DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services C/i77. AY 601 East 12" Street, Suite 355

Kansas City, Missouri 64106 CENTERS foe MEDICARE & MEDICID SERVICES

Division of Medicaid and Children's Health Operations January 12, 2012

Kari Bruffett

Executive Director

Kansas Health Policy Authority Landon State Office Building 900 SW Jackson, Room 900-N Topeka, Kansas 66612-1220

Dear Ms. Bruffett:

On October 31, 2011, the Centers for Medicare & Medicaid Services (CMS) received Kansas’ State Plan Amendment (SPA), transmittal #11-14 through which the State is attesting compliance with Section 4107 of the Patient Protection and Affordable Care Act (Affordable Care Act), P.L. 111-148. This amendment provides for Medicaid coverage of comprehensive tobacco cessation services for pregnant women, including both counseling and pharmacotherapy, without cost sharing. This provision was effective October 1, 2011.

Based upon the information received, CMS approved SPA #11-14 on January 9, 2012, with an effective date of October 1, 2011. Enclosed is a copy of the CMS 179 form, as well as, the approved pages for incorporation into the Kansas Medicaid State Plan. If you have any questions regarding this amendment, please contact Sandra Levels at (816) 426-5925.

Associate Regional Administrator for Medicaid and Children’s Health Operations

Enclosure

cc: Christiane Swartz Rita Haverkamp

Revised Stomission [1-28 if

Revision: HCFA-PM-93-5 (BPD) ATTACHMENT 3.1-B May 1993 Page 2a OMB No. State/Territory: Kansas

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S):_All medically needy groups

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

1 ( By or under supervision of a physician;

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

o (iii) Any other health care professional legally authorized to provide tobacco cessation services under State law and who is specifically designated by the Secretary in regulations. (None are designated at this time; this item is reserved for future use.) *describe if there are any limits on who can provide these counseling services

2) Face-to-Face Tobacco Cessation Counseling Services Benefit Package for Pregnant Women

Provided: EQ No timitations ‘With limitations

Please describe any limitations:

5. a. Physicians’ services, whether furnished in the office, the patient’s home, a hospital, a nursing facility, or elsewhere. &X Provided: O No limitations = With limitations* b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act). O Provided: O No limitations O With limitations*

Not provided

*Description provided on Attachment 3.1-A. TN No. KS #11-14 Supersedes _MS 05-07 Approval Dagyyy 0 9 2Uiléffective Date 10/01/11

Revised Submissin !1-23-1

KANSAS MEDICAID STATE PLAN Attachment 3.1-A #4.d. Page 1 Attachment 3.1-A: Tobacco Cessation Counseling Services for Pregnant Women 4.d. 1) Face-to-Face Tobacco Cessation Counseling Services provided (by): EX] G) By or under supervision of a physician; Dx] Gi) By any other health care professional who is legally authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; * or O Gii) Any other health care professional legally authorized to provide tobacco cessation services under State law and who is specifically designated by the Secretary in regulations. (None are designated at this time; this item is reserved for future use.) * describe if there are any limits on who can provide these counseling services 2) Face-to-Face Tobacco Cessation Counseling Services Benefit Package for Pregnant Women

Provided: [x] No limitations © With limitations

Please describe any limitations:

JAN 09 1) _ TN # MS KS 11-14 Approval Date Effective Date 10/01/11 Supersedes TN# New

DEPARTMENT OF HEALTH AND HUMAN SERVICES Revised Submission 1.23. I

FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE SPA KS #11-14 Kansas

STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4, PROPOSED EFFECTIVE DATE October 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

LJ NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

X AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

Section 4107 of the Affordable Care Act

7. FEDERAL BUDGET IMPACT: a. FFY 2012 $0 b. FFY 2013 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 3.1-A, #4.d, Page 1, (New) Attachment 3.1-B, Page 2a

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

Attachment 3.1-B, Page 2a

10. SUBJECT OF AMENDMENT: Smoking Cessation for Pregnant Women

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

X OTHER, AS SPECIFIED: Andy Allison, PhD. is the Governor’s Designee

12. SIGNATURE OF STATE AGENCY OFFICIAL: \

Badan © dhenapen

13. TYPED NAME: for Andy Allison, PhD.

14, TITLE: Director of the Division of Health Care Finance

15. DATE SUBMITTED: October 31, 2011

16. RETURN TO: Andy Allison, PhD. Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220

FORM HCFA-179 (07-92)

Table of Contents

State/Territory Name: KS State Plan Amendment (SPA) #: 14-0002-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

June 24, 2014

Susan Mosier, MD, MBS, FACS Interim Executive Director Kansas Department of Health and Environment 900 SW Jackson, Room 900N Topeka, KS 66612

Dear Dr. Mosier:

On March 27, 2014, the Centers for Medicare & Medicaid Services (CMS) received Kansas’ State Plan Amendment (SPA) transmittal #14-0002-MM1, which describes the Modified Adjusted Gross Income (MAGI) based eligibility groups in accordance with the Affordable Care Act.

SPA 14-0002-MM1 was approved on June 23, 2014, with an effective date of January 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 summary page, as well as the approved pages for incorporation into the Kansas State Plan.

The following state plan pages are approved and should be incorporated into Kansas’ State Plan: S14, S25, S28, S30, S32, S33, S50, S51, S52, S53, S54, S55, S57, and S59.

If you have any questions regarding this amendment, please contact Karen Hatcher or Megan Buck at (816) 426-5925.

Sincerely,

//s//

Leticia Barraza

Acting Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Bobby Graff-Hendrixson Jeanine Schieferecke

State/Territory name: Kansas Submitted By: Bobbie Graff-Hendrixson Last Revision Date: Jun 20, 2014 Submit Date: Mar 27, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0002 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.110; 42 CFR 435.116; 42 CFR 435.118; 42 CFR 435.119; 42 CFR 435.150;42 CFR 435.218;42 CFR 435.220;42 CF Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 341500.00 Second Year 2015 $ 455000.00 Subject of Amendment Medicaid State Plan Amendment for MAGI from the State of KS. The fiscal impact does not include administrative costs. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 06/20/2014 Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 9 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 289.32 x + 2 388.27 x + 3 480.23 x + 4 562.19 x + 5 638.14 x + 6 714.1 x + 7 790.05 x + 8 866.01 x Additional incremental amount Yes No Increment amount $ 76.12 The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996 Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 2 of 9 Medicaid Eligibility Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by region Remove Region Name of region Regions 1 and 2 - Shared Living Description Regions 1 and 2 represent the counties in the state with the lowest cost of living. Household size Standard ($) + 1 168 x + 2 263 x + 3 349 x + 4 421 x + 5 487 x + 6 557 x + 7 618 x + 8 679 x Additional incremental amount Yes No Increment amount $ 61 Remove Region Name of region Region 3 Description Region 3 represents the counties in the state with a mid-level cost of living. Household size Standard ($) + 1 170 x Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 3 of 9 Medicaid Eligibility + 2 265 x + 3 352 x + 4 425 x + 5 490 x + 6 561 x + 7 622 x + 8 683 x Additional incremental amount Yes No Increment amount $ 61 Remove Region Name of region Region 4 - Shared Living Description Region 4 represents the counties in the state with the second highest cost of living. Household size Standard ($) + 1 175 x + 2 271 x + 3 359 x + 4 432 x + 5 499 x + 6 571 x + 7 632 x + 8 693 x Additional incremental amount Yes No Increment amount $ 61 Remove Region Name of region Region 5 - Shared Living Description Region 5 represents the region of the state with the highest cost of living. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 4 of 9 Medicaid Eligibility Household size Standard ($) + 1 186 x + 2 284 x + 3 375 x + 4 449 x + 5 517 x + 6 592 x + 7 653 x + 8 714 x Additional incremental amount Yes No Increment amount $ 61 Remove Region Name of region Regions 1 and 2 - Non-Shared living Description Regions 1 and 2 represent the counties of the state with the lowest cost of living. Household size Standard ($) + 1 224 x + 2 309 x + 3 386 x + 4 454 x + 5 515 x + 6 576 x + 7 637 x + 8 698 x Additional incremental amount Yes No Increment amount $ 61 Remove Region Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 5 of 9 Medicaid Eligibility Name of region Region 3 - Non-Shared living Description Region 3 represents the counties in the state with a mid-level cost of living. Household size Standard ($) + 1 229 x + 2 314 x + 3 391 x + 4 459 x + 5 520 x + 6 581 x + 7 642 x + 8 703 x Additional incremental amount Yes No Increment amount $ 61 Remove Region Name of region Region 4 - Non-Shared living Description Region 4 represents the counties in the state with the second highest cost of living. Household size Standard ($) + 1 241 x + 2 326 x + 3 403 x + 4 471 x + 5 532 x + 6 593 x + 7 654 x Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 6 of 9 Medicaid Eligibility + 8 715 x Additional incremental amount Yes No Increment amount $ 61 Remove Region Name of region Region 5 - Non-Shared living Description Region 5 represents the counties in the state with the highest cost of living. Household size Standard ($) + 1 267 x + 2 352 x + 3 429 x + 4 497 x + 5 558 x + 6 619 x + 7 680 x + 8 741 x Additional incremental amount Yes No Increment amount $ 61 Add Region The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 7 of 9 Medicaid Eligibility Enter the statewide standard Household size Standard ($) + 1 292.64 x + 2 396.23 x + 3 491.82 x + 4 578.4 x + 5 657.99 x + 6 737.58 x + 7 817.16 x + 8 896.75 x Additional incremental amount Yes No Increment amount $ 70.96 The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 8 of 9 Medicaid Eligibility Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 9 of 9 Medicaid Eligibility Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives S25 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. ■ The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative (select any that apply): The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. Definition of domestic partner: The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: Relatives within the 5th degree of relationship. The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 2 of 4 Medicaid Eligibility Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard ■ The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 3 of 4 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other dollar amount % Income standard chosen: ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. Another income standard in-between the minimum and maximum standards allowed The state's AFDC payment standard in effect as of July 16, 1996, not converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, not converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other income standard in-between the minimum and the maximum standards allowed. The amount of the income standard for this eligibility group is: A percentage of the federal poverty level: A dollar amount % 33 There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 4 of 4 Medicaid Eligibility Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Pregnant Women S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I), (IV) and (IX) 1931(b) and (d) 1920 Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. ■ Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. Yes No MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 150 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 2 of 2 Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL The amount of the maximum income standard is: 166 % FPL Income standard chosen ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard Another income standard in-between the minimum and maximum standards allowed. There is no resource test for this eligibility group. ■ Benefits for individuals in this eligibility group consist of the following: ■ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. Presumptive Eligibility ■ The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 8 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 150 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 2 of 8 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Enter the amount of the maximum income standard: 166 % FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age one through age five, inclusive ■ Minimum income standard ■ Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 3 of 8 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 149 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 4 of 8 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Income standard chosen ■ The state's income standard used for children age six through eighteen is: Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 5 of 8 Medicaid Eligibility The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No Presumptive Eligibility for Children S16 1902(a)(47) 1920A 42 CFR 435.1101 42 CFR 435.1102 The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions: ■ Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 6 of 8 Medicaid Eligibility If the state has elected to cover Optional Targeted Low-Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR 435.118), for that child’s age. If the state has not elected to cover Optional Targeted Low Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child’s age. Children under the following age may be determined presumptively eligible: ■ Under age 19 The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The presumptive eligibility determination is based on the following factors: ■ Household income must not exceed the applicable income standard described above, for the child's age. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. ■ List of Qualified Entities S17 Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 7 of 8 Medicaid Eligibility A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP) Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV-D of the Act Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included. ✔ An attachment is submitted. PRA Disclosure Statement Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 8 of 8 Medicaid Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Adult Group S32 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. ■ The state attests that it operates this eligibility group under the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under age 26. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ■ Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. ■ The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals above 133% FPL S50 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives S51 42 CFR 435.220 1902(a)(10)(A)(ii)(I) Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 18 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 S52 42 CFR 435.222 1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: ■ Be under age 21, or a lower age, as defined within the reasonable classification. ■ Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification. ■ Not be eligible and enrolled for mandatory coverage under the state plan. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group. ✔ An attachment is submitted. Current Coverage of All Children under a Specified Age Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 2 of 18 Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 Reasonable Classifications of Children S11 Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals placed in foster care homes by public agencies Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals placed in foster care homes by private, non-profit agencies Individuals placed in private institutions by public agencies Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals placed in private institutions by private, non-profit agencies Individuals in adoptions subsidized in full or part by a public agency Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 3 of 18 Medicaid Eligibility Individuals in nursing facilities, if nursing facility services are provided under this plan Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Also individuals in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID), if these services are provided under this plan. Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Other reasonable classifications Name of classification Description Age Limit + Children in State Custody All children under 21 in State custody not reside in a public institution but who would be eligible for financial assistance except for their living arrangement. Under age 21 x + HCBS children If these children were not on a waiver they would be institutionalized. Under age 21 x Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23, 2010 and no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Click here once S11 form above is complete to view the income standards form. Individuals placed in foster care homes by public agencies Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 4 of 18 Medicaid Eligibility Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 5 of 18 Medicaid Eligibility If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals placed in private institutions by public agencies Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 6 of 18 Medicaid Eligibility The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 7 of 18 Medicaid Eligibility If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals in adoptions subsidized in full or part by a public agency Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 8 of 18 Medicaid Eligibility The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 9 of 18 Medicaid Eligibility Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals in nursing facilities, if nursing facility services are provided under this plan Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 10 of 18 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Also individuals in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID), if these services are provided under this plan. Income standard used ■ Minimum income standard ■ Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 11 of 18 Medicaid Eligibility The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 12 of 18 Medicaid Eligibility Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 13 of 18 Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 14 of 18 Medicaid Eligibility If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Children in State Custody Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 15 of 18 Medicaid Eligibility The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 16 of 18 Medicaid Eligibility If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. HCBS children Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 17 of 18 Medicaid Eligibility The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Other Reasonable Classifications Previously Covered Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 18 of 18 Medicaid Eligibility The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group. Yes No Additional new age groups or reasonable classifications covered If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. Yes No There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ■ Are under the following age (see the Guidance for restrictions on the selection of an age): ■ Under age 21 Under age 20 Under age 19 Under age 18 MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. ■ The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 2 of 2 Medicaid Eligibility No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this eligibility group under (check all that apply): ■ The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age: The minimum standard. This eligibility group does not use an income test (all income is disregarded). Another income standard higher than both the minimum income standard and the effective income level for this eligibility group in the state plan as of March 23, 2010, converted to a MAGI-equivalent. There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Targeted Low Income Children S54 1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis S55 1902(a)(10)(A)(ii)(XII) 1902(z) Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents S57 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under the following age ■ Under age 21 Under age 20 Under age 19 Were in foster care under the responsibility of a state on their 18th birthday. ■ Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. ■ Have household income at or below a standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013): ■ All children under the age selected A reasonable classification of children under the age selected: Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 2 of 2 Medicaid Eligibility Maximum income standard ■ No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this eligibility group under (check all that apply): ■ The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 demonstration as of March 23, 2010. A Medicaid 1115 demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard: This eligibility group does not use an income test (all income is disregarded). There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services S59 1902(a)(10)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20131009 Transmittal Number: KS 14-0002-MM1 Approval Date: June 23, 2014 Effective Date: January 1, 2014

Table of Contents State/Territory Name: KS State Plan Amendment (SPA) #: 14-0003-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) Application Approval Letter 4) Summary Form (with 179-like data) 5) Superseding Pages Notice 6) Approved SPA Pages 7) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations December 9, 2014

Susan Mosier, MD, MBA, FACS Executive Director Kansas Department of Health and Environment 900 SW Jackson, Room 900N Topeka, KS 66612

RE: S-94 – Eligibility Process State Plan Amendment (SPA), KS-14-0003-MM2

Dear Dr. Mosier:

Enclosed is an approved copy of Kansas’ state plan amendment (SPA) KS-14-0003- MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 27, 2014. SPA KS-14-0003-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Kansas’ Medicaid state plan in accordance with the Affordable Care Act. This SPA was approved on December 8, 2014, with an effective date of January 1, 2014.

The approval of SPA KS-14-0003-MM2 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 concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Kansas’ approved state plan:

 S94, pages S94-1 and S94-2  Attachment 1 – State of Kansas’ alternative single streamlined paper application  Attachment 2 – Statement of use with respect to the alternative single streamlined online application

In addition, enclosed is a summary of state plan pages which are superseded by SPA KS-14-0003-MM2. This summary should be incorporated into a separate section in the front of the state plan.

 Superseding Pages of State Plan Material, KS-14-0003-MM2

Page 2 – Dr. Susan Mosier 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 Karen Hatcher at (816) 426-5925.

Sincerely,

//s//

Leticia Barraza

Acting Associate Regional Administrator

for Medicaid and Children’s Health Operations

cc: Bobbie Graff-Henderixon

Jeanine Schieferecke

Kim Tjelmeland bcc: Karen Hatcher

Megan Buck

Elizabeth Walker

Kevin Slaven

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations December 9, 2014

Susan Mosier, MD, MBA, FACS Executive Director Kansas Department of Health and Environment 900 SW Jackson, Room 900N Topeka, KS 66612

RE: S-94 – Eligibility Process State Plan Amendment (SPA), KS-14-0003-MM2

Dear Dr. Mosier:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) transmittal KS-14-0003-MM2. Our review of this submission included a review of the online alternative single streamlined application developed by the state.

Until October 31, 2015, the state is using an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following changes.

MAGI-based Online Application Necessary Changes

Completion Date

The state agrees to add logic to ask questions about access to employer sponsored coverage only for applicants who appear ineligible for Medicaid and CHIP.

October 31, 2015

Pensions and retirement income is generally taxable and should be included as a MAGI income type rather than a non-MAGI income type.

June 30, 2015

Page 2 – Dr. Susan Mosier

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

If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (415) 744-3860. If you have any questions concerning this SPA, please contact Karen Hatcher at Karen.Hatcher@cms.hhs.gov or (816) 426-5925.

Sincerely,

//s//

Leticia Barraza

Acting Associate Regional Administrator

for Medicaid and Children’s Health Operations

cc: Bobbie Graff-Henderixon

Jeanine Schieferecke

Kim Tjelmeland bcc: Karen Hatcher

Megan Buck

Elizabeth Walker

Kevin Slaven

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

November 18, 2015

Susan Mosier, M.D. MBS, FACS Executive Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900N Topeka, KS 66612

Dear Dr. Mosier:

On December 9, 2014, the Centers for Medicare & Medicaid Services (CMS) approved Kansas’ State Plan Amendment (SPA) 14-0003-MM2 with an effective date of January 1, 2014. This SPA included approval for the State to use an interim alternative single streamlined online application.

The CMS has reviewed the changes submitted with respect to Kansas’ alternative single streamlined online application. The revised application addresses the concerns outlined in the companion letter that was issued with the SPA approval. This letter serves as official approval of Kansas’ alternative single streamlined online application with an approval date of November 9, 2015, and an effective date of September 28, 2015.

