. Write their names on the first line.

ig im! First:and Last Name Does this person have a ian or P Buardia OO No O Yes O No O Yes O No O yes conservator? If yes, what is their name? USS. citizen? Ono O Yes Ono O yes 0 No UO ves . if no, complete Section C an page 8. O white O Black O white O Black O white O Black O Chinese C Fitipino C chinese 11 Filipino 0 Chinese O Filipino D Japanese O Korean C1 Japanese O korean CO Japanese O Korean ha 1 Native Hawaiian 1 vietnamese | C1 Native O viet O Native O Vietnamese Race (optional) C1 other Asian C1 Asian indian | 1 other Asian Cl Asian indian | Cl other Asian O Asian indian Check all that apply O Guamanianor 1 samoan © Guamanian or C1 samoan 01 Guamanian or 0 samoan Chamorro O other Pacific Chamorro O other Pacific Chamorro OD other 1 american Indian Islander OD american indian Islander © American Indian Pacific or Alaska Native [1 Other or Alaska Native [J other or Alaska Native Islander O other Ethnicity (optional) O Mexican D puerto rican | O Mexican O puerto Rican | O Mexican D Puerto Rican ff Hispanic/Latino ethnicity, O Mexican O cuban O Mexican American O cuban 1 Mexican O cuban Ameri Chi Ameri check all that apply Chicano/a 1 other teano/a 1 other Chicano/a 5 other Has this person delivered a 2 baby in the Oo oO tase mrantha? Lee No C1 Yes Ono O yes O no O ves Did this person have Sa in the last 3 months to save life, organs, _ C1 no O yes O No O Yes Ono CO yes or bodily function? _ Does this person need help paying medical bills from the last 3 months? Oo oO oO oO oO oO If yes, please see additional questions No Yes No Yes No Yes in Section B on page 8. Does this person have a disability — that will last at least 12 months or 0 no O yes O No O yes OC no O ves result in death? es Does this person need help with oO oO Oo oO oO nursing home costs or in-home care? No Yes O No Yes No Yes Does this person live with at least one child under the age of 19 and are Oo oO oO oOo oO oO they the main person taking care of No Yes No Yes No Yes this child? First: First: First: Middle: Middle: Middle. This person’s Mother’s Full Name (only answer for children) last: fast last Maiden: Maiden: Maiden: First: First: First: This person’s Father's Full Name Middle: Middle ‘Middle. (only answer for children) Last: Last: Last

For help completing this application, call toll free: 1-800-792-4884

SPA# KS-14-0012

Approval Date:

DEC 2 2 2014

4 Effective Date: October 1, 2013

Persons 1, 2, and 3 (continued)

KC1100 Revised 09/30/14

Please continue to answer questions about Yourself, Person 2 and Person 3. Write their names on the first line. -

in|

First and Last Name

Federal Income Tax Information We have some questions about how yo

u plan to file your taxes, Answer these questions based on your current situation.

Based on your current situation, does this person plan to file a federal income tax return?

O No OI Yes Ono CO yes

_ONo C Yes

If yes, please answer questions 1 — 3. If no, please skip to question 3

1. Will this person file jointly with a spouse? S SUES A

Ono C1 Yes C1 No OI Yes

O no O yes

Ifyes,nameofspouse.

2. Does this person have any dependents on their tax return?

CO) No U1 yes O No O Yes

O No L Yes

if yes, list name(s) of dependents

3. Isthispersonclaimedasa dependent on someone else's. taxreturn? : é

Ono O Yes CO no 0 Yes

C1 No O yes

if yes, list the name of the tax filer.

How is this person related to the tax filer?

Answer the following for persons age 26 or younger

Did this person have insurance

last 3 months?

through a job and lose it within the :

O No CO yes C1 No UO yes

O no O yes

ifyes, end date and reason

Is this person a full-time student? :

0 No UO yes Ono O yes

C1 No CI yes

Was this person in Kansas foster care at the time of their 18" birthday?

Ono O Yes O No O yes

OO No O yes

Does this person have a parent living _ outside the home?

Ono O Yes O No O Yes

O No O yes

If there is'no one else in your home, skip to Section B at the bottom of page 8.

For help completing this application, call toll free: 1-800-792-4884

SPA# KS-14-0012

DEC 2 2 2014

Approval Date:

5 Effective Date: October 1, 2013

Persons 4, 5, and 6

KC1100 Revised 09/30/14

Please answer questions about Persons 4, 5, and 6 in your household. If you have more people to add, please attach another sheet of paper and send it with your application.

n

=

First Name

Middle Name

Last Name

Maiden Name

What is this person’s relationship to you? :

Self

Gender O male 1) Female [J mate C) Female OO Mate C1 Female Date of Birth (mm/dd/yyyy) / / / / / / {01 never Married C1 never Married 0 Never Married 0 married 0 married 0) Married Marital Status Oo Common-Law Oo Common-Law O Common-Law Oo Divorced (O Divorced 1 pivorced O Separated O Separated O Separated O widowed C1 widowed OO widowed OAs aie live at the same oO No oO Yes Ono © yes If no, list address. Does this person have income? Ono O Yes OO No C1 Yes C1 no O yes Oo Change jobs O Change jobs O Change jobs In the past year did this person O Stop working O Stop working Oo Stop working (Check all thet apply) O Start working less hours O Start working less hours O Start working less hours C1 None of these C1 None of these C1 None of these

We need Social Security Numbers (SSNs) for assistance, but providing a SSN can speed up

everyone applying for medical assistance. ASSN is optional for people not applying for medical the application process. We use SSNs to check income and other information to see who is eligible for help with medical assistance. If someone doesn’t have a SSN, call 1-800-772-1213 or visit www.socialsecurity.gov

Social Security #

Is this person applying for medical im No im Yes oO No oO Yes oO No im Yes assistance? if no, skip to Section D on page 9.

Has this person lived in a state other than Kansas in the last 3 months? C1 No LO Yes CI No LI Yes UO) No LU Yes If yes, when and where? Pregnant? 0 no O Yes C1 no CI Yes C1 No CI Yes

What is the expected due date? / / / / / /

How many babies are expected?

For help completing this application, call toll free: 1-800-792-4884

Approval Date:, DEC 2 2 2014

SPA# KS-14-0012

6 Effective Date: October 1, 2013

Persons 4, 5, and 6 (continued)

KC1100

Revised 09/30/14

Please continue to answer questions about Person 4, 5, and 6. Write their names on the first line.

nq

{1

on 6 : 1h First and Last Name Vv in or Does this person have a guardiar Ono O yes O no CO yes Ono C yes conservator? if yes, what is their name? . US diten? Ono O Yes Ono O yes Ono O yes If no, complete Section C on page 8. O white O Black O white O Black OC white O Black 1 chinese O Filipino O chinese O Filipino 0 Chinese O Fitipino D1 Japanese O korean D Japanese O) korean O Japanese O Korean Race (optional) _| © Native Hawaiian 1 Vietnamese 1 Native Hawaiian 1 Vietnamese | 1 NativeHawaiian 1 Vietnamese ace (Optional 1 other Asian O Asian Indian O other Asian O Asian Indian C1 other Asian D Asian indian Check all that apply O Guamanianor 1 samoan C1 Guamanianor 1 samoan 1 Guamanianor O samoan : z Chamorro O other Pacific Chamorro O other Pacific Chamorro O other -| 0 american indian Islander 0 american indian Islander O american indian Pacific or Alaska Native [1 other or Alaska Native © other or Alaska Native Islander - D other Ethnicity (optional) O Mexican 1 puerto Rican | O Mexican © puerto Rican | 1 Mexican D Puerto Rican if Hispanic/Latino ethnicity, O Mexican Ol cuban 01 Mexican American (1 Cuban O) Mexican O cuban z American O other Chicano/a CO other American O other check all that apply Chicano/a Chicano/a Has this person delivered a bab in the Spe y 0 no 0 yes Ono O yes 0 no © yes last 3. months? is Did this person have emergency care in the last 3 months to save life, organs, Oi no O ves Ono LO Yes 0 no O yes or bodily function? Z Does this person need help paying medical bills from the last 3 months? Oo oO Oo oO oO Oo if yes, please see additional questions — No Yes No Yes No Yes in Section B on page 8. oo Does this person have a disability that will last at least 12 months or OC No 0 Yes O No CO Yes C1 No CO Yes result in death? Does this person need help with Oo oO Oo Oo Oo Oo nursing home costs or in-home care?. No Yes No Yes No Yes Does this person live with at least. one child under the age of 19 and are oO oO Oo oO Oo Oo they the main person feking care of — No Yes No Yes No Yes this child? : First: First: First: = Middle: Middle: Middle: This person’s Mother’s Full Name (only answer for children) last last: last Maiden: Maiden: Maiden: First: First: First: This person’s Father’s Full Name Middle: Middle Middle: (only answer for children) Last: Last: Last:

For help completing this application, call toll free: 1-800-792-4884

SPA# KS-14-0012

Approval Date:

DEC 2 2 2014

7 Effective Date: October 1, 2013

KC1100 Revised 09/30/14 Persons 4, 5, and 6 (continued)

Please continue to answer questions about Person 4, 5, and 6. Write their names on the first line.

7. 1. . First and Last Name __ Federal Income Tax Information We have some questions about how you plan to file your taxes. Answer these questions based on your current situation. Based on your current situation, does Ono OD yes Ono O yes Ono UI yes this person plan to fe a federal i income tax return? If yes, please answer questions 1 — 3. If no, please skip to question 3 * 1. Will this person file jointly. with a Ono 1 yes Cl No C yes Cl no Ol ves spouse? : If yes, name of spouse | 2. Does this person have any dependents on their tax return? - No 0 Yes 0 No O Yes O No O Yes If yes, list name(s) of dependents 3. Is this person claimed as a dependent on someone else’s tax C1 No 0 yes OO no LI yes O no O ves return? : : If yes, list the name of the tax filer : How is this person related ¢ to the tax filer? : : : Answer the following for persons age 26 or younger, a Did this person have insurance through a job and lose it within the last 3 months? Ci No O Yes O No O Yes O No O Yes If yes, end date and reason Is this person a full-time student? OO no O Yes Ono O yes Oi No O Yes Was this person in Kansas foster care at the time of their 18" birthday? UO no O ves C1 No O Yes OC No O ves Does this person have a parent living ee eh cl Ono O Yes Ono O yes OC no O Yes

during the last 3 months? ce

B. Help with medical bills in the past 3 months

(People moving in or out) If yes, tell us:

if yes, tell u Us | about the incom

C. Immigration Status

Name (First, Middle, Last)

“Document Type |

Immigration number |

Immigration status

For help completing this application, call toll free: 1-800-792-4884

SPA# KS-14-0012

Approval Date:

DEC 2 2 2014

8 Effective Date: October 1, 2013

D. Tell Us About Jobs and Other Household Income

Job 1

KC1100 Revised 09/30/14

Job 2

Job 3

Job 4

Worker’s Name

Company Name

Company Address

Company Phone

Start Date

How many hours working per week?

Gross salary or hourly wage

How often are they paid?

Date of next paycheck?

|

/ /

/ /

Do any of these jobs include

tips, commissions or bonuses? If yes, answer the questions below... -

CI No UI yes

LI no U Yes

CT No LI ves

What type?

What is the usual amount?

(before deductions) _

How often?

Self-employed person’s. Name : a Business Name : What type of business is it? When did the business start? sty Were taxes filed on this Ono CO yes CO No O Yes Ono O Yes O No O yes income last year? if no, skip to Estimated Monthly Income O Schedule C O Schedule C Oo Schedule C O Schedule C O Schedule D Oo Schedule D Oo Schedule D O Schedule D [1 schedule € [1 schedule € C1 schedule € C1 schedule € What IRS form did you file C1 schedule F C1 schedule F C1 schedule F C1 schedule F for this income? O77 C1 4797 OD azz 1 azs7 (Check all that apply) 1 1065 C1 106s C1 1065 C1 1065 1 1120s C1 1120s C1 s120s 1 1120s O Schedule K Oo Schedule K O Schedule K O Schedule K O Other O Other Oo Other O Other Reported Annual Gross Income $ $ $ penorsee Annual Gross $ $ $ xpenses Estimated Monthly Income: | ¢ § $ (before expenses) Monthly expenses $ $ Ss

For help completing this application, call toll free: 1-800-792-4884

SPA# KS-14-0012

Approval Date:,

DEC 2 2 2014

9 Effective Date: October 1, 2013

KC1100 Revised 09/30/14

Name of Person:

Type of income: | Total Income This Yeai $ $ $ Total Income Next Year $ $ $

Who is the income for:

What type of income?

Who pays this income?

How much?

How often?

Who gives the money?

Who is it given to?

How much is given?

How often is it given?

Name of person with deduction

What type of deduction?

(alimony, student loan interest, etc)

How much?

How often?

For help completing this application, call toll free: 1-800-792-4884

SPA# KS-14-0012

DEC 2 2 2014 10

Approval Date: Effective Date: October 1, 2013

E. Tell us about your Family’s Health Insurance Answer these questions for everyone who has health insurance now or had it within the last 3 months. If you do not know

an answer, write ‘unknown.’

KC1100 Revised 09/30/14

insurance? __

Policyhe

Insurance Com

Other

Date Began / / / / / / Date Ended _ / / / / / / Policy # Group # Type of Coverage O Catastrophic Only O Catastrophic Only O Catastrophic Only | Check all that apply _ C1 pental C1 bental C1 pental O Doctor O Doctor O Doctor O Hospital O Hospital O Hospital oO Long Term Care C] Long Term Care O Long Term Care C1 Medicare Supplement O Medicare Supplement OO Medicare Supplement O Prescription Oo Prescription O Prescription vision 0 vision 0 vision Oo O Oo

Other

Policy #

O Catastrophic Only LI Catastrophic Only oO Catastrophic Only O Dental O Dental Oo Dental O Doctor O Doctor Oo Doctor O Hospital O Hospital | Hospital O Long Term Care O Long Term Care O Long Term Care OO Medicare su pplement O Medicare Supplement OO Medicare Supplement O Prescription O Prescription O Prescription O Vision O Vision O Vision 1 other C1 other 1 other

If anyone's insurance ended inthe

last. 3 months, please tell us why.

For help completing this application, call toll free: 1-800-792-4884 y) DEC 2 204 Effective Bate: October 1, 2013

SPA# KS-14-0012

Approval Date:,

KC1100 Revised 09/30/14

health

Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? 0 no (Stop here and go to the next page) OO yes (Please answer questions below)

imily plans ir ee

1 available only to the ‘ograms. See above

Date of change (mm/dd/yyyy): = ; ;

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of He iol allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(t) of

For help completing this application, call toll free: 1-800-792-4884 DEC 2 2 2014

12 SPA# KS-14-0012 Approval Date: Effective Date: October 1, 2013

F. American Indian or Alaska Native

Complete this page if you or family members are American Indian or Alaska Native.

KC1100 Revised 09/30/14

y of this page and attach.

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 these questions to make sure you and your family get the most help possible. Note: If you have more people to include, make a co

AI/AN Person 3

or urban Indian healt! or through ofthese 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?

|G no O Yes

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?

O No O yes

Member of a fel a recognized tribe? 1 No OC No OO no 0 Yes C1 yes DO ves |G no [4 No 0 wo 4 0 Yes CI yes O ves

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?

Ono O yes

Certain money received may not be counted for Med icaic

your application that includes money from these sources: « Percapita payments froma

resources, usage rights, leases, or royalties

« Payments fromnatural resources, farming, ranching, fishing, leases or : royaltiesfromland designated as Indian fue land by the Department of Interior (including reservations and former reservations)

e Money from selling things that have cultural significance

tribe that come from natural

$

$

$

| How Often?

How Often?

How Often?

For help completing this application, call toll free: 1-800-792-4884

SPA# KS-14-0012

Approval Date:.

DEC 2 2 2014

13 Effective Date: October 1, 2013

. KC1100 Revised 09/30/14

G. Choose Someone to Help You With Your Medical Assistance Case

: this $ felationship to you? (for e nif | appoint the above named person tobe my I Medical Representative, or 1 Facilitator.