Enclosed is a copy of the approved alternative single streamlined online application. Please incorporate these pages into the State Plan following the attachment to S94 entitled “Use of the Alternative Single Streamlined Application.”

If you have any additional questions or require any further assistance, please contact Karen Hatcher at (816) 426-5925 or Karen.Hatcher@cms.hhs.gov.

Sincerely,

//s//

James G. Scott Associate Regional Administrator

for Medicaid and Children’s Health Operations

cc: Mike Randol

Bobbie Graff-Hendrixson

Jeanine Schieferecke

Kim Tjelmeland

State/Territory name: Kansas Submitted By: Bobbie Graff-Hendrixson Last Revision Date: Nov 14, 2014 Submit Date: Mar 27, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0003 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment The fiscal impact does not include Administrative costs. This is the MAGI Eligibility Amendment. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 12/09/2014 Transmittal Number: KS 14-0003-MM2 Approval Date: December 8, 2014 Effective Date: January 1, 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

KS 14-0003-MM2 STATE:

Kansas

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 – Eligibility Process PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2, Page 10, section 2.1(a), TN 91-41 Effective date: 10/1/91, approved: 1/27/92 Section 2, Page 11a, section 2.1(d), TN 91-47 Effective date: 10/1/91 , approved: 2/19/92

Transmittal Number: KS 14-0003-MM2 Approval Date: December 8, 2014 Effective Date: January 1, 2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No Transmittal Number: KS 14-0003-MM2 Approval Date: December 8, 2014 Effective Date: January 1, 2014

Page 2 of 2 Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + FAX Facsimile Machine x The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency ■ If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0003-MM2 Approval Date: December 8, 2014 Effective Date: January 1, 2014

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

 Paper Application  Online Application

TRANSMITTAL NUMBER:

KS-14-0003-MM2

STATE:

Kansas

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

Transmittal Number: KS 14-0003-MM2 Approval Date: December 8, 2014 Effective Date: January 1, 2014

State of Kansas Online Medical Application Application Version ‐October 2015 Date of Document – 09‐23‐15 Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Contents Welcome ....................................................................................................................................................... 3 Let’s Get Started ........................................................................................................................................... 4 Start Application ........................................................................................................................................... 5 People ......................................................................................................................................................... 10 Job/Wages ................................................................................................................................................... 28 Other Income .............................................................................................................................................. 34 Expenses ..................................................................................................................................................... 37 Resources .................................................................................................................................................... 38 Other ........................................................................................................................................................... 39 Submit Application ...................................................................................................................................... 44 Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Welcome Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Let’s Get Started Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Start Application Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

People Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Job/Wages Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Other Income Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Expenses Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Resources Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Other Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Note: This page is used to display the initial Employee‐Sponsored Insurance question. If this application fails the federal poverty level (FPL) assessment and “Can anyone in your household get health coverage from a job” is answered “Yes,” the Information for HealthCare.Gov (Continued) screen will be displayed. The current screen displays a chart with the monthly income limits and asks the consumer if their household income is greater than the limit. The change for October 2015 calculates an estimated income and removes the chart. Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Note: The HealthCare.gov summary screen allows for multiple entries. Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Submit Application Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Transmittal Number: KS 14-0003-MM2 Approval Date: November 9, 2015 Effective Date: September 28, 2015

Table of Contents

State/Territory Name: KS State Plan Amendment (SPA) #: 14-0004-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

May 5, 2014

Kari Bruffett, Executive Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900N Topeka, KS 66612

Dear Ms. Bruffett:

On March 27, 2014, the Centers for Medicare & Medicaid Services (CMS) received Kansas’ State Plan Amendment (SPA) transmittal #14-0004-MM3, which describes the financial eligibility methodologies that will apply to all Modified Adjusted Gross Income (MAGI)-based eligibility groups covered under Kansas’ Medicaid State Plan. The MAGI financial methodologies set forth in at 1902(e)(14) of the Act 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI- based methods do not apply.

SPA 14-0004-MM3 was approved on May 2, 2014, with an effective date of January 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 Summary Page, as well as the approved pages for incorporation into the Kansas State Plan.

If you have any questions regarding this amendment, please contact Megan Buck or Karen Hatcher at (816) 426-5925.

Sincerely,

//s//

Leticia Barraza

Acting Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Susan Mosier, M.D.

Bobbie Graff-Hendrixson

State/Territory name: Kansas Submitted By: Bobbie Graff-Hendrixson Last Revision Date: Mar 27, 2014 Submit Date: Mar 27, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0004 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.603 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 21300.00 Second Year 2015 $ 28500.00 Subject of Amendment This is the Income Methodology MAGI State Plan Amendment. This does not include administrative costs. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 05/02/2014 Transmittal Number: KS 14-0004-MM3 Approval Date: May 2, 2014 Effective Date: January 1, 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

KS 14-0004 STATE:

Kansas

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

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

Notwithstanding any other provisions of the Kansas Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment KS 14-0004 will apply to all MAGI-based eligibility groups covered under Kansas’ Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Transmittal Number: KS 14-0004-MM3 Approval Date: May 2, 2014 Effective Date: January 1, 2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. ■ In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: The pregnant woman is counted just as herself. The pregnant woman is counted as herself, plus one. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: Current monthly household income and family size Projected annual household income and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Yes No Transmittal Number: KS 14-0004-MM3 Approval Date: May 2, 2014 Effective Date: January 1, 2014

Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: ■ Age 19 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0004-MM3 Approval Date: May 2, 2014 Effective Date: January 1, 2014

Table of Contents

State/Territory Name: Kansas State Plan Amendment (SPA) #: 14-0005-MM4 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan (delete if not applicable)

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

June 9, 2014

Susan Mosier, MD, MBS, FACS Interim Executive Director Kansas Department of Health and Environment 900 SW Jackson, Room 900N Topeka, KS 66612

Dear Dr. Mosier:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of Kansas State Plan Amendment (SPA) Transmittal Number 14-0005-MM4. This SPA allows the A1-A3 state plan pages to supersede the current Attorney General certification, organizational chart, description of the functions of the single state agency, the description of the professional medical and support staff, and pages 2-8 of the organization of the state agency. This amendment clarified the authority and responsibilities of the Single State Agency and its relationship to other federal and state agencies, the fair hearings process, and the process for determining eligibility.

This SPA was approved June 6, 2014, with an effective date of January 1, 2014. Enclosed is a copy of the CMS 179 form, as well as, the approved pages A-1 through A- 3 and supporting document pages for incorporation into the state plan.

We appreciate the cooperation and effort provided by your staff throughout this process. If you have any questions regarding this state plan amendment, please contact Karen Hatcher or myself at (816) 426-5925.

Sincerely,

//s//

Megan Buck

Acting Associate Regional Administrator

for Medicaid and Children’s Health Operations

cc: Bobbie Graff-Hendrixson bcc: Megan Buck Karen Hatcher

Margaret Barry

Elliott Curry

State/Territory name: Kansas Submitted By: Bobbie Graff-Hendrixson Last Revision Date: Jun 5, 2014 Submit Date: Mar 27, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0005 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 431.10 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Single State Agency Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 06/09/2014 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

KS-14-0005-MM4 STATE:

Kansas

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

A1 – A3

COMPLETE PAGES SUPERSEDED:

Page 1

Section 1.1 (pages 2-6)

Section 1.2 (page 7)

Section 1.3 (page 8)

Attachment 1.1-A (Attorney General certification)

Attachment 1.2-A (Organizational chart)

Attachment 1.2-B (Description of the functions of the single state agency)

Attachment 1.2-C (Description of professional medical and supporting staff)

Attachment 1.2-D

PARTIAL PAGES SUPERSEDED:

Section 1.4 (page 9)(State Medical Care Advisory Committee only. Tribal consultation will remain in the state plan.)

Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Page 1 of 7 Medicaid Administration OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 State Plan Administration Designation and Authority A1 42 CFR 431.10 Designation and Authority State Name: Kansas As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Kansas Department of Health and Environment, Division of Health Care Finance Type of Agency: Title IV-A Agency Health Human Resources Other Type of Agency The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: K.S.A. 75-7409 and ERO 38 The single state agency supervises the administration of the state plan by local political subdivisions. Yes No The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided. ✔ An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). Yes No Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Page 2 of 7 Medicaid Administration Waivers of the single state agency requirement have been granted under authority of the Intergovernmental Cooperation Act of 1968. The waivers are still in effect. Yes No Enter the following information for each waiver: Remove Date waiver granted (MM/DD/YY): 05/21/14 The type of responsibility delegated is (check all that apply): Determining eligibility Conducting fair hearings Other Name of state agency to which responsibility is delegated: Kansas Department of Health and Environment (KDHE), Division of Health Care Finance (DHCF) delegates authority to the Office of Administrative Hearings (OAH) Describe the organizational arrangement authorized, the nature and extent of responsibility for program administration delegated to the above named agency, and the resources and/or services of such agency to be utilized in administration of the plan: Kansas, as a state participant in the Medicaid program, has agreed to follow applicable federal Medicaid “fair hearing” statutes and regulations. 42 C.F.R. Part 431, Subpart E and Part 438, Subpart F. Kansas Department of Health and Environment (KDHE), Division of Health Care Finance (DHCF) delegates authority for conducting State Fair Hearings (SFH) to the Office of Administrative Hearings (OAH). OAH is responsible for conducting the SFH as well as providing administrative support for the SFH process. A request for a SFH is made directly to OAH by the appellant but can also be made with an agency party to the decision. For eligibility SFHs, the entity making the eligibility decision at issue is responsible for staffing the SFH as well as completing a summary of the facts of the case. Staff from KDHE DHCF or the Department of Children and Families (DCF) attend the Hearing and represent the Medicaid agency. OAH conducts all Medicaid SFHs. KDHE DHCF staff review all initial orders issued by OAH that involve the Medicaid program. Staff from other agencies with responsibility for Medicaid also review the order. Staff within KDHE DHCF are responsible for coordinating any request for review of an initial order.

After conducting the hearing, the Office of Administrative Hearings (OAH) will issue the initial order that provides all parties with a written decision made by the administrative law judge. If any party is not satisfied with the decision, a review of the initial order may be requested by submitting the request to the State Medicaid Agency, Kansas Department of Health and Environment (KDHE), Division of Health Care Finance (DHCF). The State Appeals Committee, a three member board consisting of three KDHE DHCF employees who are not party to the initial decision, will review the initial order if such a review is requested. The OAH is responsible for all communication (verbal and written) to the appellant and the state agency. If the state agency or the State Appeals Committee decision reverses or changes an OAH initial order, OAH sends the written final order to the appellant and the agency reflecting the agency’s decision. The appellant and the agency then have 30 days to file a petition for judicial review of the final order with the appropriate district court. The scope of review of the order from the administrative law judge is limited to the conclusion of law. Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Page 3 of 7 Medicaid Administration The methods for coordinating responsibilities among the agencies involved in administration of the plan under the alternate organizational arrangement are as follows: Kansas Department of Health and Environment (KDHE), Division of Health Care Finance (DHCF) ensures all Medicaid applicants and recipients are informed of their State Fair Hearing (SFH) rights. The right to a SFH is noted on the attestation page of the application. SFH rights and processes are provided on every notice of action. Each managed care organization (MCO) has a member handbook. Within the handbook is a section on Grievances, Appeals and SFHs. The member handbooks are approved by KDHE DHCF. If a member is not managed care eligible the member may request a Medicaid member handbook from the Medicaid fiscal agent or access the handbook and other Medicaid information on the fiscal agent website.

SFH rights are codified in the Kansas Administrative Procedures Act at Kansas Statutes Annotated (K.S.A) 77-501 et seq .

KDHE DHCF provides the following assurances: o KDHE DHCF retains oversight of the State Plan and has a process to monitor the entire appeals process, including the quality and accuracy of the final decisions made by the Office of Administrative Hearings (OAH). o KDHE DHCF will ensure that every applicant and beneficiary is informed, in writing, of the SFH process and how to contact OAH and how to obtain information about SFHs from that agency. o KDHE DHCF will ensure that OAH complies with all federal and state laws, regulations and policies. o KDHE DHCF and OAH have a written agreement that specifies the scope of the delegation and the responsibilities of the agencies. Add The agency that administers or supervises the administration of the plan under Title X of the Act as of January 1, 1965, has been separately designated to administer or supervise the administration of that portion of this plan related to blind individuals. The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Page 4 of 7 Medicaid Administration The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes No State Plan Administration Organization and Administration A2 42 CFR 431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency. The Kansas Department of Health and Environment (KDHE) Division of Health Care Finance (DHCF) is the single State Medicaid Agency designated to administer or supervise the administration of the Medicaid program under Title XIX of the Social Security Act. KDHE DHCF is the division which is responsible for administering the State of KS Medicaid Program inclusive of determining eligibility policy and criteria, service coverage, and payment policies for Medicaid and CHIP programs. The KDHE DHCF has 4 units. The units are: Eligibility; Medicaid Operations; Clinical Policy and Improvement; and Program Finance and Informatics.

The Eligibility Unit provides statewide policy and guidance for all Medicaid and CHIP groups. Eligibility determination and case maintenance activities for all MAGI populations are made by the KanCare Clearinghouse. Non-MAGI populations which the KanCare Clearinghouse determines eligibility are: SSI children when there is also a MAGI household member; SSI adults when there is also a MAGI household member; Breast and Cervical Cancer and SOBRA. The Eligibility Policy Unit is responsible for overseeing all eligibility program, policy, training and outreach activities related to potential Medicaid members and Medicaid members. The Eligibility Unit reviews State Fair Hearings (SFH) decisions related to eligibility determination. The unit develops statewide training strategy for eligibility workers. KDHE DHCF staff ensures automated systems support policy and are included in program integrity activities. The Working Healthy Section with the eligibility unit manages the Working Healthy program, including education, outreach and program promotion, facilitating enrollment, premium oversight and the Working Healthy supplemental personal assistance program, Work Opportunities Reward Kansans (WORK). The Presumptive Medical Disability Team (PMDT) examines disability claims for people who are seeking medical coverage but have yet to be determined eligible by the Social Security Administration (SSA).

The Medicaid Operations Unit is responsible for the procurement, management, and oversight of all Medicaid and CHIP funding contracts. This unit annually writes and amends contracts; performs program integrity; and manages third-party liability collections (including Medicare) from primary insurance carriers. Medicaid Operations is also responsible for the fiscal agent, claims processing, encounter data validation, dispute resolution, State Fair Hearings (SFH), and federal mandates. The Medicaid Operations Unit receives all Acknowledgements and Orders for State Fair Hearings (SFH) from the Office of Administrative Hearings (OAH). The Medicaid Operations Unit disseminates the Acknowledgements and Orders from OAH to the appropriate entity. The Medicaid Operations Unit is specifically responsible for provider and member SFHs not related to eligibility determination. The KanCare Clearing House is a part of the Medicaid Operations Unit. The KanCare Clearing House is a private contractor whose function is to screen medical assistance applications and determine CHIP eligibility. State staff co-located with the private contractor determines eligibility for the Medicaid program. If the application is a CHIP eligible member the private contractor works the application and determines CHIP eligibility. The private contractor does not determine Medicaid eligibility. The contractor transfers Medicaid eligible applications to state staff for Medicaid eligibility determination. The primary responsibility for provider and beneficiary relations and communication about the Medicaid program are also included in this unit. This unit manages the Medicaid State Plan and processes regulations. This unit oversees the policy implementation process, evaluates policy outcomes post implementation, and Payment Error Rate Measurement (PERM) projects for Kansas Medicaid. Audits are the responsibility of this unit.

The Clinical Policy and Improvement Unit (CPI) oversees health care purchasing and delivery of Medicaid services. The KDHE DHCF purchases health care through two product lines: capitated managed care, and fee-for-service. The CPI unit is responsible for managing the contracts with the managed care organizations (MCO) and the delivery of care through Medicaid fee-for-service. The Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Page 5 of 7 Medicaid Administration Pharmacy section within the CPI unit directs the Medicaid fee-for-service pharmacy program, the Preferred Drug List (PDL), Drug Utilization Review Board (DUR), oversight of the MCOs’ pharmacy program, and the rebate program. The Institutional Reimbursement section is responsible for establishing reimbursement rates, upper payment limits, diagnosis-related groups (DRGs) for Medicaid inpatient services. This section conducts reviews of cost reports and financial data to determine utilization of Critical Access Hospitals (CAH), FQHCs, and IHS providers. This section is responsible for overseeing and reporting on DSH payments and the UCC pool payments for the 1115 Waiver.

The Program Finance and Informatics (PFI) Unit is responsible for computing the fiscal impact of proposed policies, forecasting caseloads, performing federal financial reporting, and establishing capitation rates for Medicaid and CHIP managed care and analytical support. The PFI provides oversight over Medicaid funds to ensure adherence to state and federal regulations. This unit tracks and evaluates legislative activities which may have an impact on the activities of DHCF, both at the state and federal levels. The Medicaid Eligibility Quality Control (MEQC) team is located in this unit. MEQC performs continuous auditing for accuracy of eligibility including PERM. Upload an organizational chart of the Medicaid agency. An attachment is submitted. Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. Kansas government is modeled on the federal system, with three branches of government. The executive branch manages the day- to-day administrative duties of running the state government. The executive branch consists of the Governor, the Lieutenant Governor and Secretaries/Agency Heads of state executive departments.

Agencies headed by officials appointed by the Governor (with confirmation by the Senate) that have a role in the administration of the Medicaid program are:

Department of Administration - Provides administrative support for all agencies and departments, including human resources, payroll and information technology. The Office of Administrative Hearings, the organization delegated authority for state fair hearings, is a division of the Department of Administration.

Department for Aging and Disability Services – Provides oversight for the operation of the state’s long term care (LTC) programs, including nursing facilities, PACE and all 1915(c) waivers. This agency is also responsible for functional assessments occurring with the LTC programs.

Department of Corrections – Provides oversight of corrections, including minors in the custody of the state of Kansas who are designated Foster Children.

Department for Children and Families (DCF) – Provides oversight of most social services programs in the state, including SNAP, TANF and Child Welfare. This agency has been delegated authority to make Medicaid determinations for Child Welfare programs and some non-MAGI programs. Staff assigned to regional DCF Service Centers performs eligibility functions under the supervision of Regional Directors. DCF is the Title IV –A agency. Functions include determination of initial eligibility, adjustment of eligibility, re-determination of eligibility and related functions.

Agencies headed by an elected official that provide administrative support for Medicaid are: Kansas Insurance Department - Regulates companies licensed to provided insurance products in the state of Kansas, including all Kansas Managed Care Organizations servicing Medicaid populations.

Secretary of State – Responsible for publishing various legal documents for the state, including administrative regulations supporting the Medicaid program.

Attorney General – Responsible for providing legal services to the state. Operates the Medicaid Fraud and Investigative Unit.

Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Page 6 of 7 Medicaid Administration Legislative Division of Post Audit-Develops and conducts performance and cost audits of state programs at the request of the Kansas Legislature. This includes audits of the Medicaid program. Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. The Department of Children and Families (DCF) staff are responsible for accepting applications, processing applications and ongoing case maintenance. DCF is responsible for a subset of the non-MAGI population as follows: • Long Term Care (including Special Income Group) • Medicare Savings Plans (except when made for a MAGI person) • Medically Needy for Aged, Blind and Disabled • TWIIA Basic and Medically Improved • SSI recipients, except when there is also a MAGI household member • SSI Protected Groups – Pickle, Adult Disabled Child, Early Widows/ers, Disabled Widow/ers • Child Welfare programs – Foster Care and Adoption Subsidy groups

Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) Remove Type of entity that conducts fair hearings: An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Add Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? Yes No The types of the local subdivisions that administer the state plan under the supervision of the Medicaid agency are: Counties Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Page 7 of 7 Medicaid Administration Parishes Other Are all of the local subdivisions indicated above used to administer the state plan? Yes No State Plan Administration Assurances A3 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. ✔ All requirements of 42 CFR 431.10 are met. ✔ There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12. ✔ The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. ✔ Assurance for states that have delegated authority to determine eligibility: There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). ✔ Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130917 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Division of Health Care Finance

3-21-14 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Contents .......................................................................................................................................... 1 Contents ............................................................................................................................... 2 2642101113...................................................................................................................... 4 2645006000.................................................................................................................. 5 Sub-chart15 .................................................................................................................. 6 2645006400.............................................................................................................. 7 Sub-chart16 .................................................................................................................. 8 Sub-chart17 .............................................................................................................. 9 2647020000................................................................................................................ 10 2647021000............................................................................................................ 11 Sub-chart18 ............................................................................................................ 12 2647021300......................................................................................................... 13 2647021500......................................................................................................... 14 2647022000............................................................................................................ 15 Sub-chart19 ............................................................................................................ 16 Sub-chart20 ............................................................................................................ 17 Sub-chart21 ............................................................................................................ 18 Sub-chart22 ............................................................................................................ 19 2647022400......................................................................................................... 20 Sub-chart23 ........................................................................................................ 21 Sub-chart24 ........................................................................................................ 22 Sub-chart25 ........................................................................................................ 23 Sub-chart26 ........................................................................................................ 24 Sub-chart27 ................................................................................................................ 25 2647023500............................................................................................................ 26 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Contents Continued Sub-chart28 ............................................................................................................ 27 Sub-chart29 ............................................................................................................ 28 2649030000................................................................................................................ 29 2649032000............................................................................................................ 30 2649039000............................................................................................................ 31 Sub-chart30 ............................................................................................................ 32 Sub-chart31 ............................................................................................................ 33 Sub-chart32 ............................................................................................................ 34 2649034000............................................................................................................ 35 Index ................................................................................................................................... 36 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0057112 Cabinet Secretary OFFICE OF THE SECRETARY R u 2642101113

K0221729 Div Dir Hlth Care Finance Division Director's Office R u 2641001000

K0052211 Senior Adm inistrative Asst Division Director's Office R C 2641001000

Program Finance & Informatics Medicaid State Employee Health Benefits Plan

K0221730 Proj Finance & Est Dir Program Finance R u 2645006000

K0221732 Medicaid Director Medicaid Director R u 2647020000

K0221733 SEHBP Director State Em ployee's Director's Office R u 2649030000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221730 Proj Finance & Est Dir Program Finance R u 2645006000

Program Finance Reporting & Payments Medicaid Eligibility QC & Payment Error Rate Measurement

K0221789 Medicaid Prog Budget Officer Program Finance R u 2645006000

K0221797 MEQC Manager Medicaid Eligibility R u 2645006400

K0221957 SEHB Program Officer Program Finance R u 2645006000

K0221919 Sr Mgr Hlth Care Finance Program Finance R u 2645006000

K0222143 Database Manager Program Finance T u 2645006000

K0221795 KEES/Apd Financial Analyst Program Finance R u 2645006000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221789 Medicaid Prog Budget Officer Program Finance R u 2645006000

K0221807 Fed Reporting Analyst Program Finance R C 2645006000

K0221959 Receivables Manager Program Finance R u 2645006000

K0221781 Public Service Adm inistrator I Program Finance R u 2645006000

K0221808 Fed Claim s Analyst Program Finance R u 2645006000

K0221999 Medicaid Reporting Analyst Program Finance R u 2645006000

K0221786 Forecasting Analyst Program Finance R C 2645006000

K0222506 Health Care Data Analyst Program Finance T u 2645006000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221797 MEQC Manager Medicaid Eligibility R u 2645006400

K0221799 MEQC Reviewer Medicaid Eligibility R u 2645006400

K0221800 MEQC Reviewer Medicaid Eligibility R u 2645006400

K0221801 MEQC Reviewer Medicaid Eligibility R u 2645006400

K0221802 Senior Adm inistrativ Assistant Medicaid Eligibility R u 2645006400

K0222057 Quality Assurance Technician Medicaid Eligibility T u 2645006400

K0222058 Quality Assurance Technician Medicaid Eligibility T u 2645006400 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0222143 Database Manager Program Finance T u 2645006000

K0221821 Data Manager Program Finance R u 2645006000

K0225328 Data Analytics Supervisor Program Finance T u 2645006000

K0221822 Managem ent Analyst II Program Finance R u 2645006000

K0221820 Managem ent Analyst II Program Finance R u 2645006000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0225328 Data Analytics Supervisor Program Finance T u 2645006000

K0221953 Health Care Data Analyst Program Finance R u 2645006000

K0222508 Health Care Data Analyst Program Finance T u 2645006000

K0222509 Health Care Data Analyst Program Finance T u 2645006000

K0223759 Managem ent System s Analyst II Program Finance R C 2645006000

K0222507 Health Care Data Analyst Program Finance T u 2645006000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221732 Medicaid Director Medicaid Director R u 2647020000

K0221809 Senior Adm inistratv Specialist Medicaid Director R u 2647020000

Medicaid Eligibility

Operations

KICCM

K0221851 Director of Eligibility Eligibility and Outreach R u 2647021000

K0221810 Deputy Medicaid Director Medicaid Operations R u 2647022000

K0223743 Public Service Executive III Medicaid Director R C 2647020000

K0221812 Dir Clinical Policy & Im prove

R u 2647023500 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221851 Director of Eligibility Eligibility and Outreach R u 2647021000

K0221921 Adm inistrative Specialist Eligibility and Outreach R C 2647021000

K0222665 Sr Mgr of Eligibility Policy Eligibility and Outreach T u 2647021000

K0222616 KEES Functional Lead Mgr Eligibility and Outreach T u 2647021000

K0222617 KEES BA/Interface/Conversion L Eligibility and Outreach T u 2647021000

K0221864 Senior Manager Working Healthy/MIG R u 2647021500

K0221928 Field Supervisor Eligibility and Outreach R u 2647021000

K0221926 Elderly/ Disabled Mgr Eligibility and Outreach R C 2647021000

K0222621 KEES Business Analyst Eligibility and Outreach T u 2647021000

K0223481 Supervisor/adm inistrator Presum ptive Disability T u 2647021300

K0221925 Fam ily Med Prog Mgr Eligibility and Outreach R C 2647021000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221928 Field Supervisor Eligibility and Outreach R u 2647021000

K0221935 Program Consultant II Eligibility and Outreach R C 2647021000

K0221939 Program Consultant II Eligibility and Outreach R C 2647021000

K0221932 Program Consultant II Eligibility and Outreach R C 2647021000

K0223364 Program Consultant II Eligibility and Outreach T u 2647021000

K0221934 Program Consultant II Eligibility and Outreach R C 2647021000

K0221936 Program Consultant II Eligibility and Outreach R C 2647021000

K0221933 Program Consultant II Eligibility and Outreach R C 2647021000

K0221941 Program Consultant II Eligibility and Outreach R C 2647021000

K0221931 Program Consultant II Eligibility and Outreach R C 2647021000

K0221929 Program Consultant II Eligibility and Outreach R C 2647021000

K0221937 Program Consultant II Eligibility and Outreach R C 2647021000

K0221930 Program Consultant II Eligibility and Outreach R C 2647021000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0223481 Supervisor/adm inistrator Presum ptive Disability T u 2647021300

K0221857 Disability Exam iner Presum ptive Disability R C 2647021300

K0221853 Program Specialist III Presum ptive Disability R u 2647021300

K0221855 Senior Adm inistrative Asst Presum ptive Disability R C 2647021300

K0221856 Hum an Services Specialist Presum ptive Disability R u 2647021300

K0221861 Case Developer Presum ptive Disability R u 2647021300

K0221860 Case Developer Presum ptive Disability R u 2647021300

K0221863 Case Developer Presum ptive Disability R C 2647021300

K0221862 Case Developer Presum ptive Disability R u 2647021300 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221864 Senior Manager Working Healthy/MIG R u 2647021500

K0221867 Program Coordinator Working Healthy/MIG R u 2647021500

K0221866 Program Manager Working Healthy/MIG R u 2647021500

K0221865 Senior Adm inistratv Specialist Working Healthy/MIG R u 2647021500

K0223859 Program Consultant I Working Healthy/MIG R C 2647021500

K0223858 Program Consultant I Working Healthy/MIG R C 2647021500

K0223860 Program Consultant I Working Healthy/MIG R C 2647021500

K0224281 Wrkg Hlthy Benefits Specialist Working Healthy/MIG T u 2647021500

K0224280 Wrkg Hlthy Benefits Specialist Working Healthy/MIG T u 2647021500

K0224279 Wrkg Hlthy Benefits Specialist Working Healthy/MIG T u 2647021500 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221810 Deputy Medicaid Director Medicaid Operations R u 2647022000

K0221811 Senior Adm inistratv Specialist Medicaid Operations R u 2647022000

K0221847 Senior Manager Medicaid Operations R u 2647022000

K0221832 Senior Manager Medicaid Operations R C 2647022000

K0225537 Senior Project Manager Medicaid Operations T u 2647022000

K0221995 Senior Manager Medicaid Operations R u 2647022000

K0221872 Senior Manager Eligibility Clearinghouse R C 2647022400 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221847 Senior Manager Medicaid Operations R u 2647022000

K0222494 SuRS Manager Medicaid Operations T u 2647022000

K0221784 Program Consultant II Medicaid Operations R C 2647022000

K0221945 Fair Hearings Mgr (PSE I) Medicaid Operations R u 2647022000

K0223785 Medicaid Contracts Mgr Medicaid Operations T u 2647022000

K0221848 Prog Integrity Mgr Medicaid Operations R u 2647022000

K0223541 Contract/Procurem ent Mgr Medicaid Operations T u 2647022000

K0221996 Provider/ Cust Relations Mgr Medicaid Operations R u 2647022000

K0221993 Incentive Paym ent Analyst Medicaid Operations R u 2647022000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221832 Senior Manager Medicaid Operations R C 2647022000

K0221833 Manager Medicaid Operations R C 2647022000

K0221834 Financial Proc Manager Medicaid Operations R C 2647022000

K0221835 Claim s Research Mgr Medicaid Operations R u 2647022000

K0224663 Claim s Research Mgr Medicaid Operations T u 2647022000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0225537 Senior Project Manager Medicaid Operations T u 2647022000

K0221841 Project Manager Medicaid Operations R u 2647022000

K0221840 Manager Medicaid Operations R C 2647022000

K0221842 Project Manager Medicaid Operations R u 2647022000

K0221845 Dep Project Manager Medicaid Operations R u 2647022000

K0221839 Manager Medicaid Operations R u 2647022000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221995 Senior Manager Medicaid Operations R u 2647022000

K0221830 MCO Manager Medicaid Operations R u 2647022000

K0221854 Adm inistrative Assistant Presum ptive Disability R u 2647022000

K0222178 MCO Manager Presum ptive Disability R u 2647022000

K0221831 Analyst Medicaid Operations R C 2647022000

K0221829 MCO Manager Medicaid Operations R u 2647022000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221872 Senior Manager Eligibility Clearinghouse R C 2647022400

K0221874 Ops & Contract Spec Eligibility Clearinghouse R C 2647022400

K0221900 Hum an Services Supervisor Eligibility Clearinghouse R C 2647022400

K0221892 Hum an Services Supervisor Eligibility Clearinghouse R C 2647022400

K0221875 Hum an Services Supervisor Eligibility Clearinghouse R C 2647022400

K0221883 Hum an Services Supervisor Eligibility Clearinghouse R C 2647022400 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221900 Hum an Services Supervisor Eligibility Clearinghouse R C 2647022400

K0221904 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221903 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221906 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221891 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221902 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221905 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221907 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221892 Hum an Services Supervisor Eligibility Clearinghouse R C 2647022400

K0221895 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221897 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221893 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221896 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221899 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221735 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0222061 Hum an Services Specialist Eligibility Clearinghouse T u 2647022400

K0223776 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0222062 Hum an Services Specialist Eligibility Clearinghouse T u 2647022400 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221875 Hum an Services Supervisor Eligibility Clearinghouse R C 2647022400

K0221880 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0222060 Hum an Services Specialist Eligibility Clearinghouse T u 2647022400

K0221881 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221877 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221886 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221878 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221879 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221883 Hum an Services Supervisor Eligibility Clearinghouse R C 2647022400

K0221888 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221890 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221885 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0223775 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221889 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221901 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400

K0221884 Hum an Services Specialist Eligibility Clearinghouse R C 2647022400 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0223743 Public Service Executive III Medicaid Director R C 2647020000

K0223744 Public Service Executive II Medicaid Director R C 2647020000

K0223760 KanCare Qlty Rptg Mgr (PSE I) Medicaid Director R C 2647020000

K0223745 Adm inistrative Specialist Medicaid Director R C 2647020000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221812 Dir Clinical Policy & Im prove

R u 2647023500

K0224463 Reg Nurse Policy Supervisor

T u 2647023500

K0221813 Reim bursem ent Manager

R u 2647023500

K0221823 Senior Analyst

R C 2647023500

K0221825 Senior Manager

R u 2647023500

K0221788 Inter-Agency Liaison

R C 2647023500

K0221826 Pharm acy Program Manager

R u 2647023500

K0221828 Program Manager

R C 2647023500 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221813 Reim bursem ent Manager

R u 2647023500

K0221814 Nursing Consultant

R C 2647023500

K0221816 Reim bursem ent Analyst

R u 2647023500

K0221815 RHC Manager

R C 2647023500

K0221817 Medicaid Reim bursem ent Analyst

R u 2647023500 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221823 Senior Analyst

R C 2647023500

K0221824 Strategic Analyst

R u 2647023500

K0221785 Policy Im pl/Evaluation

R C 2647023500

K0223754 Senior Adm inistrativ Assistant

T u 2647023500 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221733 SEHBP Director State Em ployee's Director's Office R u 2649030000

Health Plan Operations State Self Insurance Worker's Comp

K0221742 Project Coordinator State Em ployee's Director's Office R u 2649030000

K0221745 Hlth Plan Ops Sr Mgr State Em ployee Health Plan Operations R C 2649032000

K0221762 SSIF Program Manager Self-Insurance Workers Com pensation R u 2649039000

K0222007 Appt/elect Bd/com m Bd Member State Em ployee's Director's Office T u 2649030000

K0222008 Appt/elect Bd/com m Bd Member State Em ployee's Director's Office T u 2649030000

K0221793 Health Plan Data Mgr SEHB Plan Design & Fiscal R u 2649033000

K0221790 Senior Manager SEHB Plan Design & Fiscal R u 2649033000

K0225664 Special Projects Coordinator State Em ployee's Director's Office T u 2649030000

K0221958 Medicaid Program Officer SEHB Plan Design & Fiscal R u 2649033000

K0221750 Senior Manager State Em ployee Health Plan Mem bership Services R u 2649034000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221745 Hlth Plan Ops Sr Mgr State Em ployee Health Plan Operations R C 2649032000

K0221744 Wellness Com m Coordinator Health Managem ent/Wellness R u 2649031000

K0221749 Vendor Specialist State Em ployee Health Plan Operations R C 2649032000

K0221747 Non-State Group Coord State Em ployee Health Plan Operations R u 2649032000

K0221751 Health Plan Coordinator State Em ployee Health Plan Operations R u 2649032000

K0221748 Adm inistrative Specialist State Em ployee Health Plan Operations R u 2649032000

K0221792 Health Plan Coordinator State Em ployee Health Plan Operations R u 2649032000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221762 SSIF Program Manager Self-Insurance Workers Com pensation R u 2649039000

K0221791 Supervisor/adm inistrator Self-Insurance Workers Com pensation R u 2649039000

K0221763 WC Claim s Supervisor Self-Insurance Workers Com pensation R u 2649039000

K0221771 Program Specialist III Self-Insurance Workers Com pensation R u 2649039000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221791 Supervisor/adm inistrator Self-Insurance Workers Com pensation R u 2649039000

K0221776 Claim s Specialist I Self-Insurance Workers Com pensation R u 2649039000

K0221775 Claim s Advisor Self-Insurance Workers Com pensation R u 2649039000

K0221778 Claim s Specialist II Self-Insurance Workers Com pensation R u 2649039000

K0221774 Claim s Specialist I Self-Insurance Workers Com pensation R u 2649039000

K0221765 Claim s Advisor Self-Insurance Workers Com pensation R u 2649039000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221763 WC Claim s Supervisor Self-Insurance Workers Com pensation R u 2649039000

K0221772 Claim s Specialist II Self-Insurance Workers Com pensation R C 2649039000

K0221770 Claim s Coordinator Self-Insurance Workers Com pensation R C 2649039000

K0221769 Claim s Specialist II Self-Insurance Workers Com pensation R u 2649039000

K0221768 Claim s Specialist I Self-Insurance Workers Com pensation R u 2649039000

K0221779 Claim s Advisor Self-Insurance Workers Com pensation R u 2649039000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221771 Program Specialist III Self-Insurance Workers Com pensation R u 2649039000

K0221767 Adm inistrative Assistant Self-Insurance Workers Com pensation R u 2649039000

K0221777 Adm inistrative Assistant Self-Insurance Workers Com pensation R u 2649039000

K0225642 Assistant Self-Insurance Workers Com pensation T u 2649039000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

K0221750 Senior Manager State Em ployee Health Plan Mem bership Services R u 2649034000

K0221761 NSE Benefits Consultant State Em ployee Health Plan Mem bership Services R u 2649034000

K0224809 Educational/Info Rep I State Em ployee Health Plan Mem bership Services T u 2649034000

K0221755 Retirees/Direct Bill Prog Spec State Em ployee Health Plan Mem bership Services R u 2649034000

K0221754 Senior Adm inistrativ Assistant State Em ployee Health Plan Mem bership Services R u 2649034000

K0224808 Educational/Info Rep I State Em ployee Health Plan Mem bership Services T u 2649034000

K0224806 Educational/Info Rep I State Em ployee Health Plan Mem bership Services T u 2649034000

K0224805 Educational/Info Rep I State Em ployee Health Plan Mem bership Services T u 2649034000

K0224807 Educational/Info Rep I State Em ployee Health Plan Mem bership Services T u 2649034000

K0224804 Educational/Info Rep I State Em ployee Health Plan Mem bership Services T u 2649034000

K0221758 Active EE Group Prog Spec State Em ployee Health Plan Mem bership Services R u 2649034000

K0221760 Active EE Group Prog Spec State Em ployee Health Plan Mem bership Services R u 2649034000

K0221756 Benefits/FSA Consultant State Em ployee Health Plan Mem bership Services R u 2649034000

K0221757 Retirees/Dir Bill Prog Spec State Em ployee Health Plan Mem bership Services R u 2649034000

K0221752 COBRA/FSA Program Spec State Em ployee Health Plan Mem bership Services R u 2649034000 Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Index Continued

Transmittal Number: KS 14-0005-MM4 Approval Date: June 6, 2014 Effective Date: January 1, 2014

Table of Contents

State/Territory Name: KS State Plan Amendment (SPA) #: 14-0006-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

June 26, 2014

Susan Mosier, MD, MBS, FACS Interim Executive Director Kansas Department of Health and Environment 900 SW Jackson, Room 900N Topeka, KS 66612

Dear Dr. Mosier:

On March 27, 2014, the Centers for Medicare & Medicaid Services (CMS) received Kansas’ state plan amendment (SPA) transmittal #14-0006-MM5, which describes the Modified Adjusted Gross Income (MAGI) residency requirements. The MAGI based residency requirements are set forth in at 1902(b)(2) of the Act and in 42 CFR § 435.403.