Choose Your Health Plan

Most people approved for Kansas medical assistance receive services through KanCare. There are 3 KanCare health plans to choose from. Please review the Extra Services Highlights flyer and choose your plan. If you choose, we will enroll you in that plan if eligible for KanCare. If you do not choose, a plan will be assigned for you. If you do not like your assignment, you will have 90 days to change plans. You will receive a packet of information about your plan. For more information about these plans, visit www.KanCare.ks.gov

Note: For persons who are not eligible for a KanCare plan, information about coverage and services will be sent separately.

Amerigroup y,.# RealSolutions SB sunstaues sare () Unitedteattheare

in healtheare

For help completing this application, call toll free: 1-800-792-4884

14 SPA# KS-14-0012 Approval Date:, DEC 2 2 2014 Effective Date: October 1, 2013

KC1100 Revised 09/30/14

H. Signature Page

You must sign and date this form before you send it back. If this form is not signed, it will be returned to you. This will

cause a delay in processing your application. Read the information below. Sign and Date. l understand:

| have the right to equal treatment regardless of race, color, sex, age, disability, religion, political belief, or national origin.

| have the right to have information | have provided kept confidential unless directly related to the administration of Kansas medical assistance programs.

| have to provide or apply for a Social Security number for anyone who is applying for health benefits and | authorize use of these numbers to administer the program. These numbers will also be used for computer matches with other organizations such as banks, the Social Security Administration, and Internal Revenue Service.

{tis important to provide current income, address, and household composition information, and | am responsible for reporting changes during the application process and while eligible.

Some or all of the people for whom | am applying may receive similar health coverage under the Medicaid program if eligible.

| have the responsibility to use and report any third-party resources (such as health insurance, court settlements, medical support payments, trusts, conservatorships, etc.) that may have a legal obligation to pay any or all of the medical expense of those for whom | am applying. | understand that payment for a particular service may be withheld while a determination of failure to use a third-party resource is made.

Any payments made to me by a third-party resource for medical services covered under Kansas medical assistance programs will be used to pay for the applicable medical bills and that these programs will only pay for services not covered by that third-party resource. | agree to cooperate with the medical subrogation unit in pursuing those third-party resources.

\f | receive medical assistance after age 54 or while in an institutional arrangement, there may be a claim against my estate to recover the medical expenditures made on my behalf. | understand that my financial institution(s) will be notified of a pending claim.

| have the responsibility to read and truthfully answer all the questions on this application. | understand that if | provide false or purposefully misleading information on this application or hide information requested by the application, | will be subject to penalties for my actions.

| have the right to request a fair hearing if | disagree with a decision. A written request must be made within 30 days of the decision.

l agree: ¢ — To turn over any medical support payments for all persons receiving medical assistance if adults in the household are determined eligible for medical assistance. * — To help Child Support Services (CSS) in establishing and enforcing support orders (if needed) if adults in the household are determined eligible for medical assistance. ¢ To pay the Children’s Health Insurance Program (CHIP) premium each month if | qualify for that program. The premium may be as little as $0 or as much as $50 depending on my income. I certify: « That everyone | am requesting health coverage for — and who is determined eligible for such coverage — is a U.S. citizen or is a non-U.S. citizen in lawful immigration status. Proof of immigration status may be required. (Exception: persons applying for emergency medical assistance under SOBRA) « Under penalty of perjury, that my answers are correct and complete to the best of my knowledge. | authorize:

Payments under this program to be made directly to the physicians and other medical providers, or managed care organizations for covered medical and other health services furnished to those for whom | am applying who are eligible.

Medical providers to release medical information to the Kansas Department of Health and Environment, Division of Health Care Finance (KDHE DHCF), the Department for Children and Families (DCF), the Kansas Department for Aging and Disability Services (KDADS), the U.S. Department of Health and Human Services, insurance companies, and other contracted medical providers. | also authorize KDHE, DCF, and KDADS to share medical information for administrative purposes with other agencies and contractors.

Employers, medical providers, financial institutions, insurance providers, benefit providers, and ather persons or agencies with knowledge of my circumstances, to release to KDHE, DCF, KDADS, or other benefit programs, any information including financial and other confidential information necessary to establish my eligibility.

My signature on this application signifies that | have read and understand the conditions above. All information provided on this application is protected by state and federal confidentiality laws. This release is valid from this date. A copy of this authorization is as valid as the original.

Signature of Applicant (required) Date FOR AGENCY USE ONLY: Signature of Other Adult Applying Date Signature of First Witness (if “X” is used) Date Signature of Second Witness (if “x” is used) Date Would you like to register to vote today? . 7 — ~ No Yes Already registered Signature of Medical Representative (if applicable) Date —_,_ —_ _—_

For help completing this application, call toll free: 1-800-792-4884

15 SPA# KS-14-0012 Approval Date: HEL 2 2 2014 Effective Date: October 1, 2013

KC1100 Revised 09/30/14

You may have to send proof of certain things for us to process your application. You do not need to send anything now. We will contact you if we need more information.

Proof of Income

If you are reporting that you have a job

We may need copies of your paystubs for the last 30 days, or a statement from your employer with your gross income (before deductions.)

If you are reporting that you are self-employed

You must send your most recent personal and business income tax returns, including all pages and attachments.

If you are reporting that you have other income

We may need a copy of the check or benefit letter that shows the amount of income you get and how often you get the payment.

If you have unpaid medical bills from the past 3 months and would like help

We may need copies of all paystubs or checks your family has received in the past 3 months.

Mail your signed application form to: KanCare Clearinghouse P.O. Box 3599 Topeka, KS 66601-9738

or Fax it to: 1-800-498-1255

For help completing this application, call toll free: 1-800-792-4884

SPA# KS-14-0012 Approval Date:

Proof of Health Insurance

If you are reporting that someone in the household has other health insurance

You must send a copy of the front and back of your health insurance card.

ne in your family if they don’t need

on page 15?

DEC 2 2 2014

16 Effective Date: October 1, 2013

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application

[XI Online Application

TRANSMITTAL NUMBER:

KS-14-0012-MC4

STATE:

Kansas

Through October 31, 2015, the state is using an interim online alternative single streamlined application. After October 31, 2015, the state will use a revised online 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: Kansas

State Plan Amendment (SPA) #: KS-14-0013

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

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

Children and Adults Health Programs Group

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

APR 0 3 2015

Susan Mosier, MD State Medicaid Director

Kansas Department of Health and Environment

Division of Health Care Finance Landon State Office Building

900 SW Jackson Street, Suite 900-N Topeka, KS 66612-1220

Dear Dr. Mosier:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title

XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number KS-14-0013

>

submitted on March 27, 2014. This SPA is related to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number KS-14-0013 describes the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, non-payment of premiums, continuous eligibility and presumptive eligibility. Copies of the approved state plan pages are attached and these approved pages supérsede sections of Kansas’ current state plan as

detailed below:

New State Plan Page

Impact on Current State Plan Section

CS$17: Non-Financial Eligibility — Residency

Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship

Sections 4.1.5 and 4.3 on citizenship

CS19: Non-Financial Eligibility — Social Security Number

Section 4.1.9

CS20: Non-Financial Eligibility — Substitution | Section 4.4.4 of Coverage CS21: Non-Financial Eligibility — Non- Section 8.7

Payment of Premiums

C827: General Eligibility — Continuous Eligibility

Section 4.1.8

CS28: General Eligibility - Presumptive Eligibility for Children

Section 4.3 on presumptive eligibility

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Page 2 — Dr. Susan Mosier

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

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12" St, Room 355

Kansas City, MO 64103-2808

If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs, at (410) 786-0719. We look forward to continuing to work with you and your staff.

Director

Enclosures

ce: James G, Scott, Associate Regional Administrator, CMS Region VII

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

7500 Security Boulevard, Mail Stop: $2-26-12 ( t or M &,

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

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

APR 0 3 2015

Susan Mosier, MD

State Medicaid Director

Kansas Department of Health and Environment Division of Health Care Finance

Landon State Office Building

900 SW Jackson Street, Suite 900-N

Topeka, KS 66612-1220

Dear Dr. Mosier:

The Centers for Medicare & Medicaid Services (CMS) has recently completed the review and approval of Kansas CHIP state plan amendment (SPA) KS-14-0013 related to non-financial eligibility matters, including the state’s substitution strategy. In the course of our review of SPA KS-14-0013, however, we determined that state systems are not yet in full compliance with the federal CHIP rules regarding coordination of coverage for children subject to a waiting period. This letter documents the agreed upon mitigation strategies associated with the state coming into full compliance with our regulations regarding this area.

Consistent with final rulemaking published in the Federal Register on July 15, 2013, states are required to implement processes to coordinate coverage of children subject to a waiting period with other insurance affordability programs. The processes must ensure a smooth transition for children from coverage through the Marketplace or other insurance affordability program to CHIP, and enrollment of otherwise CHIP-eligible children at the end of a waiting period as specified at 42 CFR 457.340. In addition, states must promptly transfer each individual’s electronic account to the applicable insurance affordability program and notify such program of the date on which the waiting period ends for each individual. Kansas informed us during the SPA review process that current system functionality is incapable of transferring electronic accounts to the Marketplace. The state is working closely with CMS to implement a system change to correct this lack of functionality.

In the interim, the state has been approved to implement a mitigation strategy to inform families regarding possible eligibility under all other insurance affordability program coverage options during a waiting period. A phone contact will be made for children subject to a waiting period due to previous enrollment in other health insurance. If phone contact is not successful, Kansas will send a letter to the impacted families. If the member is interested in coverage during the waiting period, the state will initiate a direct contact with a Navigator. The Navigator will work directly with the Marketplace to discuss coverage options during the waiting period, including the application of special enrollment periods offered to the child. The Navigator will also assist with the enrollment process after the waiting period is over, and help facilitate coverage for a

Page 2 — Dr. Susan Mosier

child that is subsequently eligible for CHIP without requiring a new application or information already provided by the family.

We are available to provide technical assistance during this time. If you have any questions or wish to discuss this issue further, your staff may contact Martin Burian at (410) 786-3246. He

will provide or arrange for any technical assistance that you may require. Thank you for your cooperation.

Sincerely,

Kelly Whitener Director Division of State Coverage Programs

ce: James G. Scott, Associate Regional Administrator, CMS Region VII

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility KS.0841.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Kansas State Funds: $ Federal Funds: $ Submitted By: KIM Tjelmeland Last Revision Date: Apr 1, 2015 Submit Date: Mar 27, 2014 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0013 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320; 42 CFR 457.320(b)(6), (c) and (d); 42 CFR 457.340(b); 42 CFR 457.340(d)( Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:59 out of 2000 KS CHIP MAGI Non-Financial Eligibility State Plan Amendment Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/13/2015 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Cems CHIP Eligibility

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

CS17

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SPA# KS-14-0013 Approval Date: APR 0 3 2015

Effective Date: January 1, 2014 Page I of 2

coms. CHIP Eligibility

One or more interstate agreement(s). No

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

Fes]

Provide a description of the policy:

(Not considered KS residents.

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

V.20130917

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Effective Date: January 1, 2014 Page 2 of 2

coms CHIP Eligibility

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

CSi8

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457,320(b)(6), (c) and (d)

Citizenship

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

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

Who are citizens or nationals of the United States; or

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

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

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

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

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

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

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

C Other date, as described:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing No in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009. P.L. 11 1-3).

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

Income Pregnant Women. APR 0.2.

SPA# KS-14-0013 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

Ss CHIP Eligibility

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

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CHIP Eligibility

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

CS19

42 CFR 457.340(b)

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

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

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

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

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

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

How the state will use the SSN. The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

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

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

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

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

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

PRA Disclosure Statement

SPA# KS-14-0013 Approval Date: APR 0 3 2015 Effective Date: January 1.20" age 1 of 2

Ms. CHIP Eligibility

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

V.20130917

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ccmMms CHIP Eligibility

State Name:|Kansas | OMB Control Number: (938-1148 Transmittal Number: KS - 14-0013

Separate Child Health In Insurance Program ae Non-Financial Eligibility - Substitution o sonsak :

Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3). 457.350(i), and 457.805

Expiration date: 10/31/2014

CS20

Substitution of Coverage

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

[im] Substitution of coverage prevention strategy:

Name of policy Description

+

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

How long is the waiting period?

C One month C Two months @ 90 days C Other

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

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

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

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

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

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

[i] The child has special health care needs.

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

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

SPA# KS-14-0013 Approval Date: APR 0 3 2015

Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

Describe

+ Lifetime maximum reached

D4

i Describe the processes the state employs to facilitate enrollment of CHIP-eligible children who have satisfied the waiting period.

Applications for children eligible for CHIP except for their previous enrollment in other health insurance are held until the expiration of the waiting period. Children are not denied eligibility, or required to reapply for CHIP. at the end of the waiting period. Once the waiting period has been satisfied, the agency prospectively conducts an eligibility determination for the child using information provided by the family on the application. Should additional information be needed. the state accepts self-attestation or checks electronic data sources to verify information. If the child is determined eligible for CHIP after satisfying the waiting period. the agency notifies the family and initiates the enrollment process. No additional action is required by the family.

Describe the processes the state employs to coordinate coverage of children subject to a waiting period with other {m) insurance affordability programs. including safeguards to prevent gaps in coverage for children transitioning from another insurance affordability program to CHIP after satisfying the waiting period.

The agency has an integrated eligibility system for Medicaid and CHIP and interoperable with the Exchange. A child is screened for Medicaid and then CHIP, and enrolled in the appropriate program based on the eligibility determination. Ifa child is eligible for CHIP except for their previous enrollment in other health insurance and subject to a waiting period. the

state transfers the account to the applicable (e.g., Exchange) insurance affordability program, and notifies the program of the date on which the waiting period ends.

The state provides assurance that: It does not require a new application or the submission of information already provided by the family immediately preceding the waiting period for the purpose of enrolling CHIP-eligible children who have satisfied a waiting period. For children subject to the waiting period, it will promptly transfer each individual's electronic account to the

applicable insurance affordability program and notify such program of the date on which the waiting period ends for each individual.

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

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

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

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

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

SPA# KS-14-0013 Approval Date:, APR 0 3 2015

V.20140415 Effective Date: January 1, 2014

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chemo foe weoic am Anat INIT

ccms CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

C821

42 CFR 457.570

Non-Payment of Premiums Does the state impose premiums or enrollment fees? Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes

Does the state have a premium lock out period? Yes

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

Please describe the lock-out period:

Families who fail to pay premiums for two consecutive months are considered delinquent and shall be ineligible for CHIP coverage through the end of the lock out period.

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

C One month

C Two months

@ 90 days

C Other (not to exceed 90 days)

(1) Individual's income decreased to a level where no premium is required or within Medicaid standards (1 Other financial hardship KK] Other

Describe

+ Family income decreased to within Medicaid standards.

» 4

The state assures that:

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

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

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

KS-14-0013

Approval Date: APR 0 3 2015

Effective Date: January 1, 2014 Page | of 2

(cms CHIP Eligibility

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

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coms CHIP Eligibility

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

C827

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

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

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

@ For children up to age 19

C For children up to age

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

{] At the end ofthe [12 months continuous eligibility period.

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

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

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

[Ml The child dies.

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

(1 Other

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

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ccCmMs CHIP Eligibility

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

CS28

General Eligi lity - Pre tive Eligibility

42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. | Yes

[i] Describe the population of children to whom presumptive eligibility applies:

Children between the ages of 0 and 18 (through the month of the 19th birthday)

[Ml] Describe the duration of the presumptive eligibility period and any limitations:

Duration policies are consistent with those used in the Medicaid program: 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 coverage is made, if an application 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

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

[@ Describe the application process and eligibility determination factors used:

The determination is integrated with the Medicaid Presumptive Eligibility process. A written application is not required for presumptive eligibility. A separate application is used. Self-declaration of the following are accepted:

The child's age.