SPA 14-0006-MM5 was approved on June 25, 2014, with an effective date of January 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Kansas State Plan.

If you have any questions regarding this amendment, please contact Karen Hatcher at (816) 426-5925.

Sincerely,

//s//

Leticia Barraza

Acting Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Bobbie Graff-Hendrixson

Jeanine Schieferecke bcc: Karen Hatcher Megan Buck Twana Brown Suzette Seng

State/Territory name: Kansas Submitted By: Bobbie Graff-Hendrixson Last Revision Date: Jun 24, 2014 Submit Date: Mar 27, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0006 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.403 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment This is the Residency MAGI State Plan Amendment. This does not include Administrative costs. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 06/25/2014 Transmittal Number: KS 14-0006-MM5 Approval Date: June 25, 2014 Effective Date: January 1, 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER:

14-0006-MM5 STATE:

Kansas

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S88 – State Residency PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Attachment 2.6-A: Page 3, Item 4, TN 14-0007 MM6 Section 2.3: Page 13, TN 87-18

Transmittal Number: KS 14-0006-MM5 Approval Date: June 25, 2014 Effective Date: January 1, 2014

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ Transmittal Number: KS 14-0006-MM5 Approval Date: June 25, 2014 Effective Date: January 1, 2014

Page 2 of 4 Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ Transmittal Number: KS 14-0006-MM5 Approval Date: June 25, 2014 Effective Date: January 1, 2014

Page 3 of 4 Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual Name of Type Description + Non-IV-E /State Subsidized Adoption Kansas is a reciprocal state and we provide Medicaid to children under state-subsidized adoption agreements with other ICAMA states. x The state has a policy related to individuals in the state only to attend school. Yes No Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ Transmittal Number: KS 14-0006-MM5 Approval Date: June 25, 2014 Effective Date: January 1, 2014

Page 4 of 4 Medicaid Eligibility The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No Provide a description of the definition: Persons temporarily absent from Kansas continue to hold Kansas residency status in accordance with 42 CFR 435.403(j)(3). The residency status of such persons shall be verified every six months.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. Transmittal Number: KS 14-0006-MM5 Approval Date: June 25, 2014 Effective Date: January 1, 2014

Table of Contents

State/Territory Name: KS State Plan Amendment (SPA) #: 14-0007-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

April 9, 2015

Mike Randol, Director Kansas Department of Health and Environment Division of Health Care Finance 900 SW Jackson, Room 900N Topeka, KS 66612

Dear Mr. Randol:

On March 27, 2014, the Centers for Medicare & Medicaid Services (CMS) received Kansas’ State Plan Amendment (SPA) transmittal #14-0007-MM6, which describes the Medicaid requirements related to citizenship and non-citizen eligibility. The citizenship and immigration status requirements are set forth at 1902(a)(46)(B) and 1903(v)(2),(3), and (4) of the Act and in 42 CFR § 435.4, 435.406, and 435.956.

SPA 14-0007-MM6 was approved on April 6, 2014, with an effective date of January 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Kansas State Plan.

We do not require any further action on the part of the state in relation to the approval of this state plan amendment. However, as outlined in the state’s responses to the RAI received on February 17, 2015, the state has committed to working with CMS on the implementation of the Operational Advanced Planning Document (OAPD) for the Kansas Eligibility and Enrollment System (KEES) related to the use of the Federal Data Services Hub to verify citizenship and satisfactory immigration status.

If you have any questions regarding this amendment, please contact Karen Hatcher at (816) 426-5925.

Sincerely,

//s//

James G. Scott

Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Susan Mosier, M.D. Bobbie Graff-Hendrixson

Jeanine Schieferecke bcc: Karen Hatcher Megan Buck Suzette Seng

State/Territory name: Kansas Submitted By: Bobbie Graff-Hendrixson Last Revision Date: May 28, 2014 Submit Date: Mar 27, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS-14-0007 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.4; 42 CFR 435.406; 42 CFR 435.956 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment This is the State of KS Medicaid MAGI Citizenship and Immigration Amendment. This does not include Administrative costs. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 04/07/2015 Transmittal Number: KS 14-0007-MM6 Approval Date: April 6, 2015 Effective Date: January 1, 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

14-0007 MM6 STATE:

Kansas

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S89 Non-Financial Eligibility- Citizenship and Non-Citizen Eligibility PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Attachment 2.6-A, Page 2, Item 3, Subparagraphs (a) and (b), 97-08 Attachment 2.6-A, Page 3, Item 3, Subparagraphs (c), 97-15

Transmittal Number: KS 14-0007-MM6 Approval Date: April 6, 2015 Effective Date: January 1, 2014

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

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

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: Transmittal Number: KS 14-0007-MM6 Approval Date: April 6, 2015 Effective Date: January 1, 2014

Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); Transmittal Number: KS 14-0007-MM6 Approval Date: April 6, 2015 Effective Date: January 1, 2014

Page 3 of 3 Medicaid Eligibility 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Transmittal Number: KS 14-0007-MM6 Approval Date: April 6, 2015 Effective Date: January 1, 2014

Table of Contents

State/Territory Name: KS State Plan Amendment (SPA) #: 14-0019-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

August 26, 2014

Susan Mosier, MD, MBS, FACS Interim Executive Director Kansas Department of Health and Environment 900 SW Jackson, Room 900N Topeka, KS 66612

Dear Dr. Mosier:

On June 30, 2014, the Centers for Medicare & Medicaid Services (CMS) received Kansas’ State Plan Amendment (SPA) transmittal #14-0019-MM1, to amend the Modified Adjusted Gross Income (MAGI) page S30, for the MAGI based eligibility groups Mandatory Coverage – Infants and Children under Age 19.

SPA 14-0019-MM1 was approved on August 25, 2014, with an effective date of April 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 summary page, as well as the approved pages for incorporation into the Kansas State Plan.

If you have any questions regarding this amendment, please contact Karen Hatcher or Megan Buck at (816) 426-5925.

Sincerely,

//s//

James G. Scott

Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Bobby Graff-Hendrixson Jeanine Schieferecke

State/Territory name: Kansas Submitted By: Bobbie Graff-Hendrixson Last Revision Date: Aug 13, 2014 Submit Date: Jun 30, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. KS14-0019 Proposed Effective Date 04/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.118; 42 CFR 435.1101; 42 CFR 435.1102 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment This is an amendment to supersede S30 in TN No. 14-0002. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 08/26/2014 Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Page 1 of 8 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No Enter the amount of the minimum income standard (no higher than 185% FPL): 150 % FPL Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Page 2 of 8 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Enter the amount of the maximum income standard: 166 % FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age one through age five, inclusive ■ Minimum income standard ■ Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Page 3 of 8 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 149 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Page 4 of 8 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Income standard chosen ■ The state's income standard used for children age six through eighteen is: Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Page 5 of 8 Medicaid Eligibility The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No Presumptive Eligibility for Children S16 1902(a)(47) 1920A 42 CFR 435.1101 42 CFR 435.1102 The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions: ■ Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Page 6 of 8 Medicaid Eligibility If the state has elected to cover Optional Targeted Low-Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR 435.118), for that child’s age. If the state has not elected to cover Optional Targeted Low Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child’s age. Children under the following age may be determined presumptively eligible: ■ Under age 19 The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The presumptive eligibility determination is based on the following factors: ■ Household income must not exceed the applicable income standard described above, for the child's age. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. ■ List of Qualified Entities S17 Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Page 7 of 8 Medicaid Eligibility A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP) Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV-D of the Act Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included. ✔ An attachment is submitted. PRA Disclosure Statement Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Page 8 of 8 Medicaid Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. Transmittal Number: KS 14-0019-MM1 Approval Date: August 25, 2014 Effective Date: April 1, 2014

Table of Contents

State/Territory Name: KS State Plan Amendment (SPA) #: 0012 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, MO 64106 Division of Medicaid and Children's Health Operations January 26, 2018 Jonathan Hamdorf, Interim Medicaid Director and Division Director Kansas Department of Health and Environnment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900N Topeka, KS 66612 Dear Mr. Hamdorf: The Centers for Medicare & Medicaid Services ( CMS), Kansas City Regional Office, has completed its review of Kansas State Plan Amendment (SPA) Transmittal Number #17-0012. This amendment, submitted December 19, 2017, corrects the State plan regarding the state’s payment of Medicare Part A and B deductibles and cost-sharing on Medicare crossover claims. Kansas SPA 17-0012 was approved on January 25, 2018, with the state’ s requested effective date of December 19, 2017. Enclosed is a copy of the CMS 179 form, as well as, the approved pages for incorporation into the Kansas State plan. If you have any questions regarding this state plan amendment, please contact Barbara Cotterman, at Barbara.Cotterman@cms.hhs.gov or (816) 426-5925. 1/26/2018 X Signed by: James G. Scott -A Enclosures cc: Bobbie Graff-Hendrixson – KS KDHE Jason Osterhaus - KS KDHE Sara Rhoades – CMS James G. Scott Associate Regional Administrator for Medicaid and Children’s Health Operations Sincerely,

S

KANSASMEDICAIDSTATEPLAN Revision: HCFA-PM-91-4 Supplement1toAttachment4.19-B August 1991 Page1 OMBNo.: 0938- STATEPLANUNDERTITLEXIXOFTHESOCIALSECURITYACT State/Territory: _____Kansas_______________________ METHODSANDSTANDARDSFORESTABLISHINGPAYMENTRATES OTHERTYPESOFCARE PaymentofMedicarePartAandPartBDeductible/Coinsurance Exceptforanominalrecipientcopayment (asspecifiedinAttachment4.18ofthis Stateplan), ifapplicable, theMedicaidagencyusesthefollowinggeneralmethodfor payment: 1.PaymentsarelimitedtoStateplanratesandpaymentmethodologiesforthegroupsand paymentslistedbelowand ForspecificMedicareserviceswhicharenototherwisecoveredbythisStateplan, the MedicaidagencyusesMedicarepaymentratesunlessaspecialrateormethodissetout onPage3initem __ ofthisattachment (See3. Below). 2.PaymentsareuptothefullamountoftheMedicarerateforthegroupsandpayments 3.Paymentsareuptotheamountofaspecialrate, oraccordingtoaspecialmethod, describedonPage3initem __ ofthisattachment, forthosegroupsandpayments lis 4.Anyexceptionstothegeneralmethodsusedforaparticulargrouporpaymentare specifiedonPage3initem ____ ofthisattachment (see3. above). TN# 17-012ApprovalDate ________EffectiveDate12/19/17Supersedes TN#MS-92-30

KANSASMEDICAIDSTATEPLAN Revision: HCFA-PM-91-4 (BPD) Supplement1toAttachment4.19-B August1991 Page2 OMBNo.: 0938- STATEPLANUNDERTITLEXIXOFTHESOCIALSECURITYACT State/Territory: Kansas METHODSANDSTANDARDSFORESTABLISHINGPAYMENTRATES OTHERTYPESOFCARE PaymentofMedicarePartAandPartBDeductible/Coinsurance QMBs: PartA SPDeductibles SPCoinsurance PartB SPDeductibles SPCoinsurance OtherPartA SPDeductibles SPCoinsurance Medicaid RecipientsPartB SPDeductibles SPCoinsurance DualPartA SPDeductibles SPCoinsurance Eligible QMBPlus) PartB SPDeductibles SPCoinsurance TN #KS17-012ApprovalDate _ EffectiveDate12/19/17SupersedesTN#KS13-04

KANSASMEDICAIDSTATEPLAN Revision: HCFA-PM-91-4 Supplement1toAttachment4.19-B August 1991 Page3 OMBNo.: 0938- STATEPLANUNDERTITLEXIXOFTHESOCIALSECURITYACT State/Territory: Kansas METHODSANDSTANDARDSFORESTABLISHINGPAYMENTRATES OTHERTYPESOFCARE PaymentofMedicarePartAandPartBDeductible/Coinsurance TN #KS17-012ApprovalDate EffectiveDate12/19/17SupersedesTN#MS92-30

Table of Contents

State/Territory Name: KS State Plan Amendment (SPA) #: 18-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106 Division of Medicaid and Children's Health Operations November 6, 2018 Jon Hamdorf, Division Director, and State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Suite 900N Topeka, KS 66612-1220 Dear Mr. Hamdorf: On September 26, 2018, the Centers for Medicare & Medicaid Services (CMS) received Kansas’ State Plan Amendment ( SPA) transmittal # 18-0012, which expands tobacco cessation counseling to all Medicaid enrollees. SPA # 18-0012 was approved on November 6, 2018, with an effective date of September 21, 2018, as requested by the state. Enclosed is a copy of the CMS-179 form, as well as the approved pages for incorporation into the Kansas State Plan. If you have any questions regarding this amendment, please contact Michala Walker at (816) 426- 5925. 11/6/2018 X Signed by: James G. Scott -A Enclosure cc: Kim Tjelmeland Bobbie Graff-Hendrixson Bill Stelzner James G. Scott Associate Regional Administrator for Medicaid and Children’ s Health Operations Sincerely,

September 26, 2018 November 6, 2018 September 21, 2018 James G. Scott Associate Regional Administrator for Medicaid and Children's Health Operations

KANSASMEDICAIDSTATEPLAN Attachment3.1-A Page6 AMOUNT, DURATIONANDSCOPEOFMEDICAL ANDREMEDIALCAREANDSERVICESPROVIDEDTOTHECATEGORICALLYNEEDY b. ScreeningServices Provided: NolimitationsWithlimitations* Notprovided. c. PreventiveServices Provided: NolimitationsWithlimitations* Notprovided. d. Rehabilitativeservices Provided: NolimitationsWithlimitations* NotProvided. 14. Servicesforindividualsage65orolderininstitutionsformentaldiseases. a. Inpatienthospitalservices Provided: NolimitationsWithlimitations* NotProvided. b. Skillednursingfacilityservices Provided: NolimitationsWithlimitations* NotProvided. c. Intermediatecarefacilityservices Provided: NolimitationsWithlimitations* NotProvided. Descriptionprovidedonattachment. KS18-0012ApprovalDate_________EffectiveDate 09/21/18SupersedesTN#MS90- 4711/ 6/18

KANSASMEDICAIDSTATEPLAN Attachment3.1-A 13.c PREVENTIVESERVICESLIMITATIONS TobaccoCessationCounselingServices TobaccocessationcounselingiscoveredforallKSMedicaidmembers. Inaccordancewiththe preventiveservicesbenefitrequirementsat42CFR440.130(c), theseservicesaredesignedto reducetheincidenceandprevalenceoftobaccouse. Tobaccocessationcounselingservicesinclude: Intermediateandintensivesmokingand tobaccousecessationcounseling visits. TobaccoCessationcounselingserviceswillbeprovidedbythefollowingKansasMedicaid enrolledlicensedproviderswithintheirscopeofpracticeunderstatelaw: Physicians PhysicianAssistants LicensedAdvancedPracticeRegisteredNurses Psychiatrists Psychologists LicensedClinicalSocialWorkers LicensedProfessionalCounselors. KS18-0012 ApprovalDate: ________ _ EffectiveDate: 09/21/2018Supersedes:New Revised Submission 10.11.18 11/6/2018

KANSASMEDICAIDSTATEPLAN Attachment4.19-B 13.c. PREVENTIVESERVICES TobaccoCessationCounselingServices Exceptasotherwisenotedintheplan, thestate-developedfeescheduleratesarethesamefor bothgovernmentalandprivateprovidersfortheaboveservices. Theagency’sfeeschedulerate wassetasofSeptember21, 2018andiseffectiveforservicesprovidedonorafterthat date.Theagency’sestablishedfeescheduleratesarepublishedontheagency’swebsiteat https://www.kmap-state-ks.us. KS18-0012ApprovalDate EffectiveDate09/21/2018Supersedes NEW11/ 6/2018

Table of Contents State/Territory Name: KS State Plan Amendment (SPA) #: 19-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH HUMAN SERVICES Centers for Medicare Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106 2898 Kansas City Regional Operations Group September 13, 2019 Christiane Swartz, Deputy Medicaid Director Kansas Department of Health and Environment Division of Healthcare Finance Landon State Office Building 900 SW Jackson, Room 900N Topeka, KS 66612-1220 Dear Ms. Swartz: On August 14, the Centers for Medicare & Medicaid Services (CMS) received Kansas’ State Plan Amendment (SPA) transmittal #19-0010. This SPA is amending the amount that would otherwise be paid methodology for the KS’ Program of All-Inclusive Care for the Elderly (PACE). SPA #19-0010 was approved September 13, 2019, with an effective date of July 1, 2019, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Kansas State Plan. If you have any questions regarding this amendment, please contact Karen Hatcher or Michala Walker at (816) 426-5925. 9/13/2019 X Signed by: James G. Scott -S Enclosure cc: Adam Proffitt, Medicaid Director Bobbie Graff-Hendrixson William Stelzner Kim Tjelmeland James G. Scott, Director Division of Medicaid Field Operations - North Sincerely,