Household income must not exceed the highest applicable CHIP income standard

State Residency

Citizenship

[Mi] The CHIP Agency uses qualified entities. as defined in section 1920A, to determine eligibility presumptively for children.

th

CS30

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 the types of entities used to determine presumptive eligibility:

i Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan

SPA# KS-14-0013 Approval Date: APR 0 3 2015 Effective Date: January 1, 2014 Page | of 2

ccomMs CHIP Eligibility

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 1V-D of the Act

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

Oo Oooo Oo OO 0

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

o 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.)

[2 Any other entity the state so deems, as approved by the Secretary The CHIP Agency 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.

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

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_____________________________________________________________________________ Table of Contents State/Territory Name: Kansas State Plan Amendment (SPA) #: KS-17-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages The complete title XXI state plan for Kansas consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-16 Baltinrore, MD 21244-1850 lvts ctNlÉts tol MtDtc¡tt & MtDtc^n s¡RvtcHi cEN¡tn fon ¡utDtcÁtD & clllp sf,f,vtcrs Children and Adults Health Proerams Grouo APR 0 5 zotz Michael Randol State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance 900 SW Jackson Suite 900-N Landon State Office Building Topeka, KS 66612-1220 Dear Mr. Randol: I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) number KS-17-0002, submitted on March 3,2017. This SPA relates to Modified Adjusted Gross Income (MAGI) eligibility and methodology with an effective date of April1,2017. Through SPA number KS-17-0002, the state updates the supporting document for the CS7 page, which describes the annual update to the upper income standard for CHIP. The supporting document is attached; it supersedes the previously approved supporting document for the CS7 and should be incorporated as an attachment to the current CHIP state plan. Your title XXI project officer is Ms. Kristin Edwards. She is available to answer questions conceming these amendments. Ms. Edwards' contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1 850 Telephone: (410) 786-5480 Facsimile: (4 I 0) 786-5882 E-mail: kristin.edwards@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Kristin Edwards and to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Richard Bolling Federal Building 601 East l2th St, Room 355 Kansas City, MO 64103-2808

Page2-MichaelRandol If you have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (4I0) 786-0721. We look forward to continuing to work with you and your staff. Director Enclosures cc: Mr. James G. Scott, Associate Regional Administrator, CMS Region VII, Kansas City

Upper Income Limit Methodology for Targeted Low-Income Children TRANSMITTAL NUMBER: CHIP SPA KS-I7.OOO2 STATE: Kansas Kansas state law requires that the maximum family income for eligibility as a targeted low- income child in CHIP is 250 percent ofthe 2008 federal poverly level (FPL). In order to express the equivalent income standard in terms ofthe current year FPL, the state uses a simple ratio for each household size, expresses the limit as percentage ofthe current FPL and adopts the highest resulting percentage. This percentage is used for the entire CHIP population for the year. The revision is effective on April I of each year. The income standard equivalent to 250 percent ofthe 2008 FPL was 225 percent ofthe FPL in 2013. This amount \¡r'as converted for use with MAGI-based methodology to 245 percent of the FPL. Each year the state will update the CHIP upper income table below with the current year income standard and submit it to CMS as a state plan amendment. Year (Beginning April 1) Upper Income Standard in Current Year FPL 2013 24s% 2014 242Yo 2015 239% 2016 238Yô 2017 2360/o sPA # KS-17-0002 ApprovalDate: APR 0 5 2017 Efrect¡ve Date: April l,2ol7

_____________________________________________________________________________ Table of Contents State/Territory Name: Kansas State Plan Amendments (SPA) #: KS-18-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) Final Approved State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-"1'6 Balrirnore, MD 21244-1850 urs ctNf¡Rs fot MfotcAßE & MfDtc^rD stflv¡c$ CENIE¡ 'OT MEDICAID & C'IIP STRVICES Children and Adults Health Proprams Group APR 2 5 2018 Jon Hamdorf Medicaid Director Department of Health and Environment 900 SW Jackson Avenue Suite 900 Topeka, KS 66612-1220 Dear Mr. Hamdorf: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) KS-lS-0005, submitted on March 23,2018, has been approved. KS-l8- 0005 implements mental health parity regulations at 42 CFR 457.496 to ensure that treatment limitations and financial requirements applied to mental health and substance use disorder benefits are no more restrictive than those applied to medical/surgical benefits. This SPA has an effective date of October 1,2017 . Section 2103(c)(6)(B) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457 ,496(b), provides that if CHIP coverage includes Early, Periodic Screening, Diagnostic and Treatment (EPSDT) as defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the state plan will be deemed to satisfy parity requirements. Kansas has provided the necessary assurances and supporting documentation that EPSDT is covered under Kansas' CHIP program and provided in accordance with sections 1905(r) and 1902(aX43) of the Act. During our review of this SPA, the Centers for Medicare & Medicaid Services (CMS) identified areas of the Kansas' member handbooks that could be modified to better describe EPSDT coverage, including dental benefits. As part of this SPA approval, Kansas has agreed to make modifîcations to the medical and dental membership handbooks no later than January 1,2019 to coincide the updates with the next managed care plan contract cycle. This update ensures that the member handbooks align with the requirements of 42 CFR 457.496(b), which cross reference to Medicaid's EPSDT informing requirements in section 1902(a)(43) of the Act. Should the state not be able to make these modifications within this time period, it should notify CMS. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately. Your title XXI project officer is Ms. Kristin Edwards. She is available to answer questions concerning these amendments. Ms. Edwards' contact information is as follows:

Page 2 - Mr, Jon Hamdorf Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Seruices 7500 Security Boulevard, Mail Stop 52-01-16 Baltimore, MD 21244-1850 Telephone: (41 0) 786-5480 E-mail: k¡istin.edwards@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Kristin Edwards and to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Richard Bolling Federal Building 601 East 12th St, Room 355 Kansas City, MO 64103-2808 Ifyou have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (410) 786-0721. We look forward to continuing to work with you and your staff. 'eþ-rJ-"#b Director Enclosures cc: Mr. James G. Scott, ARA, CMS Region VII, Kansas City / Anne Marie Costello /

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

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

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

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

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

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

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

Name: Jonathan J. Hamdorf Position/Title: Medicaid Director, Division Director Name: Greg Lakin, MD

Position/Title: Medical Director

Name: Adam Proffitt

Position/Title: Director of Program Finance and Informatics

*Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes:  Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance.  Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including:  Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)  Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)  Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)  Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)  Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)  Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)  Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)  Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5.  Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template

3 that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary-approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements

4 provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below:  Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid.  Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections:  1 (General Description)  2 (General Background) They will also be required to complete the appropriate program sections, including:  4 (Eligibility Standards and Methodology)  5 (Outreach)  9 (Strategic Objectives and Performance Goals and Plan Administration including the budget)  10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements

5 States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections:  3 (Methods of Delivery and Utilization Controls)  4 (Eligibility Standards and Methodology)  6 (Coverage Requirements for Children’s Health Insurance)  7 (Quality and Appropriateness of Care)  8 (Cost Sharing and Payment)  11 (Program Integrity)  12 (Applicant and Enrollee Protections)

 Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

6 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

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

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

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

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

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

1.2.

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

1.3.

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

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

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

7 effective date.

Original Plan Effective Date: July 1, 1998 Implementation Date: July 1, 1998

Amendment #1- Effective April 20, 2000 Amendment #2 - Effective May 1, 2001 Amendment #3 - Effective August 21, 2001 Amendment #4 - Effective January 1, 2003 Amendment #5 - Effective July 1, 2003 Amendment #6 - Effective July 1, 2005 Amendment #7 - Effective July 1, 2006 Amendment #8 - Effective January 1, 2010 Amendment #9 - Withdrawn February 6, 2013 Amendment #10 - Effective November 19, 2010 Amendment# 11 - Effective January 1, 2013 Amendment#12 - Effective July 1, 2014 Amendment #13 - Effective October 1, 2017

SPA #18-0005 Purpose of SPA: CHIP Parity Proposed effective date: October 1, 2017

Proposed implementation date: October 1, 2017

Superseding Pages of MAGI CHIP State Plan Material State: Kansas Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) KS-14-0009

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

CS13

CS15 Eligibility – Targeted Low-Income Children

Eligibility- Deemed Newborns

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

Incorporate within a separate subsection under section 4.3

Incorporate within a separate subsection under section 4.3

KS-15-0004

Effective/Implantation Date: April 1, 2015

MAGI Eligibility & Methods CS7 Supporting Document for Eligibility-Targeted Low-Income Children Supersedes the previously approved CS7 supporting document

8 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) KS-15-0005

Effective/Implementation Date: July 1, 2014

MAGI Eligibility & Methods CS15 MAGI-Based Income Methodologies Supersedes previously approved CS15

KS-16-0001

Effective/Implementation Date: January 1, 2016 MAGI Eligibility & Methods CS10 Eligibility- Children Who Have Access to Public Employee Coverage

Supersedes information on dependents of public employees in Section 4.4.1 KS-16-0003

Effective/Implementation Date: April 1, 2016

MAGI Eligibility & Methods CS7 Supporting Document for Eligibility-Targeted Low-Income Children Supersedes the previously approved CS7 supporting document

KS-17-0002

Effective/Implementation Date: April 1, 2017

MAGI Eligibility & Methods CS7 Supporting Document for Eligibility-Targeted Low-Income Children Supersedes the previously approved CS7 supporting document

KS-18-0003

Effective/Implementation Date: April 1, 2018 MAGI Eligibility & Methods CS7 Supporting Document for Eligibility- Targeted Low-Income Children Supersedes the previously approved CS7 supporting document KS-14-0010

Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 KS-14-0011

Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 KS-14-0012

Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 KS-14-0013

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

CS17

CS18

CS19

Residency

Citizenship

Social Security Number

Supersedes the current section 4.1.5

Supersedes the current sections 4.1.5 and 4.3 on citizenship

Supersedes the current section 4.1.9.1

9 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s)

CS20

CS21

Substitution of Coverage

Non-Payment of Premiums Supersedes the current section 4.4.4

Supersedes the current section 8.7 KS-14-0013 General Eligibility CS 27

CS28 Continuous Eligibility

Presumptive Eligibility for Children Supersedes the current section 4.1.8

Supersedes the current section 4.3.2

KS-15-0006

Effective/ Implementation Date: April 1, 2015 General Eligibility CS28 Presumptive Eligibility for Children Supersedes the previously approved CS28

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. TN No. 18-0005: Approval Date_____________ Effective Date October 1, 2017 Kansas did not seek tribal consultation because the SPA does not impact the tribal nations. This SPA’s intent is to demonstrate Parity. The Kansas CHIP State plan under section 2.3-TC states: “The Division of Health Care Finance will consult and obtain feedback from the Indian Health Clinic Directors and/or Tribal contacts, prior to implementation of any state plan amendments, and proposals for demonstration projects likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations.”

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description.  Population  Number of uninsured

10  Race demographics  Age Demographics  Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low- income children and other groups of children specified) identified, by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a)) From 1997 to today, certain studies and reports have been promulgated regarding the uninsured in Kansas. In summary, those are: September 1997 -The Kansas Health Foundation and the Kansas Department of Health and Environment funded a statewide survey and review of secondary data on insurance coverage. That survey found that 9.4% of the nonelderly population in Kansas was uninsured, and that 31% of the uninsured were children under age 18 (approximately 64,200 children, based on the 1994 Census figures) who were without insurance at the time of the survey. Another 29.9% of those uninsured at some point during the prior year (approximately 25,700) were in this age group. This results in a range of uninsurance for this age group of 64,200 at a point in time to 89,900 at any time over the past year. Adding children aged 18 to this review would, by interpolation, increase the range of uninsured to 67,800 to 91,500. CPS data from 1993, 1994, 1995 - This data is the basis for the CHIP allocations in FFY 1998. While not statistically significant for Kansas, it showed that there were 60,000 uninsured children under age 19, plus or minus 12,300, for a range of 47,700 to 72,300 children. March 2001 - Kansas Health Institute Issue Brief 11 - As part of the three-year evaluation of HealthWave 21, the dynamics of the Title 21 and Title 19 programs between July 1, 1998 and June 30, 2000 were evaluated. One of the findings was a majority (68%) of children entering HealthWave 21 had prior experience with Medicaid, and only 19% to 30% of enrollees were new to public insurance. This implies that while children "aging out" of the stair-step Medicaid eligibility ladder still have access to no-cost or low-cost insurance, the program is not reaching as many of the previously uninsured as was anticipated. August 2001 - Kansas Health Insurance Study-This study, commissioned by the Kansas Insurance Department and funded by a grant from the Health Resources and Services Administration, Department of Health and Human Services, looked at insurance status by age, gender, marital status, education, employment status, and region. Questions about the reasons for uninsurance and health status were asked. This study found that 7.8% of children under age 19 were not insured at the time of the survey. While this percentage is lower than that found in the August 1997 survey for children under age 18 (9.4% versus 7.8%), it translates into approximately 55,600 children, based on the 2000 population figures for Kansas from the Census Bureau.

11 Other notable findings were that children were enrolled in Medicaid/HealthWave 21 at three times the rate of the general public, and that the main reason for uninsurance was the cost. PROJECTED BASED ON 1997 CPS DATA Age 0-99% FPL 100- 132% FPL 133- 149% FPL 150- 159% FPL 160- 169% FPL 170- 184% FPL 185- 199% FPL Total 0 10 10 15 15 50 1-5 1,150 783 783 1,174 1,221 5,111 6-14 12,097 6,212 4,230 4,230 6,347 6,597 39,713 15-18 4,608 2,365 1,612 1,612 2,417 2,513 15,126 Total 16,705 9,727 6,635 6,635 9,953 10,346 60,000

In October 2012, The Georgetown University Health Policy Institute, Center for Children and Families, published "Uninsured Children 2009-2011: Charting the Nations Progress". Using data from the American Community Survey, the report examines trends in children's coverage over a two-year period, from 2009-2011. In 2009, the number of uninsured children under age 18 in Kansas was 57,717, in 2011, the number of uninsured children was 46,345. During this time period, the total change in percent of uninsured children under 18 shows a decrease of 1.8 percentage points, tying Kansas for 7th in the nation.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-

12 recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

The Division of Health Care Finance will consult and obtain feedback from the Indian Health Clinic Directors and/or Tribal contacts, prior to implementation of any state plan amendments, and proposals for demonstration projects likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations. The process includes the following:  The Agency will seek advice concerning changes that have a direct impact on Indians, Indian health programs, or Urban Indian Organizations. For example, such changes may be items such as more restrictive eligibility determinations, changes to reduce payment rates or changes in payment methods, or covered services and changes in consultation policies.  Advice will be sought through phone calls and emails directly to the Kansas Indian Health Services and urban Indian (1/T/Us) Programs.  Documents relevant to the proposed change will be shared for comments and advice through email. The Indian organizations will not be required to provide input should they choose not to.  If Indian organizations, desire to have a face-to-face meeting, or conference call concerning the proposed change, such meetings will be arranged.