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED 0MB No 0938-0193 TRANSMITTAL ANDNOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: KS 19-0010 2. STATEKansas FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) 3.PROGRAM IDENTIFICATION: TITLE XIX OF THESOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATEJuly 1, 2019 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT ' Se arate Transmittal or each amendment6. FEDERAL STATUTE/REGULATION CITATION42 CFR §460 (SubchapterE) 7. FEDERAL BUDGET IMPACTa. FFY 2019 $ 1,099,687. 50b. FFY 2020 $ 4,398,750. 008. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Supplement3 to Attachment 3 1-A Pages 6-7-8 10.SUBJECT OF AMENDMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTIONOR ATTACHMENT (IfApplicable) Supplement 3 to Attachment 3 1-A Pages 6-7-8 The Amount that Would Otherwise be Paid (AWOP) Methodology forthe State's Program ofAll-Inclusive Care fortheElderly (PACE). 11.GOVERNOR'SREVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED NO COMMENT0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL UREOF STATE AGENCY OFFICIAL . + 11,14.. u_ 13. TYPED NAMEChristiane Swartz14. TITLEDeputy Medicaid Director15. DATE SUBMITTEDAugust 14, 2019 IR] OTHER, AS SPECIFIED: Christiane Swartz is the Governor'sDesignee 16. RETURN TOChristianeSwartz, Deputy Medicaid DirectorKDHE, Division ofHealth Care FinanceLandon State Office Building900 SW Jackson, Room 900-N Topeka, KS 66612-1220 FOR REGIONAL OFFICE USE ONLY 17.DATE RECEIVED 1 · 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21.TYPED NAME 22. TITLE 23. REMARKS FORM CMS-179 (07/92 Instructions on Back Revised Submission 9.11.19 August 14, 2019 September 13, 2019 July 1, 2019 James G. Scott Director Division of Medicaid Field Operations - North, Kansas City

KANSAS MEDICAID STATE PLAN KS 19-0010__ Approval Date Effective Date07/01/19 Supersedes TN #13-011 Supplement 3 to Attachment 3.1-A Page 6 II. Rates and Payments A. The State assures CMS that the capitated rates will be equal to or less than the cost to the agency of providing those same fee-for-service State plan approved services on a fee-for-service basis, to an equivalent non-enrolled population group based upon the following methodology. Please attach a description of the negotiated rate setting methodology and how the State will ensure that rates are less than the cost in fee-for- service. 1.__ Rates are set at a percent of fee-for-service costs 2.___ Experience-based (contractors/State’ s cost experience or encounter date( please describe) 3.___ Adjusted Community Rate (please describe) 4._ X Other (please describe) Rates are set at a percent of the Amount that Would Otherwise be Paid. The development is based on KanCare encounter data since in the absence of joining the PACE program these members would be enrolled in managed care. B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner. Please list the name, organizational affiliation of any actuary used, and attestation/description for the initial capitation rates. Actuarial Firm: The state contracts with an actuarial firm to develop the AWOP. The PACE rates for Medicaid are established based upon services rendered to the SSI and Medically Needy populations residing in the service area. The Amount that Would Otherwise be Paid (AWOP) include the aged, blind, and disabled populations that are age 55 and older, meet the state’s criteria for nursing home level of care, live in an area that offers PACE, and have the ability to live safely in the community. The most recent encounter claims data is used for all services including targeted case management, with the exception of Medicare Part A and Part B premiums (Medicare buy-in). Data for persons in an ICF/IDD, HCBS/IDD, NF-MH, or state hospital setting are excluded. Only data for persons in a Nursing Facility (NF) or in the Physically Disabled (PD) or Frail Elderly (FE) waivers are included. The costs in the base period are inflated to the present for rate setting purposes and adjusted for any applicable program changes. Inflation is based on state historical costs. Beneficiary eligibility data for the same time period as the encounter claims data and with the same exclusions as above is used. This data was analyzed in a manner similar to that used for capitated managed care rate setting. AWOPs on a per member per month basis are computed by several dimensions: Dual vs. Non-Dual, age groups 55-74 vs. 75+, and the four regions Johnson County Region (JO), Northeast Region (NE), Southeast Region SE), and Sedgwick County (SG). Revised Submission 9.9.19 09/13/19

KANSAS MEDICAID STATE PLAN KS 19-0010__ Approval Date Effective Date07/01/19 Supersedes TN #13-011 Supplement 3 to Attachment 3.1-A Page 7 Actual encounter data expenditures by Medicaid are used to calculate the AWOP with the exceptions noted below. The claims completion factor was completed for Incurred But Not Reported (IBNR) and Underreporting. The PACE provider shall be responsible for collection of and reporting of third party liability. No adjustment is necessary to payments because claims do not reflect any receipts of third party liability by Medicaid. Adjustments to expenditures are made equal to the amount of average MCO pharmacy rebates received. The percentage is based upon the aggregate receipt of pharmacy rebates versus aggregate pharmacy payments as rebates cannot readily be identified to a particular population or county of residence. In the absence of being in the PACE program, members would be in the KanCare managed care program which does not have any co-payment requirements for members. Medicare Part D medication drugs were deducted from the AWOP, along with any other Medicare payments. In addition, an administrative cost consistent with existing administrative levels in KanCare, along with applicable taxes and fees, was included in the AWOP development. Disproportionate share payments are not included in any claims data as they cannot be identified to a particular beneficiary, nor will they be the responsibility of the PACE provider. For those individuals who have client participation for cost of care requirements, the actual rate paid will be the applicable rate less the client participation for that particular person. In order to set AWOPs for a future time period, trend factors will be completed at least every 3 years. Separate trends for the following are computed using the same methodology that is used for the Medicaid budget process: SSI Aged regular medical expenditures (all expenditures except for long term care and HCBS related), SSI Blind and Disabled regular medical expenditures, Medically Needy Aged regular medical expenditures, Medically Needy Blind and Disabled regular medical expenditures, HCBS/FE expenditures, HCBS/PD expenditures, and Nursing facility expenditures. The rates are made prospectively to the PACE organization and are less than what would have been paid under the State Plan if the participants were not enrolled in PACE. Revised Submission 9.9.19 09/13/19

KANSAS MEDICAID STATE PLAN KS 19-0010__ Approval Date Effective Date07/01/19 Supersedes TN #13-011 Supplement 3 to Attachment 3.1-A Page 8 The AWOP will be discounted by a budget savings factor determined by the state to arrive at the final rates paid. The budget savings factor will be based upon: negotiations with the provider, efficient operation of the PACE site, savings to be accrued to the State Agency, and the experience of the PACE site. The State will document its rationale for choosing the specific budget percentage factor in its submittal to the CMS RO with the annual rates. C. The State will submit all capitated rates to the CMS Regional Office for prior approval. III. Enrollment and Disenrollment The state assures that there is a process in place to provide for dissemination of enrollment and disenrollment data between the State and the State Administrating Agency. The state assures that it has developed and will implement procedures for the enrollment and disenrollment of a participants in the State’ s management information system, including procedures for any adjustment to account for the difference between the estimated number of participants on which the prospective month payment was based and the actual number of participants in that month. Revised Submission 9.9.19 09/13/19

Table of Contents State/Territory Name: KS State Plan Amendment (SPA) #: 19-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH &HUMAN SERVICES Centers for Medicare & Medicaid Services 75ffi Security Boulevard, Mail Stop 32-26-12 Baltimore, Maryland 21244-ß50 wrs ccNrtRs Ío¡ MtDtc^¡f & Mtfrc^tD st¡vrcEs CTNTEN FOR MEDIC/TID & CTIIP SCNVICES Financial Management Group December 2,2019 Adam Proffitt, State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Offrce Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220 RE: Kansas SPA 19-0012 Dear Mr. Proffitt: We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 19-0012. This amendment updates the State's Disproportionate Share Hospital allotment allocation and payment methodology. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923(9) of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment 19-0012 is approved effective October 1,2019. We are enclosing the CMS-I79 andthe amended plan pages. If you have any questions, please call Tim Weidler at (816) 426-6429. Sincerely, Kristin Fan Director cc: Heather Juhring Tim Weidler

DEPARTMENT OF HEALTH AND HIJMAN SERVICES CENTERS TRANSMTTTAL AND NOTICD OF APPROVAL OF STATE PLAN MATERIAL FOR¡ CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF I.IEALTII AND }IUMAN SERVICES 5. TYPE OF PLAN MATERIAL (CheckOne) E NEw STATE PLAN 2. STATE Kansas 3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE Octobet l,2019 I'ORM APPROVED fl AMENDMENTI'o BE coNSIDERED AS NEw PLAN SeveNounNr I. TRANSMITTAL NTJMBER: KS 19-0012 6 lO IFTHI 6. FEDERAL STATUTE/RECULA'TION CITATION 42 CFR $447 Subpart E 8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 4.19-4, Outline Pages i and iii, Page 4, Page 4a (new), Page 26, Page26a,Page27, Page 28, Page29,Page29a (new), Page 30, Page 30a (new)' Page 30b (new), Page 3 l, Page 3la, Page 32. 7. FEDERAL BUDGET IMPACT a. FFY 2020 $0 b. FFY 2021 $0 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (lf Applicable) Attachment 4.19-4, Outline Pages i and iii, Page ,Page26,Page26a, Page27, Page 28, Page29, Page 30, Page 31, Page 3la, Page32' IO. SUBJECT OF AMENDMENT Update the allocation methodology for the Medicaicl Disproportionate Share Hospital (DSH) allotment. ll. GOVERNOR'S REVIEW (CheckOne) fl covBRNoR's oFFIcE REPoRTED No coMMENT fl o'rnnR, AS SPECIFIED: Adam Profütt is the Govemor's Designee 16. RE'I'URN TO Adam Proffitt, State Medicaid Director KDHE, Division of Health Care Finance Landon State Offico Building 900 SW Jackson, Room 900-N Topeka, KS 666¡2-1220 ntr COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITH¡N 45 DAYS OF SUBMIT'TAL OF STATE AGENCY 12. sl I3. TYPED NAME Adam Proffitt I4. TITI.E State Medicaid Director I5. DATE SUBMITTED 2019 offtar" I7. DATE RECEIVED I9. EFFECTIVE DATE OF 23. REMARKS I8. DATE APPROVED PLAN APPROVDD - ONE COPY ATTACHDD 20. SIGNA OF REGIO}TAL OFFICIAL i n¿cfou" ( N^Gl 0 2 20t9 APPRovEDd/tTT't?org 2r'TYPED*o"t Kni sirn l"v 22.TITLE FORM CMS-r79 (07/92 Instructions on BRck

KÀìISÀS MEDICAÍD STÀTE PIÀIi¡ Methods and standards for Bstablishing Payment Rates - Attachment 4.19-À outline De fini tions Page i Inpatient Bospital- care Page section 1.0000 2.0000 Re-imbursernent foi fnpatienL General Hospjta-l setvices According to Diagnosis ReÌated Groups (DRGS) 2.1000 Hospital Participation Effective Date 2.2000 Bí1.ling Requirenents 4a 4a 4a 4a 5 5 2\0 a 2204 2300 ceneral BilIing Transfer Bi l.L i ng lnterirn Billing 2.3000 Hospil-al Grouping 2.4000 The DRG Reimbursenent System Components 2 ,4100 Data Base 2 .4L10 2.4L20 4 310 4 320 4330 I B II 8-10 10- 11 . 1.2- Claims Excluded fro¡rì the Data Base claims Modified Befo¡e Including in the Data Base '7 I B L2 T2 13 2.42OA Dêtermination of the CosLs of Claims 2 .42 J.0 cost Reports 2 .4220 Cost Data. 2.4230 Cost De terrninaLion 2.4240 Hospital Specific Àdjustments. 2.4250 Exarnple to Illustrate Cost Determination 2.4260 Inf.lation of the Cost and Char:ge Data. 2.4300 Tclent-ri fi cãtion of Outlier Claims in the Data Base Mean Costs and Mean Lengths of Stay Establishnent of Out.lier Limits . ExampÌe of Ideni:ifying OutÌiers . 2.4400 DRG Relative Weights I4 1.4 14 t5 16 4410 4420 4 430 4440 Data Base Àdjusbments for DRG I/üeight Computations Determination of Kansas Medica id-spec i fi c DRG Relative l,l]ej gh Ls Exanple to Illustrate the Computation of Kansas MedicaidrSpecific DRG Í{eiqhts . . . . Modification of ReÌative Weights for Low-Volume DRGS. Ks 19-0012 Àpproval. Dat{]Ëe_10 :P rz{lgE f fect ive Date I0/0I/I9 suPersedes TN#00-23

KANSAS MEDICAID STATE PLAN for lnter¡m Bill¡ngs.,.............,...... Payment for First lnter¡m g¡f l¡ng........' Payment for Second ând Subsequont Attachmênt 4.'19-A Outl¡nê Page iii Methods and Stândards for Establ¡shing Payment Rates - lnpat¡ent Hospital Care 2.5700 Payment 2.5710 lnterim B¡llings...... 25b 25b 25b 2.5720 Page 25c 25c 25d 25d-25e 26 26 26 27-28 29-31 31a 32 32 35 óo JO JO 3.0000 4.0000 5.0000 2.6000 Settlementsand Recoupments.. General Hospital Reimbursement for lnpat¡ent Serv¡ces Excluded From the DRG Re¡mbursement system.........,..,....... 3.1000 Critical Access Hosp¡tal Reimbursement. Reimbursemênt for lnpatient Services in State Operated Psychiatric and Large Publ¡c Kansas Teaching Hospitals..... 4.1000 Reìmbursement for lnpatient Sêrv¡ces in Border City Children's Hosp¡ta|s............. Reimbursement for SNF and ICF Services (Swing Beds) in General Hospitals............. 6.0000 D¡sproportionateSharePaymentAdjustment... 6.1000 ô.2000 6.3000 6_3500 6,4000 6.5000 Eligibility for DSH Payment............. L¡m¡tation on DSH Payments,,... Allocation of DSH Funds...... Payment Methodology of DSH Allocat¡on... Transition Prov¡sions........... Request for Review 7.0000 Change of Ownership..... DepartmentNotificationandProviderAgreements................,........ Certification Surveys.............. Cost Limitations.... 7.1000 7.2000 7.3000 Audits... Publ¡c Process.. Direct and lndirect Graduate Medical Educat¡on Payments......... 8.0000 9.0000 10,0000 KS l9-0012 Approval Da{çFl fì 6, ?ßffective Date l0/01/19 Supersedes TN # 09-05 37

KANSAS MEDICAID STATE PI-AN fvlethods and Stabdards for Estãblishing Payment Rates - lnpåtient Hosp¡talCare 1.0000 continued Attachment 4.19-A Page 4 "Readmission" means the subsequent adm¡ssion ol a recipient as an inpatient into ã hospital with¡n 15 days of dischãrge âs an inpatient from the same or another hospital participating ln the DRG reimbursement system. "Recallbrâtion" means the adjustment of âll DRG weights to reflect changes in relat¡ve resource use associated w¡th all existihg DRG categories and/or the creat¡on or elimination of DRG cate8or¡es, bb. "Standard diågnos¡s related group DRG) amount" means the amount computed by multiplying the Eroup reimbursement rate for the Benerâl hosp¡tal by the diagnosis related group weight. State-operated hosp¡tâl' means an establlshment operated by the State of Kansas with an organized medical stâff of phys¡cians, w¡th permanentfacilit¡esthât ¡nclude inpatient beds, with medicalservices, including physic¡an services and continuous registered profess¡onâl nursing services for not less than 24 hours of every dav, and whlch provides diagnos¡s and treatment for nonrelated pâtients. dd. "Stay as an inpât¡ent in a general hospitâ|" ñeâns the period of time spent in a general hosp¡tal from admission to d¡schârge. ee. "Transfer" means the movement of an ¡ndivldual rece¡v¡ng hospital ¡npat¡ent serv¡ces from one hospitalto another hosp¡tal for additional related inpatient care after adm¡ss¡on to the p¡evious hospltal or hospitâls, ff. "Transferring hospital" means the hospitâl which transfers a rec¡p¡ent to another hosp¡tal. There may be more than one transferrlng hosp¡tal for the sâme reclplent unt¡l discharge, gg. "Cr¡tical Access Hosp¡tal": Hosp¡tals that are certif¡ed as crlt¡cal access hosp¡tãls by Medicãre. hh. "Border city ch¡ldren's hospltã1" ¡s def¡ned as a comprehenslve pedlaft¡c medlcâl center wlth 200 beds or more, a level I pediatrlc trâuma center, and at least a level ll¡c intens¡ve câre nursery. The border city children's hosp¡tal must be located ¡n a Kansas border city. A Kansas border c¡ty means those communit¡es outside ofthe state of Kânsas, but within a 50-mile rânge of the state border. "Hospitâllocated in a frontier county"r Ahospitâflocatedw¡thinacountywherethepopulationlsfewerthån 6.90 persons/sq, mi. The populat¡on density is taken from the 2010 Census. jj. "Hosp¡tâl located in a ruralcounty": Ahosp¡tallocatedwithinacountywherethepopulation¡s6.0-19.9 person/sq. mi. The population density is taken from the 2010 census. kk. "Hospltal located ìn a densely-settled rural county": A hosp¡tal located withlh a county where the population ¡s 20.0 - 39,9 persons/sq, mi. lhe populat¡on dens¡ty is taken from the 2010 Census "La.ge Hospltal" ls defined âs any hospltal ln the State of Kânsas with 500 or more ãvallâble beds, âs reported on the Med¡care cost report, defined ¡n Sect¡on 6.2000 B. z. aa. cc, , . (5194012 ApprovalDate LrEt t g 80r$ Effect¡ve Date 10/01/19 Supersedes TN# 18-008

KANSAS MEDICAID STATE PI.AN Attachment 4,19-A Pdge 4a Methods and Standards for Estâblishing Payment Râtes - lnpat¡ent Hospital Care 2.OO0O Reìmbursement for lnpatient General HospitalServ¡ces According to D¡agûos¡s Related Groups (ÐRGs) 2.1000 Hospital Partlc¡pation Effective Date Effective w¡th servlces provided on or after October 1, 2000, general hospitals w¡ll be paid ¡n accordance w¡th the Kansas Med¡caid/MediKan Dlagnosis Related Groups (DRG) Reimbursement System descr¡bed ¡n 2.0000 ând 3,0000. This does not ihclude state-operâted hospitals. ståte-operâted hospitals are dlscussed in 4.0000. 2.2000 EllllngRequlremeñts -fhis section describes var¡at¡ons in how billings should be mâde by hosp¡tals. 2.2100 General Billing Under the DRG Reimbursement System a hosp¡tal may bill only upon discharge of the .ecipient except as noted in subsectìons 2.2AOO ànd 2.23OO. KS 19-0012 Approval Date nFf fi q 2fitq Eff ect¡ve Date 101!1119 Supersedes NgE

KANSAS MEDICAID STATE PI,AN AttachmeÍt 4.19-A Page 26 Methods and Standards fot Establishing Payment Ratos - Inpaticnt Hospital Carc 5.0000 Reimbursement for NF Servioes (Swing Beds) in General Hospitals Reimbursenent for NF services (swing beds) provided in general hospitals (swing bed hospitals) shall be pursuant to 42 CFR 447,280. 6.0000 Disproportionate Share Payment Adjustment The Kansas Medical Assistance Prograln slrall make a leimbulsement adjustment for dispt opottionate share hospitals which are either located in the State ofKansas or located outside ofthe State ofKansas but operate a hospital that is located within the State ofKansas. The reimbursement adjustment for disproportionate slrare hospitals shall be nrade for hospitals eligible under criteria contained ìn 6. 1000 below. The calculatecl reinrbursement adjustrnent will be rnade in quarterly installments to DSH eligible hospitals. For hospitals to bc cligible under'6.1000, they must have at least 2 obstctricians who have staffprivileges at the hospital and who have agreed to prcvide obstetric services to indivicluals who are entitled to medical assistance for suclr services under the State Plan, except where the hospital serves predominantly individuals under' 1 8 years of age, ol wher e non-enrergency obstetric services to the gener"l population were not offered as ofJuly 1,1988. In rural areas the tenn "obstetrician" includes any physician with staffprivileges at the hospital to perfbnn non-enrorgency obstetric procedures. Please see section 6.5000 for adclitional inshuctions. All references in the Dispropor tionate Share sections to Medicaid payments and days refer to both fee for service and managed care. 6.1000 Eligibility for DSH Paynrent Eligibility for Disproportionate Shale Hospital (DSH) payments slrall be determined if: (A) The hospital's Medicaid inpatient utilization rate exceeds the lesser ofone standatd deviation above the mean Medìcaid inpatient utilization taie for hospitals receivíng Medicaid payments in the State or 25 percent; or (B) The hospital's low-incolne utilization rate exceeds 25 perceÍìt. (C) For purposes of para$aph (A), the tenn "Medicaid inpatient utilizatiou tate" means, for a hospital, â frâction (expressed as a peicentage), the nutnerator of which is the hospital's number of inpatient days attributable to patients who (for such days) were eligible for medical assistance under a State plan approved under this title in a period (regardless of whether such patients receive medical assistance on a fee-for-services basis or through a nanaged care entity), and the denominator of which is the total number ofthe l'ìospital's inpatient days in tlìat period. In this paragrapb, the term "inpatient day" includes each day in which an individual (including a newborn) is an inpatient in thc hospital, wlìether or not the individual is in a specialized ward and whether or not the individual rennius in the hospital for lack ofsuitable placement elsewhere. KS 19-0012 Approval Date DEc o 2 Zol9sff..tiu" nut" l 0/01/1 9 Supersedes TN#07-12

KANSAS MEDICAID STATÐ PLAN Attachment 4.19-A Page 26a Methods and Standards fol Establishing Payment Rates - Inpatient Hospital Care 6. 1000 Eligibility for DSH Payment (continued) (D) For purposes ofparaglaph (B), the term "low-income utilization rate" means, for a hospital, the sum of* (l) the fraction (expressed as a percentage) - a. the nurnerator of which is the sum (for a period) of (I) the total revenues paid the hospital fol patient services under a State plan apploved under this title (regardless ofwhether the services were furnished on a fee-for-service basis or tlrrough a nranaged care entity) and (II) the amount ofthe cash subsidies fol patient services received directly from State and local governments, and b. the denominator of which is the total amount ofnet inpatient revenues of the hospital for patient services in the period; and (2) a fraction (expressed as a percentage) - a. the lrumerator of which is the total amount ofthe hospital's chatges for inpatient and orìtpatieut hospital selices which are atttibutable to charity care in a period less the portion of any cash subsidies described in (l) a. in the period reasonably attributable to inpatient hospital seruices, and b. the denominator of which is the total amount of the hospital's charges for inpatient hospital services in the period. (E) Hospitals will be deerned disproportionate share hospitals in accordance with 42 U.S.C. $1396r-4(b). KS l9-0012 Approval Dato DEC 0 2 20t9 Effective Date l0l0ll19 Supersedes TN#QE:IQ

6.2000 A. KANSAS MEDICAID STATE PLAN Attachment 4.19-A Page 27 Methods and Standards for Establ¡shing Payment Rates - lnpat¡ent Hospital Care B, Limitation on DSH Payments L¡mitation on Total DSH Funds Allocated The allocation of DSH funds is structured so as not to exceed the allotment determined by Centers for Med¡care & Med¡caid Serv¡ces (ClvlS) in accordance with section 1923(f)(3) of the social Security Act. As the DSH payment methodology dèscribed in subsequent sections allocates only available DSH funding, ¡n no case shall allocated DSH funds exceed the Kansas federâl allotment. All Hosp¡tals are limited to no more than the¡r Uncompensated Care Costs (UCC). UCC is the uncompensâted cost of care to the Kansas portion of uninsured and the uncompensated cost of care to Medicaid participânts. The data to be used ¡n the calculating of each hospital's UCC will be obta¡ned from several sources including a hospital DSH survey, Medicaid pâid cla¡ms data, and the hospital's Medicare cost report. The period of the data to be utilized will co¡nc¡de with the period of the Medicare cost report, filed with lrledicare, for each hospital that is available no later thân four months prior to the start of the state fiscal year (SFY) for wh¡ch payments are being made. This limitation is computed by Medicaid below. UCC Uninsured lnpâtients - For purposes of the DSH calculat¡on the un¡nsured âre def¡ned as those individuals who lack th¡rd party coverage for el¡g¡ble services received. Hospitals are [equired to submit on their annual DSH survey the amount of uninsured days, charges, and payments attr¡butable to inpatient hospital services. These uninsured days and charges will be grouped by cost center and multiplied by the hospital's inpatient per diems and cost-to-charge ratios, as calculated from the¡r Medicare ôost report, to arr¡ve at total ¡npat¡ent uninsured costs The total inpatient pâyments received from the uninsured will be subtracted from the costs to arrlve at thê uncompensated uninsured inpâtient costs. The reported uninsured charges and payments should exclude non-hospital seru¡cos such as: Skilled Nursing Facilities (SNF), Nurs¡ng Facil¡ty (NF), Rural Health clinics (RHC), Federally Qual¡fied Health Centers (FQHC), âs wêll as physiciân chârges. Ucc Uninsured outpatients * For purposes of the DSH calculation the un¡nsured are defined as those individuals who lack third party coverage for eligible services received. Hospitals are required to submit on their annual DSH suruey the amount of uninsured chargês and payments attributable to outpatient hospital services. These uninsured charges will be grouped by cost center and mult¡pl¡ed by the hospital's outpat¡ent (ancillary) cost to charge ratios, as calculated from the¡r Medicare cost Íeport, to arr¡ve at total outpat¡ent un¡nsured costs. The total outpat¡ent payments received from the uninsured will be subtracted from the costs to arrive at the uncomponsated uninsured outpatient costs. The reported uninsured charges and payments should exclude non-hospital services such ast Skilled Nursing Facilities (SNF), Nursing Facility (NF), Rural Hêalth Clin¡cs (RHC), Federally Qualified Health centers (FQHC), as well as physician charges. Kansas Med¡caid lnpatient Days in last availâble fiscal year of hospital. The Kansas Med¡caid lnpatient Days will be obtained from paid claims data for the period of the hospital's cost report used in the DSH calculation as identif¡ed in Section 6.2000 B. 81. B2. 83. KS 19-0012 Approval Date nEc 02 2CIt9 Effective Date 10/01/19 SupersedeslN#M5ü02:!2

KANSAS MEDIGAID STATE PLAN Attachment 4.19-A Page 28 84. AII Med¡ca¡d lnpâtient Days in last avâilable fiscal year of hospital. All Med¡caid inpatient days are lhe total of Kansas inpatient Medicaid days obta¡ned from the paid claims summary, and the hospitals out-of-state Medica¡d inpâtient days obtained from the hospìtal DSH survey. The service period for accumulating these dâys will coincide w¡th the cost reporting period ¡dentifiêd ¡n 6.2000 B. 85. Kansas portion of Medicaid inpat¡ent days (83 / B4). 86. Kansas portion of Uninsured lnpatient Uncompensated Cost (81 x B5). 87. Kansas portion of Uninsured Outpatient Uncompensâted Cost (82 x B5). 88. UCC Kansas Medica¡d lnpatients - The UCC related to Kansas Medica¡d inpatients is calculated by multiplying the Kansas Medicaid inpatient days and charges, as obtained from lhe paid claims summary, times the inpat¡ent per diems and cost-to-charge ratios by cost center, as determined from the hospital's cost report, to arr¡ve at calculated Medicaid ¡npatient costs. Total Kansas ¡npatient Medicaid payments, ¡ncluding any supplemental or enhanced payments, are then subtÌacted from the calculated Medica¡d ¡npatient costs to arr¡ve at the UCC for Kansas inpatient Medicaid services. ¡f the rêsult of th¡s calculat¡on is a negat¡ve, or gain, this âmount is used to reduce the hospital's overall UCC. 89. UCC Kansas Medicaid Outpatients -The UCC related to Kansas Medicaid outpatients is calculated by multiplying the Kansas Medicaid outpatient charges, as obtained from the paid cla¡ms summary, t¡mes thê outpat¡ent (ancillary) cost-to-charge ratios by cost center, as determined from the hospital's cost report, to arrive at calculated Med¡caid outpat¡ent costs. Total Kansas Outpat¡ent Medicaid payments, includ¡ng any supplemenlal or enhanced payments, are then subtracted from the calculated Medica¡d outpatient costs to arrive at the UCC for Kansas outpatient Med¡caid services. lf the result of this calculation ¡s a negâtive, or ga¡n, this amount is used to reduce the hospital's overall UCC. 810. Total HospitaFspec¡fic DSH Limitation ("DSH l¡m¡t") = (86 + B7 + BB + Bg), The calculated DSH limit will be annualized if a cost report period less than 12 months is used in the calculations. KS 19-0012 Approval Date DEC û P 2019 Effective Dare lp0ll:lgsupersedesTN#l\4S#07-1 2

KANSAS MüDICAID STATE PLAN Attachruent 4.19-A Page 29 Methods and Standaltls fo¡ Establishing Paynìe[t Rates. Inpatient Hospital Care 6,3000 Allocation ofDSH Funds Effective fbr DSH calculations beginning with lederal fisoal year (FFY) 2020, totdl avajlablc DSH funds shall be d¡stributed among DSH-eligible hospitals as defined jn Scction 6.1000 above based upon cach hospital's burden ofUCC (DSH limit) relative to their peers within the pools cstablislìed below. The calculations ofthe total avaìlable DSH fi¡nds and the DSH funding pools is contained in Sections ó.3000 A and B. Thc State will expend its annÙal DSH allotlìlent. If CMS changes the DSH allotment for a prior yoar, the Stâtc wìll adjust the expeuditurcs bascd on Scctions 6.3000 A, B, C, and D. ln addilion, pools o1' DSH funding will be established ftrr like groups ofhosÞitals to establi$h Iimitations on the available ftnding for each pool. A. Available DSH funds to the following types ofhospitals will be established as follows: L The fistitutes fot Mental Dìsease (lMD) Pool - W¡ll bc cquai to thc Foderal IMD DSH âllotment for the Stûte ofKansas. 2. out-of-State Hospital Maxinlum Pool - DSH-el¡gible out-of-state hospitals will share up to a maximum pool ofI)SH funds. The ¡rool ofDSH fintls avajlablo foÌ DSH-cljgible out-of-state hospitals will be calcu¡ated each year and limited to the lesser ol' I0 pe¡cent ofthe non-lMD Fedçral DSI-I allotment fot th€ State ofKansas o¡ the anroùnt calculated in Sections 6.3000 C and lJ. 3. state-o\À7ned or Operated Teaching l-lospital Maxirnurr Pool - DSl{-eligible hospitals that arc state-owned or operated and provide graduate medical educat¡on programs will share up to a maximurn pool of DSH funds. The pool ofDSH funds available for DSH-eligible sta(e-ownsd or operuted teâchi¡g hospitals will be calculated each year, and linrited to .25 peloeDt ofthe nonlMD Federal DSH allotment for the State ofKansas. 4. Largc Hospital Pool - Large hospitals will sharc a pool ofDSH funds. Large hospitals are dcfincd as all DSH-cligiblc, non-lMD, non-statc hospilals, in drc statc ofKansas, with 500 or nore available lros¡rital beds, as reported on tlÌe Mcdicare cost repolt, defined in Section 6.2000 B. a. lnitial largc hospitalpool datermination is as followsl i. lior thc initial ycar (FFY 2020), thc availablc DSH funds for thc largc hospital pool will initially be equal to $18,677,107. l. For purposes ofthe init¡al year (FFY 2020) only, references to tlìc prior year DSH payne[ts or allotments in tbis scction are referencing IrI'Y 2018, ii. For FFY 2021 ând aftcr, thc largc hospital pool will initially bc cquâl to thc prior year large hospital pool excluding any IMD allotlnent leclassified in the priol year to the la¡g€ hospital pool, in accorrlaucc with Scctiou 6.3000 B,I .a. b. Adjùst for thc changc in thc hospitals qualifying unclcr thc largc hospital pool. i, A rcduction to thc largc hospital pool will be nüdc cqual to thc hospital's p|iol ycar' DSH payn:ent, if thc hospital is no longer eligible for the large hospital pool but ìvas included in the prior year. The prior year DSH paylrclt will exclude pool reclassifications f¡om the IMD Þool clefined uncler 6,3000 A. l. ii. Au iricrcase to the large hospital pool will be made equal to the hospital's prior year DSH paymcnt, ifthc hospital is newly eligible for the Iarg€ hosÞital pool but was not included in the prior ycar. The priol year DSH payment will cxcludc pool reclassifications fiom the IMD pool dsfinçd under 6.3000 A,l, KS 19-0012 Approval Datc nFfl (}q 2ûfql Effective Date l0/01/19 Supcrscdes TN#MS KSIó405

KANSAS MEDICAID STATE PLAN Attachrnent 4.19-A Page 29a Methods and Standards for Est¿blishing Payment Rafes - Inpatient Hospital Care c. Take the lesser ofì i. Thc sunr ofSections 6.3000 4.4.4 and b, above, rnultiplied by tho percontagc change in the currcnt yeaÌ Kansas non-IMD fedcral DSH allotment, courpared to the Kansas non-IMD federal DSH allotment used in the pl ior year's DSH calculations. ii. The sum of all large hospital DSH limits calculated under Section 6.2000 B in the cu ent year DSH payment calculâtion. d. Prior year federal DSH allotment changes will only be t ecognized in the large pool when the allohnent for the specific DSI{ payment year is determinod to be final by CMS and the State. Ifthe change in allohnent is for a prior year but impacts the speciftc DSH year indilectly, no change will bs made to the indirectly impacted DSH year until thât DSH year allotrnent is also deerned final by CMS and the State. 5. Other ln-State DSH-Eligible Hospital Pool - Hospitals eligible for DSH payments that are not classified as IMDs and were not included in any of tlte pools undet Section 6.3000 A, above, will be distributed the remaining DSH funds ftom the non- IMD federal DSH allotrnent. The remaining DSH ftinds for distribution to this pool will consist ofthe nonJMD federal DSH allohllent for the State ofKansas less the DSH payrnents calculated for DSH-eligible hospitals included in alt other pools under Section 6.3000 A, above. B. Funds available will be established in the following order: 1. IMD Hospital Pool a. Alìy IMD allotment not able to be used by the IMD hospital pool, duc to DSH limits, under Section 6.2000 B, may be reclassified, to all non-lMD hospital pools under Section 6.3000 A, based on each pool's initial calculated proportion ofthe total non-IMD pool. 2. Non-lMD Pools a, Out-of-State Hospitâl Maximum Pool b. State-Owncd/Operated Teaching Hospital Maxirnum Pool c, Large Hospital Pool d. Other in-State DSH-EIigible Hospital Pool i. Unused DSH funds from any non-IMD pool will be reclassified to the "Other in-State DSH-EIìgible Hospital Pool". Thc follo\ ing table illustrates the methodology ùsed to calculate the total DSH funds available and the anìounts allocâted to each pool. The amounts are fbr example purposes only and wiìl not be used in the actual DSH payment calculations. KS l9-0012 Approval Datc DEe tg 2úll9 rffectivc oat c to/ottle Supcrsedes \9y

KANSAS MEDICAID STATE PLAN Attachment 4.l9-A Page 30 Methods and Standalds for Establishing PaymeDt Rates - lDpatient Hospital Care EXAMPLE Larqc Hospitrl Pool Calculàt¡ons Prior Ycar Finnl Adjustcd Latge Hospital Pool Loss Prior Year IMD Pool Reclassifications to the Large Hospital Pool Reductions for Largc Hospitals No Longer Eligiblc for the Pool (Prior Ycar DSH Payment excluding IMD Pool Reclassifications) Inçrease for Newly Eligible Large Hospitals (Prior Y€ar DSH Payment excluding IMD Pool Reclassifi cations) Sub-total Largc Hospital Pool Prior Year Kansas Non-lMD Federul Allotment Cufrent Year Kansar Non-IMD Federal Allohìrent Percentage Change in NonlMD Federal Allotrnent Sub-total Large llosp¡tal Pool Sum of All Large Ilospital DSI-I Linits For Cuffent DSI-I Payrnent Year' Total Large Hospital Pool (Lcsser of) s 21,485,362 s (3;140,416\ $- $ $ r?J44f86 $53,9r 6,26tì $s6.748.739 DescriDtion lnil¡al Pnôl Proportional 7n ofNon- IMD Pnol Pool Reclassifications for Unused Pool f,'rrn¡ls Adjusted Pool 5.25% $ 18,677,107 $6s,s06,030 $ 18,677,107 fi ( r4.905.997) $ 13"044.875 FMAP Totâl DSH Funds Available IMD Pool ofDSH Funds (Publishcd by CMs) Non-IMD Pool ofDSH Funds Out-of-Stntc Hospitals (10% of Norr- IMD Pool) State-Owned/Operatod Tcâching Hospitsls (,25% ofNon- IMD Pool) Large Hospital Pool (Calculatod above) Non-IMI) Pool Sub-Total Remairring Non-IMD Allohnent fol Othel In-State DSH-Elj gible Hospitâl Pool s4.74% $ 84,699,61 I s 27,950,8',12 $ 56,748,739 100.00% 8 5,6'14,8'74 )0.00% $ 141,872 0.2s% $ 14,905,997 $ I,490,600 $ 3',l ,265 s 71,654;736 s 7 ,t6s,4'7 4 s 179,137 S 18,6'77,107 32.91yo $ 4,905,s64 $ 23,582,6'11 s 24,493,8s3 43.t6% $ 6,433,429 S 10,92',7,282 $ 32,254,88ó s6.84yo $ 8,472,569 S 40,721,45s KS l9-0012 ApprovalDate 0EË 0g &0l$ffective Datc l0/01/19 Supcrscdcs TN# MS KS l6-005