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4. Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to the CMS Regional Office servicing them for

13 review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school-based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42 CFR 457.490(a))

3.1. Delivery Standards Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42 CFR 457.490(a)) In December 2012, Kansas was awarded an 11l5(a) Medicaid demonstration waiver by the Centers for Medicare and Medicaid Services. The demonstration known as KanCare is effective January 1, 2013 through December 31, 2017. KanCare will demonstrate a statewide Medicaid reform effort that expands managed care to most Medicaid state plan populations with physical, behavioral, and long-term care services and supports (LTSS). KanCare also provides managed care authority for the State's concurrent 1915(c) home and community based services (HCBS) waivers, providing the first 1115(a)/1915(c) combination. Under KanCare, Kansas will expand Medicaid managed care to include all Medicaid populations, including the aged and disabled. By doing so, the State will focus on providing integrated whole person care, creating health homes, preserving or creating a path to independence, alternative access models and an emphasis on home and community based services. Since 1988, Kansas statute (K.S.A. 38-2001) required CHIP to be provided in a capitated managed care environment. In addition, the statue requires the Kansas CHIP program to be as seamless with Medicaid as possible. Prior to approval of the 1115(a) demonstration, Dental, and Behavioral Health services were carved out of CHIP managed health care programs and provided separately. Within KanCare, CHIP members will continue to receive the same covered services, but no services will be carved out. Moving CHIP into KanCare allows the State to improve the seamlessness between Medicaid and CHIP, improve integration of care, especially behavioral and physical health care; improve outcomes through the provision of

14 enhanced quality requirements and more clearly defined coordination of care expectations, as well as the provision of health homes and other value added services, and continue to enable coordinated efforts for improvement of immunization and well child visit rates across both Medicaid and CHIP members. Services under KanCare will be delivered statewide by three contracting Managed Care Organizations and their subcontractors. In order to assure the highest level of service to Kansans, the contracted MCOs will be required to undertake a health risk assessment to identify health and service need in order to develop care coordination and integration plans for each member; provide health homes to members with complex needs, take steps to improve members' health literacy in order to make effective use of services and share responsibility for their health; provide value added services at no additional cost to the state to incentivize members to participate in health and wellness initiatives; create member Advisory Committees to receive regular feedback. By state statute, service delivery for the CHIP program is provided through capitated managed care arrangements. Other health services are obtained through direct contracts with MCOs chosen for participation as a result of a competitive Request for Proposal (RFP) process. The program is statewide, with coverage and access requirements contained in the contracts and monitored by the state. Effective with Dates of Service on or after October 1, 2009, Kansas will ensure the Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) will receive a reimbursement equivalent to that received by those providers under the Medicaid Prospective Payment System (PPS). For FQHC and RHC services, CHIP encounter claims are included in the clinic reimbursement method in the same manner as Medicaid encounter claims. Effective January 1, 2001, the State implemented the prospective payment system (PPS) to conform with the Benefits Improvements and Protections Act (BIPA) of 2000. There are no retroactive settlements under the PPS system. As an alternative to PPS, providers are offered the opportunity for reimbursement under the rebased PPS. The rebased PPS averages the two most recent finalized cost settlement rates and applies the MEI trend to the rate. This reimbursement method provides the monies on a current basis rather than retroactive. Clinics are paid the greater of rebased PPS or PPS-based reimbursement. CHIP encounters in Indian Health Clinics are reimbursed by the managed care organizations at 100% of the Medicare Indian Health Service encounter rate negating the need for a wraparound payment.

15

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b))

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

Utilization control mechanisms are in place for the CHIP program to ensure that children use only health care that is appropriate, medically necessary, and approved by the State or the participating MCO. Before being approved for participation in the CHIP Program, MCOs must develop and have in place utilization review policies and procedures that include protocols for prior approval and denial of services, hospital discharge planning, physician profiling, and retrospective review of both inpatient and ambulatory claims meeting pre-defined criteria. MCOs must develop procedures for identifying and correcting patterns of over and underutilization on the part of their enrollees. More information can be found on utilization control in Section 7 - Quality and Appropriateness of Care.

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Children who are determined Presumptively Eligible (PE) for Title XXI will receive the Title XIX benefit package until such time as eligibility for Title XXI is confirmed or denied. The State of Kansas provides Secretary Approved Coverage for Title XXI eligibles plus additional coverage that is medically necessary. When formal determination of the PE application is complete, the child will be enrolled in the appropriate program, either Title XIX or Title XXI. Program placement will be based on established eligibility criteria. Children who are found presumptively eligible for Title XIX will receive the Title XIX benefit package. Title XIX offers services to persons eligible for Medicaid through a managed care organization system. These services are available statewide. Access to medically necessary services are provided by the beneficiaries' MCO.

Section 4. Eligibility Standards and Methodology

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

4.1.

Separate Program Check all standards that will apply to the State plan. (42 CFR 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

See Approved SPA KS 14-0013

4.1.1 Geographic area served by the Plan if less than Statewide:

The plan is available statewide.

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

17 See Approved SPA 14-0009. The ages in SPA 14-0009 remain intact but the income standards have been revised in approved SPA 18-0003.

4.1.2.1-PC Age: through birth (SHO #02-004, issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

See Approved SPA 18-0003

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through % of the FPL (SHO #02-004, issued November 12, 2002)

4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

No resource test is applied.

4.1.5 Residency (so long as residency requirement is not based on length of time in state):

See Approved SPA 14-0013

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7 Access to or coverage under other health coverage:

Children up to 200% Federal Poverty Level are ineligible for CHIP if currently covered by other health insurance or eligible for Medicaid coverage. Children with family income above 200% FPL would be those persons not enrolled in a comprehensive health insurance for the identified time period prior to the application date. The identified time period is 90 days per approved SPA 14-0013.

4.1.8 Duration of eligibility, not to exceed 12 months:

See Approved SPA 14-0013

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 42 CFR 457.310 and 457.320 that are not addressed above. For instance:

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

18

 To be eligible for CHIP coverage, families above 167% of the poverty level of the current year must agree to pay a monthly premium which does not exceed the limitations of section 2103(e).

 Children are ineligible for CHIP coverage if they are eligible for health coverage under the Kansas Group Health Insurance Program, if they are an inmate in a public correctional institution, or if they are a patient in an institution for mental diseases.

 The state requires a social security number for all applicants in accordance with the provisions at 42 CFR 457.340(b).

 Effective on July 1, 2016 date, the state began providing coverage to dependents of public employees. See approved SPA 16-0001.

See Approved SPAs 14-0009 and 14-0013

4.1.9.1

States should specify whether Social Security Numbers (SSN) are required.

See Approved SPA 14-0013

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility

See Approved SPA 14-0013

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1) “lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such

19 individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days;

20 (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental- only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

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

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

standards do not cover children of higher income families without covering

children with a lower family income. This applies to pregnant women included

21

in the State plan as well as targeted low-income children.

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

medical condition. This applies to pregnant women as well as targeted low-

income children.

4.2-DS Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

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

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42 CFR 457.350)

See Approved SPAs 14-0013 and 15-0005, as well as 15-0006 (PE Procedures)

A simplified application/enrollment form is used to access both Medicaid and CHIP coverage. The form is available through a number of access points including schools, churches, medical providers and Department for Children and Families (DCF). The form is mailed in with supporting documentation such as wage information to a central clearinghouse. The clearinghouse is responsible for initial processing and eligibility determination for both Medicaid and CHIP and involves privately contracted staff. The Medicaid state agency administers the portion of the clearinghouse responsible for Medicaid determination and case maintenance. Contracted staff is responsible for all CHIP processing and determinations as well as ongoing case management.

The Income Eligibility Verification System (IEVS) is used to confirm income information on an ongoing basis and the Systematic Alien Verification for Entitlements (SAVE) program or an appropriate alternative is used to verify immigration status.

Eligibility is continuous for 12 months and re-established annually. The family must meet all eligibility criteria and have paid any applicable premiums from the prior year to be re- enrolled for a new 12-month period. The amendment effective 1/1/99 allows an infant born to a KanCare enrolled mother will be retroactively enrolled in KanCare starting with

22 the month of birth, but will be subject to Medicaid screening and enrollment requirements no later than 90 days from the date the Agency has been notified of the birth of the infant.

The application/enrollment form will be used to ascertain current health insurance coverage as well as access to state employee coverage. Children found to have current health coverage will be denied eligibility for CHIP coverage.

If application is made for medical assistance under Medicaid or CHIP, the applicant must provide approved documentation for verification of citizenship and identity.

The amendment effective 7/1/01 allows children who had health coverage within eight months prior to application for the CHIP program to receive benefits. They will be denied benefits in the situation when other private health coverage is active on the day of application. Kansas does track those who had health coverage within 90 days, per approved SPA 14-0013, prior to application. Premiums will be charged to families above 167% of FPL in the CHIP program. There are exceptions which are listed in section 4.4.4.2.

The agency will verify the applicant is not covered by any insurance at the time of application and will monitor any conditions that may contribute to crowd out on at least an annual basis for up to 200% of Federal Poverty Level. For those applicants above 250% of the 2008 Federal Poverty Guidelines the agency will require that private insurance has not been voluntarily terminated within the previous 90 days, per approved SPA 14-0013.