KANSAS MEDICAID S]'AI'E I'LAN Attachment 4.19-A Page 30a Methods a¡d Standalds for Establishing Payment Rates - InÞatient Hospital Care C. The allocation ofDSH fulds among eligible hospitals that arc notlMDs wili distribute DSH fu¡ds proportionally to hospitals in each pool based upon each hospital's relative bu[den ofKansas UCC (DSH limìt) to their total hospilal cost, as follows: Three-Ycar Rolling Avcragc Hospital Bnrdcn - Tho hospilal burden ofeach DSH-eligiblc hospital is calculated to detenìrine the Þercentage of the hospital's business that is related to providing Kansas uncompensated care. This burden is calculated by dividirrg the hospital's DSH linrit, as defined in Section 6.2000 8., by the hosÞital's total cost. For purpo¡jes of the hospital burde¡ calculation, the total hospital cost w¡ll be determined frorn the hospital's cost leport as identified in Section 6.2000 B. The total hospital cost will be the total cost from Worksheel B PaÍt I ofthe cost report less any cos(s associated with non-hospital services such as: Skilled Nursìng Faoilities (SNF), Nursing Facilities (NF), Rural Health Clinics (Rl{C), HoD'ìe Health Agenoies (HHA), and FedcÏally Qualitìeil Health Centers (FQHC). Total hospital cost will be annualized ifthe cost report period is less than I2 months, A three-year lollirg average of the hospital l¡urden will be used fol the allocation of the DSII funds. The llìree-year rolling average ol'lhe hospital burden will be calculatecl as follows: a. U = hospitnl-specific DSH limit calculated under Section ó.2000 B. b. C = hospital-specific total costs as deternined in this section, excluding non*ospifal sçIvioes. c. I-lospital-specific burden: B = tI/C d. F^ : three-year rolling averagc hospital burdcn. Ths averagc ofthc cuncDt year and two prcvious DSH years' hospital-spccific burdon, ifavailablc. lf no burdcn was calculated in oithcr ol'the plcvious two ycars, thc applicablc ycars will not bc uscd in thc avcragc. lfa burden was calculated in the previous two yoars for DSH paynront eligibility, evcn if it was zclo, it will bc uscd in the three-yeâr rolling avel ag€ hospital brìrde¡r. 2. Hospitâl Scâling Ì-actor - All rural lìospilals will havc a scâling factor of 150 percent applied to thc lÌospital-spccific DSH limit calculatcd undet Scction 6.2000 B. Thc tcrff "tural hospitals", as used in this section, refels to all critical access hospitals, n¡ral hospitals, frontiel hosPitals, and densely settled rural hospitals, as determined by the State, no later than foul lnonths prior to th€ stalt of the federal fisoal year fol which payments arc being madc. All othcr hospitals will havc a scali¡g factor of 100 pcrccnt applicd to the hospital-spccific DsH liorit. a. Fs - ìrospital scaling factor 3. Burden-Adjusted DSH Lirnit - Represcnts the hospital's DSH lirnit adjusted for the hospital's tlücc- yeal lolling average burden and the hospital scaling factors. a, ts^=Ë^xUxFs KS l9-0012 Approval Date llË0 (}g ä0îg EffectiveDat€"r!1q!2q19 Supersedes !9¡y

KANSAS MEDICAID STATE PLAN Attachnrent 4.19-A Page 30b Methods and Standards for Establishing Paylnent Rates - Inpatient Hospital Cale 4, Proport¡on of Brrldeu-Adj usted DSH Limit - Rcpresents the hospital's proport¡on of the burden- adjusted DSH limit coupared to all other DSH-€lig¡ble ronJMD hosp¡tals. a. DL = propoltion of burdcn-adjustod DSH Limit fot large hospifal pool hosÞitals. b. Do = proportiorl of burdcn-adjustecl DSH Limit for all othcr nonlMD hospitals. c. Lalge Hospital Poolr Dr'= B^ / Totsl Burden-Adjustcd DSH Liurit (B^) for all DSH-eligible non- IMD hospitâls included in the lârge hosÞ¡tal pool. d, NonlMD Pool Excludirg Large l-Iospital Pool; Do = B^ / Total Burden-Adjustcd DSH Limit (B^) fol all DSH-eligible non-lMD lÌospitals cxcludcd frorn thc Iarge hospital pool. Formulâ for DSH PaymeÌt - a. PL: large hos¡ritâl pool as detemìined und€r Section 6.3000 4.4, includirrg any nonJMD pool reclassificâtion to thc large hospital pool, undcr Scction 6,3000 B.1. b, PN: total Kansas noû-lMD allotment, inalùdjng any non-IMD pool reclassification, under Sectjon 6.3000 B,I less PL. c, DL * PLfor largc lrospital pool. d, Do * PN for all other non-IMD hospital pool. 6. Reclâssificâtions - Ally anìounts allocated to a noülMD hospital in excess oftheir available DSH litnit or in excess of nraxinrum allowcd payments under any pool will be reclassificd to othel hospitals in accordance with Section 6.3000 B. Thc propottion allocated to each applicablc ltospital will be based on their propoft¡on ofthe total calculated DSH paynents under Section 6,3000 C.5, above, not to exceed their hospital-spacific DSH liIrlit. 7. Critical Äccess Hospital (CAH) minimum percent of DSH limit påid - CAHs eligiblc for a DSH paymeut will receive the greatet ofthe cu¡rent year calculated bospital-specific l)SH ÞaymeDt or 37 percent of their hospital-speçifio DSH lirnit. a. lncreases in CAII DSH payments due to the 37 petcent minimum will be offsct by proportional adjùstmerts to all hospitals in the other in-stale DSH-eligitrle hospital poolbased on the¡r indivictual calculated DSH payment allocations, It will not impaÇt the out-of-st[te, state- owncd/operated teachiug, or largc ltospital pools. Kll9:qql2 Approval Date ÐEC 09 ¿0fg Effective Date 10/01/2019 Supelsedes lg¡y

KANSAS MEDICAID STATE PI,AN Attachment 4.19-A Page 3l Methods and Standards lor Establishing Paymcnt Rates - Inpatio¡ìt Hospi{al Care D. Eligible hospitals that rìre defined as hstitutes for Mental Disease (lMDs) will rcceive an allocation ofDSH tìnds frorn the allotted IMD pool as defined in Sections 6.3000 A and B, above. The allooation to DSH-eligible IMD hospitals will be calculated by dividing each elìgible IMD hospital's DSH limit by tbe total DSH li¡rit for all DSH-eligible IMD hospitals. The percentagc calculated wìll then be multiplicd by the totâl allotlnent fol IMD hospitals, as defined ir Sections 6.3000 A alld B, above. Each IMD hospital will rcceive the lesser ofthe calcul¿ted anìotìnt o¡ their DSH linrit as defìned in Section 6.2000 B. E. DSH payments found in the DSII audit process that exceed the hospital-specific DSH limits may be recouped from the hospitals to reduce their DSH payments to their hospital-specific DSH limit. Any payrnents that are recoùped fiom hospitâls as a result of the DSH audit will be redistributed to hospitals that arc shown to have been paid less than their hospital-specific DSH limits. Total redistlibution payments may not exceed total DSH recoupment to date. To redistribute the frrnds, the State will do the following: a. Hospitals closed or bankrupt as of thc datc of the redistribution calculation may be excluded flonr the funds available for redistribution and will be excluded from any available lcdistribution, b. Redistribute the state IMD DSH recoupment to all other eligible state IMD hospitals that are shown to have been paid less than their hospital-specific DSH limits in the DSH audit. The redistribution will ocour propolionally based on each hospital's total available DSH linrit in the DSH aûdit (shortfall) to tho total shortfall for all state IMD hospitals, not to exceed each hospital-specific DSH lirrit. ADy overyayrrent which cannot be redistributed within the statelMD hosp¡tals will be redistributed to non-IMD state hospitals using the san'ìe rnethodology, \ c. Redistribute the rernaining DSH rccoupmont to all in-state cligible hospitals that are shown to have been paid less thân their hospital-specilic DSH limits in the DSH audit. The redistribution will occur propoltionally based on each hospital's rernaining DSH limit in the DSH audit (shortfaU) to the total shortfall for all in- state eligible hospitals, not to exceed each hospital-specific DSII limit. F. Hospital Paynent Adjustnrent - If a hospital Medicaid non-DSH payment (claims, supplemental, etc.) is adjusted in a subsequent period, and the amount previously was included in the calculation ofthe hospital's DSH linit, the claims payment adjustment irnpact on the DSH lilìrit will be reflected in the period of adjustrnent (repaynent). As such, the transaction will be troated prospectively and prior year DSH payments will not be adjusted. KS l9-0012 Approval Date DEO (}9 Date l0/01/19 Supersedes TN#!!QQI

KÄNSAS MEDICAID STATE PLAN Attachment 4.19-A Pagc 3 la Methods and Standar'ds for Establishing Paymcnt Rates - Inp¿tient Hospìtal Câre 6.3500 Payment MetJrodology of DSH Allocation The Medicaid State Agency will make federal quafterly paynìents to eaoh hospital thlough the MMIS as allocated in Section 6.3000. KS 19-0012 Approuul Dat" DEt 0 2 a0l9 Effective Dare 10/01/19 superse<les TN#!!¡QQf

KANSAS MEDICAID STATE PLAN Attachrnent 4.1 9-A Page 32 Methods and Stanclards for Establishing Payment Rates - Inpatient Hospital Care 6.4000 Tlansition Provisions The following transition provisions are provided to lessen the immediate impact of tlre new DSI{ rnethodology. The hansition provisions will bé applied to tlre cornputed DSH payments at the end ofthe çalculation using the following rnethod: A. The IMD pool and the stâte-owned/operated teaching lrospital maximum pool ale both excluded fro¡n the transition provisious. B. Transition will be accomplished over a three year peliod (FFY 2020 through 2023). C. A pe¡centage of the current yeâr calculated DSH payment and t\Ã7ô previous year s DSH payments, ifapplicable, will resuh in an adjusted DSH payment. l. 50 percent of cuuent year DSH payment. 2. 25 percent of one year prior DSH payment. 3. 25 perccnt oftwo ycars pdor DSH payment, Thc adjustcd DSH payments will then be proportionally adjusted separately botwocn the large hospital pool and all others subject to the transition provision. The large hospital pool will retain the total DSH payments allocated pr¡or to the transition provision. The large hospital pool âdjustment will be nrade based on each hospital's adjusted DSH payment as a percentage ofthe total ad.justed DSH payments multiplied by the available pool funds. All others subject to the transition provision will receíve an adjustment based on each hospital's adjusted DSI-I payrnent as a percent.age ofthe total adjusted DST-I payments multiplied by the retnaining available funds. 6.5000 Request for Review lf a hospital is not detelrniDed eligìble for a dispropofionate share paynent adjustment according to Section 6.1000, they Íìay request, in writing, a review of the determination within l5 dâys frorn the notification oftho final payment adjustmeut anlount. Any data supporting the redetermination of eligibility must be pfovided with the ìvr¡tten request. A. Appeals rights are limited to errors in the DSH lorrnula and errors that may result in nìaterial overstateÍìrent ofDSH based on data submitted in the hospital's DSH form. KS 19-0012 Approval Date ti)Eo. @)# ffiEffective Date 10101/19 Supersedes TN# 09_l!

Table of Contents State/Territory Name: KS State Plan Amendment (SPA) #: 19-0018 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages KS - Submission Package - KS2019MS0003O - (KS-19-0018) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID KS2019MS0003O Program Name N/A SPA ID KS-19-0018 Version Number 2 Submitted By Bobbie Graff-Hendrixson Package Disposition Priority Code P2 Submission Type Official State KS Region Kansas City, KS Package Status Approved Submission Date 10/15/2019 Approval Date 11/5/2019 12:14 PM EST Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Page 1 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Kansas City Regional Office 601 E. 12th Street, Suite 355 Kansas City, MO 64106 Division of Medicaid and Children's Health Operations November 05, 2019 Dr. Lee Norman Secretary Kansas Department of Health and Environment, Division of Health Care Finance 900 SW Jackson, Suite 900 N Topeka, KS 666 Topeka, KS 66612 Re: Approval of State Plan Amendment KS-19-0018 Dear Dr. Lee Norman: On October 15, 2019, the Centers for Medicare and Medicaid Services (CMS) received Kansas State Plan Amendment (SPA) KS-19-0018 to The purpose of this amendment was to transfer some basic eligibility information into the MACPro system, without making any changes to Kansas' current covered groups.. We approve Kansas State Plan Amendment (SPA) KS-19-0018 on November 05, 2019 with an effective date(s) of October 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Michala Walker at michala.walker@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Medicaid Field Operations - North Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID N/A SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date N/A State Information State/Territory Name: Kansas Medicaid Agency Name: Kansas Department of Health and Environment, Division of Health Care Finance Submission Component Page 2 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

State Plan Amendment Medicaid CHIP Page 3 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID N/A SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date N/A SPA ID and Effective Date SPA ID KS-19-0018 Reviewable Unit Proposed Effective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 10/1/2019 Unknown Mandatory Eligibility Groups 10/1/2019 Unknown Optional Eligibility Groups 10/1/2019 Unknown Page Number of the Superseded Plan Section or Attachment (If Applicable): Page 4 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID N/A SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Creating the base RU for Eligibility in order to transition the information into MacPro. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $0 Second 2020 $0 Federal Statute / Regulation Citation 42 CFR 435.120 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Page 5 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID N/A SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Page 6 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID N/A SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Page 7 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID N/A SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Yes No Explain why this SPA is not likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations: Transitioning the eligibility information into MacPro Page 8 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID Unknown User-Entered SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date 10/1/2019 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: 1. SSA Eligibility Determination State (1634 State) The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneficiaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines financial eligibility based on SSI income and resource methodologies. 2. State Eligibility Determination (SSI Criteria State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility based on SSI income and resource methodologies. 3. State Eligibility Determination (209(b) State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) Page 9 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID Unknown User-Entered SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date 10/1/2019 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW NEW             Page 10 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Working Individuals under 1619(b) Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW     Page 11 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID Unknown User-Entered SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date 10/1/2019 B. The state elects the Adult Group, described at 42 CFR 435.119. Yes No C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A Page 12 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID Unknown User-Entered SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date 10/1/2019 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. Yes No The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 CONVERTED Children with Non- IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children NEW Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled     Page 13 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization NEW Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneficiaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW       Page 14 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID Unknown User-Entered SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date 10/1/2019 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. Yes No The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women NEW Medically Needy Children under Age 18 NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classifications of Individuals under Age 21 NEW Medically Needy Parents and Other Caretaker Relatives NEW Aged, Blind and Disabled     Page 15 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Populations Based on Age, Blindness or Disability NEW  Page 16 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | KS2019MS0003O | KS-19-0018 Package Header Package ID KS2019MS0003O Submission Type Official Approval Date 11/5/2019 Superseded SPA ID Unknown User-Entered SPA ID KS-19-0018 Initial Submission Date 10/15/2019 Effective Date 10/1/2019 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A Page 17 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 11/5/2019 1:12 PM EST Page 18 of 18 Medicaid State Plan Print View 11/05/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Table of Contents State/Territory Name: Kansas State Plan Amendment (SPA) #: 20-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop $2-26-12 g RY Ss

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Financial Management Group

June 25, 2020

Christiane Swartz, Interim State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance

Landon State Office Building

900 SW Jackson, Room 900-N

Topeka, KS 66612-1220

RE: Kansas SPA 20-0008 Dear Ms. Swartz:

We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 20-0008. This amendment adds "State Institutional Alternative (SIA)" to the Medicaid state plan.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We have found that the proposed reimbursement methodology complies with applicable requirements and therefore have approved them with an effective date of April 3, 2020. We are enclosing the CMS-179 and the amended approved plan pages.

If you have any questions, please contact Fredrick Sebree at Fredrick.sebree@cms.hhs. gov.

Sincerely,

Karen Shields Acting Director ce: Fredrick Sebree

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 1, TRANSMITTAL NUMBER: 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF KS 20-0008 Kansas

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

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

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

4, PROPOSED EFFECTIVE DATE April 3, 2020

5. TYPE OF PLAN MATERIAL (Check One)

(NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

[x] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION 42 CFR 447 Subpart C

7, FEDERAL BUDGET IMPACT a. FFY 2020 $0 b. FFY 2021 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Attachment 4.19-A Page 4 Attachment 4.19-A Page 25d

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

Attachment 4,19-A Pages i, ii, iii (Removal) Attachment 4.19-A Page 4 Attachment 4.19-A Page 25d

10. SUBJECT OF AMENDMENT

The state is adding “State Institutional Alternative (SIA)” to the Medicaid state plan. The definition of an SIA is, “a facility that provides inpatient psychiatric treatment and is authorized by the Kansas Department for Aging and Disability Services (KDADS) to serve as an alternative to placement in a state mental health institution.” In addition, the Table of Contents (TOC) for Attachment 4.19-A will be removed from the Kansas Medicaid State Plan.