Once determined eligible for the CHIP program, children are enrolled into one of three Managed Care Organizations contracted to provide services. Once approval is authorized in the state's eligibility system, the record is transferred to the MMIS, which in turn sends an 834 enrollment record to the MCO. Applicants may choose any of the MCOs in which to enroll, however if a choice is not indicated on the application the beneficiary will be auto- assigned to an MCO. There is a 90-day choice period after enrollment during which beneficiaries may chose a different MCO. Once the 90-day choice period is over, the beneficiary remains assigned to the plan for one year.

Procedures for disenrollment for cause:

All disenrollment requests are processed by the Single State Medicaid Agency. MCOs are not permitted to process disenrollments. Oral or written requests are received and documented by the State's fiscal agent. Determination criteria mirror 42 CFR 438.56 with the following additions for case continuity: children who change custodial arrangements between family households (change cases) or are adopted by a new family may change health plans outside the open enrollment period. The State of Kansas does not require enrollees to seek redress through the MCO grievance process prior to requesting

23 disenrollment. Requests based on provider access are compared with the MCO network. If a provider is available, the MCO is required to offer assistance to the beneficiary in scheduling an appointment for needed services. If the MCO is unable to offer an appointment, disenrollment is allowed. Disenrollment requests based on provider quality are allowed if another in-network provider is not available. Quality grievances are investigated by the MCO and reviewed by the State. Information explaining how to access the State Fair Hearing process is included on all disenrollment denial notices.

Presumptive Eligibility Process

Staff of designated entities selected and trained by the Medicaid state agency are authorized to determine presumptive eligibility. The determination will be completed using only the Kansas Presumptive Eligibility determination tool. The tool will be provided by the agency. If the income of the family group is above 250 % of the 2008 Federal Poverty Guidelines the child is presumptively eligible for medical coverage. Children within the CHIP income guidelines may be eligible for medical coverage if he or she has no other health coverage. Information on eligible children will be submitted by the qualified entity to the central clearinghouse within 5 working days. The staff at the designated entity will assist the family in completing a formal application for CHIP and submit it to the central clearinghouse.

Presumptive eligibility begins on the day the designated entity determines that the child appears eligible. If an application is filed on the child's behalf by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on the day a final determination of eligibility is made. If an application is not filed by the last day of the month following the month the determination of presumptive eligibility was made, the presumptive period ends on that last day.

Each child is eligible for only one period of presumptive eligibility within a 12-month period. The 12-month period begins on the first day of presumptive eligibility determination.

Children who are determined presumptively eligible for Title XXI will receive the Title XIX benefit package until such time as eligibility for Title XXI is confirmed or denied. When formal determination of the PE application is complete, the child will be enrolled in the appropriate program, either Title XIX or Title XXI. Program placement will be based on established eligibility criteria.

Claims for services being provided to individuals found to be presumptively eligible for CHIP will be processed in accordance with the State Medicaid Manual, Option 1 (report all expenditures at Medicaid match rate). For applicants who qualify at or under 250% of the 2008 Federal Poverty Guidelines would be those persons not enrolled in a

24 comprehensive health insurance for the time period of the application date minus eight months.

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42 CFR 457.305(b))

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

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the

Citizenship status of the child. States electing this option should indicate so in the

State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

See Approved SPA 15-0006

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other

25 methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42 CFR 457.350(a)(1) and 457.80(c)(3))

4.4. Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

The State does not apply a waiting period for pregnant women. Most current Medicaid financial and non-financial requirements as specified in the Title XIX

26 State Plan are applicable to both the Medicaid and CHIP populations. The central clearinghouse described in section 4.3 determines initial eligibility for either Medicaid or CHIP by reviewing income and other information submitted by families. Families are provided coverage under either Medicaid or CHIP dependent upon total income available.

4.4.2. children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42 CFR 457.350(a)(2)).

Through the use of a combined simplified application/enrollment form and the central clearinghouse, eligibility is determined for either Medicaid or CHIP coverage based on income and age level.

4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

All applications are first reviewed for potential Medicaid eligibility, those found ineligible for Medicaid are immediately screened for CHIP eligibility. This process occurs at the same location, with the same workers, and no referral is required.

4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42 CFR, 457.805)

The application/enrollment form is used to ascertain current health insurance coverage. Children found to have current health coverage are denied eligibility for CHIP coverage.

Premiums are charged to families above 167% of FPL in the CHIP program.

The central Clearinghouse application processing contractor monitors for substitution for coverage under group health plans through their application decisions software.

Effective January 1, 2014, see approved SPA 14-0013 related to substitution of coverage. See approved SPA 16-0001 for public employees of all income groups, at or below 200%, and above 200%.

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions

27 to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42 CFR 457.810(a)-(c))

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

The State has undertaken the following actions:

 Including ethnic information on the application for tracking Indian numbers.

 Including in the outreach media campaign and other outreach activities, the names of the community based organizations that serve Indian children, to assure that families are aware of the program and assist in the enrollment process.

 Using the three Indian Health Clinics as access points to provide enrollment materials and assistance to potentially eligible children.

Guidance: When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process, or elect one of two new options to fulfill these requirements.

4.4-EL The State should designate the option it will be using to carry out screen and enroll

requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was

28 calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Section 5. Outreach and Coordination

5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42 CFR 457.80(b))

Guidance: The information below may include whether the state elects express lane eligibility a description of the State’s outreach efforts through Medicaid and state- only programs.

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

The 2012 Legislative session under an Executive Order of Reorganization issued by Governor Sam Brownback consolidated the financing arm of Medicaid in the Kansas Department of Health and Environment Division of Health Care Finance; renaming the former Department on Aging as the Department for Aging and Disability Services and consolidating all disability waiver and mental health services from the Department of Social and Rehabilitation Services into the new agency; and renaming the Department of Social and Rehabilitation Services as the Department for Children and Families.

Outreach for Medicaid programs are administered through the Kansas Department of Health and Environment, Division of Health Care Finance. Enrollment activities are coordinated by the Medicaid fiscal agent.

Education regarding the Medicaid program is provided to advocacy groups, schools, health care professionals, social service agencies, and other community organizations who may have contact with children requiring health insurance coverage in an effort to enlist the help of these organizations in identifying children without health insurance coverage and assisting the families in making application for Medicaid. There are also staff located in Regional Service Centers and in Central Office who conduct public awareness and education activities for the Medicaid program. In addition, field staff are located in throughout the State in local health departments.

This provides additional opportunities for outreach and education as well as the initial processing of Medicaid applications. Outreach activities for Maternal and Child Health

29 and Title V programs are conducted by the Kansas Department of Health and Environment, which is the Medicaid agency.

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured children from the time the State’s plan was initially approved. States do not have to rewrite his section but may instead update this section as appropriate.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership:

Kansas has a joint application for Title XXI and Title XIX. For Title XXI, income must be at or below 250% FPL. This coverage is available to all Title XIX and Title XXI children including those children who are determined presumptively eligible. Title XIX and presumptively eligible children receive local education agency and early childhood intervention services through a fee for service model.

Guidance: The State should describe below how it’s Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid- eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42 CFR 457.80(c))

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. (Section 2102(a)(3), 2102(b)(3)(E) and 2102(c)(2)) (42 CFR 457.80(c)). This item requires a brief overview of how Title XXI efforts – particularly new enrollment outreach efforts – will be coordinated with and improve upon existing State efforts.

KanCare Tribal Consultations

The Division of Health Care Finance will consult and obtain feedback from the Indian Health Clinic Directors and/or Tribal contacts, prior to implementation of any state plan amendments, and proposals for demonstration projects likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations. The process includes the following:

• The Agency will seek advice concerning changes that have a direct impact on Indians, Indian health programs, or Urban Indian Organizations. For example, such changes may be items such as more restrictive eligibility determinations, changes to reduce payment rates or changes in payment methods, or covered services and changes in consultation

30 policies.

• Advice will be sought through phone calls and emails directly to the Kansas Indian Health Services and urban Indian (I/T/Us) Programs.