11. GOVERNOR’S REVIEW (Check One) (-] GOVERNOR’S OFFICE REPORTED NO COMMENT ( COMMENTS OF GOVERNOR’S OFFICE ENCLOSED LJ NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED: Adam Proffitt is the Governor’s Designee

12. FICIAL

13. TYPED NAME Adam Proffitt

14, TITLE State Medicaid Director

15. DATE SUBMITTED May 7, 2020

16. RETURN TO Adam Proffitt, State Medicaid Director KDHE, Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED 5/7/2020

18, DATE APPROVED 6/25/20

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL 47375999 20. SI 2 OF RE 21. TYPED NAME _ rs ©

Karen Shields

Acting Director, FMG

23. REMARKS

FORM CMS-179 (07/92

Instructions on Back

KANSAS MEDICAID STATE PLAN Attachment 4.19-A Page 4 Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care 1.0000 continued z. "Readmission" means the subsequent admission of a recipient as an inpatient into a hospital within 15 days of discharge as an inpatient from the same or another hospital participating in the DRG reimbursement system. aa. "Recalibration" means the adjustment of all DRG weights to reflect changes in relative resource use associated with all existing DRG categories and/or the creation or elimination of DRG categories. bb. "Standard diagnosis related group DRG) amount" means the amount computed by multiplying the group reimbursement rate for the general hospital by the diagnosis related group weight. cc. State-operated hospital’ means an establishment operated by the State of Kansas with an organized medical staff of physicians, with permanent facilities that include inpatient beds, with medical services, including physician services and continuous registered professional nursing services for not less than 24 hours of every day, and which provides diagnosis and treatment for nonrelated patients. dd. "Stay as an inpatient in a general hospital" means the period of time spent in a general hospital from admission to discharge. ee. "Transfer" means the movement of an individual receiving hospital inpatient services from one hospital to another hospital for additional related inpatient care after admission to the previous hospital or hospitals. ff. "Transferring hospital" means the hospital which transfers a recipient to another hospital. There may be more than one transferring hospital for the same recipient until discharge. gg. “Critical Access Hospital”: Hospitals that are certified as critical access hospitals by Medicare. hh. “Border city children’s hospital” is defined as a comprehensive pediatric medical center with 200 beds or more, a level I pediatric trauma center, and at least a level IIIc intensive care nursery. The border city children’s hospital must be located in a Kansas border city. A Kansas border city means those communities outside of the state of Kansas, but within a 50-mile range of the state border. ii. “Hospital located in a frontier county”: A hospital located within a county where the population is fewer than 6.90 persons/sq. mi. The population density is taken from the 2010 Census. jj. “Hospital located in a rural county”: A hospital located within a county where the population is 6.0 – 19.9 person/sq. mi. The population density is taken from the 2010 Census. kk. “Hospital located in a densely-settled rural county”: A hospital located within a county where the population is 20.0 - 39.9 persons/sq. mi. The population density is taken from the 2010 Census. ll. “Large Hospital” is defined as any hospital in the State of Kansas with 500 or more available beds, as reported on the Medicare cost report, defined in Section 6.2000 B. mm. “State Institutional Alternatives (SIA)” are defined as facilities that provide inpatient psychiatric treatment and are authorized by the Kansas Department of Aging and Disability Services (KDADS) to serve as an alternative to placement in a state mental health institution. KS 20-0008 Approval Date Effective Date 4/3/2020 Supersedes KS 19-0012 6/25/20

KANSAS MEDICAID STATE PLAN Attachment 4.19-A Page 25d Methods and Standards for Establishing Payment Rates – Inpatient Hospital Care 4.0000 Reimbursement for Inpatient Services in State Operated Psychiatric Hospitals, State Institutional Alternatives (SIA) and Large Public Kansas Teaching Hospitals Reimbursement for inpatient services in state operated psychiatric hospitals shall be based upon the lesser of reasonable costs or customary charges for covered services rendered to eligible individuals. These costs shall include Medicare allowable costs, including but not limited to malpractice, capital, physician services, and education as allowed under federal law. Reimbursement for inpatient services in State Institutional Alternatives (SIA) shall be based upon the lesser of reasonable costs or customary charges for covered services rendered to eligible individuals. These costs shall include Medicare allowable costs, including but not limited to malpractice, capital, physician services, and education as allowed under federal law. Reimbursement for inpatient services in large public Kansas teaching hospitals is determined upon the Standard DRG payment plus an additional amount for outlier claims. Outlier payment for large public Kansas teaching hospitals are calculated consistent with the method described at 2.5100 and 2.5300. Effective May 17, 2019, and updated annually on a calendar year basis beginning January 1, 2020, the group payment rate for large public Kansas teaching hospitals calculated pursuant to sections 2.4500- 2.4520 will be calculated in the following manner: 1. FFS DRG Pricing: a. The most recent two historical years of FFS utilization will be priced at the current effective DRG schedule to align with the year that the Academic Base Rate will be effective. b. This uses the KU Peer Group Rate prior to the adjustment for the Academic Base Rate and includes both the projected base DRG payment and outlier payments. 2. Encounter DRG Pricing: a. The most recent two historical years of encounter utilization at the current effective DRG schedule to align with the year that the Academic base rate will be effective. b. This uses the KU Peer Group Rate prior to the adjustment for the Academic Base Rate and includes both the projected base DRG payment and outlier payments. 3. Encounter percent of billed pricing: a. The most recent historical years of Encounter utilization is priced at the effective percent of billed schedule for the following year that the Academic Base Rate will be effective. b. The billed charges are trended from the historical period to the current calendar year effective period based on KU’s historic charge master increases. 4. Upper Payment Limit (UPL): a. KU provided historic UPL information for the prior two historical years. b. Fiscal year was used as a benchmark due to KU UPL reporting period. 5. Academic Base Rate Adjustment: a. The KU Peer Group rate will be increased through an iterative process in such a manner the following conditions are met: i. The encounter DRG pricing with the updated KU Peer Group will be less than the Encounter percent of billed pricing; and ii. The FFS DRG Pricing with the updated KU Peer Group will be less than the historic UPL levels. b. Once the conditions are met, the updated KU Peer Group is finalized as the KU Academic Base Rate. KS 20-0008 Approval Date

Effective Date 4/3/2020 Supersedes KS 19-0008 6/25/20

Table of Contents State/Territory Name: Kansas

State Plan Amendment (SPA) #: 20-0011 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 Financial Management Group Sarah Fertig, State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220 RE: Kansas SPA 20-0011 Dear Ms. Fertig: We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 20-0011. This amendment adds "unit” to “transfer” definition and “wing” is changed to “unit” in section 2.5400. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We have found that the proposed reimbursement methodology complies with applicable requirements and therefore have approved them with an effective date of July 1, 2020. W e are enclosing the CMS-179 and the amended approved plan pages. If you have any questions, please contact Fredrick Sebree at Fredrick.sebree@cms.hhs.gov. Sincerely, Rory Howe Acting Director For September 20, 2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED ‘CENTERS FOR MEDICARE & MEDICAID SER VICES OMB No 0938-0193 1, TRANSMITTAL NUMBER: 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF KS 20-0011 Kansas

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

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

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

4, PROPOSED EFFECTIVE DATE July 1, 2020

5. TYPE OF PLAN MATERIAL (Check One)

(NEW STATE PLAN

CU AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION

7. FEDERAL BUDGET IMPACT

42 CFR 447 Subpart C a. FFY 2020 $0 b. FFY 2021 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (Jf Applicable)

Attachment 4.19-A, Page 4 Attachment 4.19-A, Page 24

Attachment 4.19-A, Page 4 Attachment 4.19-A, Page 24

10. SUBJECT OF AMENDMENT

The word “unit” is added to ee, “Transfer” definition, Section 1.0000 — Definitions. The word “wing” is changed to “unit” in Section 2.5400

— Payment for Transfers.

11. GOVERNOR’S REVIEW (Check One) (J GOVERNOR’S OFFICE REPORTED NO COMMENT

kx] OTHER, AS SPECIFIED:

(J COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Sarah Fertig is the (JNO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL ‘ Governor's Designee 12. ENCY OFFICIAL 16. RETURN TO Sarah Fertig, State Medicaid Director

* Sarah Fertig

14, TITLE State Medicaid Director

15. DATE SUBMITTED July 14, 2020

KDHE, Division of Health Care Finance Landon State Office Building

900 SW Jackson, Room 900-N

Topeka, KS 66612-1220

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED July 14, 2020

18. DATE APPROVED 9/20/20

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL

20.

July, 1, 2020 For 21. TYPED NAME 22. Rory Howe Acting Director, FMG 23. REMARKS FORM CMS 179 (07/92 Instructions on Back

KANSAS MEDICAID STATE PLAN Attachment 4.19-A Page 4 Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care 1.0000 continued z. "Readmission" means the subsequent admission of a recipient as an inpatient into a hospital within 15 days of discharge as an inpatient from the same or another hospital participating in the DRG reimbursement system. aa. "Recalibration" means the adjustment of all DRG weights to reflect changes in relative resource use associated with all existing DRG categories and/or the creation or elimination of DRG categories. bb. "Standard diagnosis related group DRG) amount" means the amount computed by multiplying the group reimbursement rate for the general hospital by the diagnosis related group weight. cc. State-operated hospital’ means an establishment operated by the State of Kansas with an organized medical staff of physicians, with permanent facilities that include inpatient beds, with medical services, including physician services and continuous registered professional nursing services for not less than 24 hours of every day, and which provides diagnosis and treatment for nonrelated patients. dd. "Stay as an inpatient in a general hospital" means the period of time spent in a general hospital from admission to discharge. ee. "Transfer" means the movement of an individual receiving hospital inpatient services from one hospital to another hospital, or different units within the same hospital, for additional related inpatient care after admission to the previous hospital, hospitals, or hospital units. ff. "Transferring hospital" means the hospital which transfers a recipient to another hospital. There may be more than one transferring hospital for the same recipient until discharge. gg. “Critical Access Hospital”: Hospitals that are certified as critical access hospitals by Medicare. hh. “Border city children’s hospital” is defined as a comprehensive pediatric medical center with 200 beds or more, a level I pediatric trauma center, and at least a level IIIc intensive care nursery. The border city children’s hospital must be located in a Kansas border city. A Kansas border city means those communities outside of the state of Kansas, but within a 50-mile range of the state border. ii. “Hospital located in a frontier county”: A hospital located within a county where the population is fewer than 6.90 persons/sq. mi. The population density is taken from the 2010 Census. jj. “Hospital located in a rural county”: A hospital located within a county where the population is 6.0 – 19.9 person/sq. mi. The population density is taken from the 2010 Census. kk. “Hospital located in a densely-settled rural county”: A hospital located within a county where the population is 20.0 - 39.9 persons/sq. mi. The population density is taken from the 2010 Census. ll. “Large Hospital” is defined as any hospital in the State of Kansas with 500 or more available beds, as reported on the Medicare cost report, defined in Section 6.2000 B. mm. “State Institutional Alternatives (SIA)” are defined as facilities that provide inpatient psychiatric treatment and are authorized by the Kansas Department of Aging and Disability Services (KDADS) to serve as an alternative to placement in a state mental health institution. KS 20-0011 Approval Date Effective Date 7/1/2020 Supersedes KS 20-0008 9/20/20

KANSAS MEDICAID STATE PLAN Attachment 4.19-A Page 24 Methods and Standards for Establishing Payment Rates – Inpatient Hospital Care Section 2.5320 continued Total Claim Payment = Standard DRG Payment + Outlier Payment = $11,995 + $2,354 = $14,349 2.5330 Simultaneous Cost and Day Outlier Payment If a covered general hospital inpatient stay is determined to be both a cost outlier and a day outlier, the reimbursement will be the greater of the amounts computed for cost outlier and day outlier. Example of Payment for Simultaneous Cost and Day Outlier: Data Total Claim Payment for Cost Outlier…$14,308 (subsection 2.5310) Total Claim Payment for Day Outlier…. $14,349 (subsection 2.5320) Analysis The higher of the two amounts, $14,349, will be the reimbursement amount for the claim which meets both cost outlier and day outlier criteria. 2.5340 Pay No More Than Charges After the determination of the payment, including any applicable outliers, hospitals shall be paid the lesser of the Medicaid allowed amount and their allowed charges. Allowed charges are determined based upon which revenue codes are allowed as covered services. 2.5400 Payment for Transfers When a recipient is transferred during a covered general hospital inpatient stay from one hospital to another hospital, or to a psychiatric or rehabilitation unit of the same hospital, the reimbursement to all hospitals involved in the transfer(s) will be computed as follows. 2.5410 Transferring Hospital(s) The reimbursement to each transferring general hospital shall be the DRG daily rate for each covered day of stay. Total payment to each transferring hospital shall be no greater than the standard DRG amount, except where the transferring hospital is eligible for outlier payments. 2.5420 Discharging Hospital The discharging general hospital shall be reimbursed the standard DRG amount. If the claim qualifies as an outlier, the discharging hospital shall be eligible for an outlier payment based solely on the length of stay at the discharging hospital. KS 20-0011 Approval Date Effective Date 07/01/2020 Supersedes TN # 18-009 9/20/20

Table of Contents State/Territory Name: Kansas State Plan Amendment (SPA) #: 20-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May , 2020 Adam Proffitt State Medicaid Director Division of Health Care Finance Kansas Department of Health and Environment Landon State Office Building 900 SW Jackson Street, Suite 900 N Topeka, KS 66612-1220 Re: Kansas State Plan Amendment (SPA) 20-0012 Dear Mr. Proffitt: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0012. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and

exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID-19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. 7KH 6WDWH RI .DQVDV UHTXHVWHG D ZDLYHU RI SXEOLF QRWLFH UHTXLUHPHQWV DSSOLFDEOH WR WKH 63$ VXEPLVVLRQ SURFHVV Pursuant to section 1135(b)(1)(C) of the Act, CMS is also waiving public notice requirements applicable to the state plan amendment (SPA) submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request for flexibility to waive these notice requirements otherwise applicable to SPA submissions. 7KH VWDWH RI .DQVDV DOVR UHTXHVWHG D ZDLYHU WR PRGLI\ WKH WULEDO FRQVXOWDWLRQ WLPHOLQH DSSOLFDEOH WR WKLV 63$ VXEPLVVLRQ SURFHVV Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA GRHV not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Kansas’ Medicaid SPA Transmittal Number 20-0012 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

Please contact Michala Walker at 816-426-6503 or by email at michala.walker@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Kansas and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.11 08:46:24 -04'00'

DEPARTMENT OF HEALTH ANDHUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 4. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF KS 20-0012 STATE PLAN MATERIAL eal

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL : SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES March 1, 2020 5. TYPE OF PLAN MATERIAL (Check One) CO NEW STATE PLAN LJ AMENDMENT TO BE CONSIDERED AS NEW PLAN OO X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a FFY 2020 $10,519 Section 1902 of the SSA b. FFY 2021 $18,176 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Section 7.4 OR ATTACHMENT (/fApplicable)

10. SUBJECT OF AMENDMENT

Disaster Relief SPA

11. GOVERNOR'S REVIEW (Check One)

MB GOVERNOR'S OFFICE REPORTED NO COMMENT CO OTHER, AS SPECIFIED CJ COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

1 FICIAL 16. RETURN TO 13. PED NAME Adam Proffitt 14. TITLE Medicaid Director FOR REGIONAL OFFICE USE ONLY 17, DATE RECEIVEDX 18. DATE APPROVED April 8, 2020 May 11, 2020 PLAN APPROVED - ONE COPY ATTACHED 19, EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL Anne M. Costello 2igtaty signed by Annem. March oe 2020 Ss Date: 202000511 0647.32 0400 21. TYPED NAME : 22. TITLE Anne Marie Costello Deputy Director, CMCS

23. REMARKS

Pen and Ink change made by CMS to Box 8 as authorized by Kansas on May 8, 2020

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

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ĂƐƚĞƌŶ ^ƚĂŶĚĂƌĚ dŝŵĞ ŽŶ DĂƌĐŚ ϭϱ͕ ϮϬϮϬ͕ ǁŝƚŚ Ă ƌĞƚƌŽĂĐƚŝǀĞ ĞĨĨĞĐƚŝǀĞ ĚĂƚĞ ŽĨ DĂƌĐŚ ϭ͕ ϮϬϮϬ͘ dŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ǁŝůů ƚĞƌŵŝŶĂƚĞ͕ ĂŶĚ ǁĂŝǀĞƌƐ ǁŝůů ŶŽ ůŽŶŐĞƌ ďĞ ĂǀĂŝůĂďůĞ͕ ƵƉŽŶ ƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ŝŶĐůƵĚŝŶŐ ĂŶLJ ĞdžƚĞŶƐŝŽŶƐ͘ dŚĞ ^ƚĂƚĞ DĞĚŝĐĂŝĚ ĂŐĞŶĐLJ ;ĂŐĞŶĐLJͿ ƐĞĞŬƐ ƚŽ ŝŵƉůĞŵĞŶƚ ƚŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͕ ǁŚŝĐŚ ĂƌĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ƚŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ŽƚŚĞƌǁŝƐĞ ĂƉƉůŝĞĚ ƵŶĚĞƌ ƚŚĞ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĚƵƌŝŶŐ ƚŚĞ ƉĞƌŝŽĚ ŽĨ ƚŚĞ WƌĞƐŝĚĞŶƚŝĂů ĂŶĚ ^ĞĐƌĞƚĂƌŝĂů ĞŵĞƌŐĞŶĐLJ ĚĞĐůĂƌĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ;Žƌ ĂŶLJ ƌĞŶĞǁĂůƐ ƚŚĞƌĞŽĨͿ͕ Žƌ ĨŽƌ ĂŶLJ ƐŚŽƌƚĞƌ ƉĞƌŝŽĚ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ ĞƐĐƌŝďĞ ƐŚŽƌƚĞƌ ƉĞƌŝŽĚ ŚĞƌĞ͘ EKd ͗ ^ƚĂƚĞƐ ŵĂLJ ŶŽƚ ĞůĞĐƚ Ă ƉĞƌŝŽĚ ůŽŶŐĞƌ ƚŚĂŶ ƚŚĞ WƌĞƐŝĚĞŶƚŝĂů Žƌ ^ĞĐƌĞƚĂƌŝĂů ĞŵĞƌŐĞŶĐLJ ĚĞĐůĂƌĂƚŝŽŶ ;Žƌ ĂŶLJ ƌĞŶĞǁĂů ƚŚĞƌĞŽĨͿ͘ ^ƚĂƚĞƐ ŵĂLJ ŶŽƚ ƉƌŽƉŽƐĞ ĐŚĂŶŐĞƐ ŽŶ ƚŚŝƐ ƚĞŵƉůĂƚĞ ƚŚĂƚ ƌĞƐƚƌŝĐƚ Žƌ ůŝŵŝƚ ƉĂLJŵĞŶƚ͕ ƐĞƌǀŝĐĞƐ͕ Žƌ ĞůŝŐŝďŝůŝƚLJ͕ Žƌ ŽƚŚĞƌǁŝƐĞ ďƵƌĚĞŶ ďĞŶĞĨŝĐŝĂƌŝĞƐ ĂŶĚ ƉƌŽǀŝĚĞƌƐ͘ ZĞƋƵĞƐƚ ĨŽƌ tĂŝǀĞƌƐ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ͺͺyͺͺͺ dŚĞ ĂŐĞŶĐLJ ƐĞĞŬƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƵŶĚĞƌ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ;ϭͿ;Ϳ ĂŶĚͬŽƌ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ;ϱͿ ŽĨ ƚŚĞ Đƚ͗ Ă͘ ͺͺͺyͺͺ ^W ƐƵďŵŝƐƐŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚ ƚŽ ƐƵďŵŝƚ ƚŚĞ ^W ďLJ DĂƌĐŚ ϯϭ͕ ϮϬϮϬ͕ ƚŽ ŽďƚĂŝŶ Ă ^W ĞĨĨĞĐƚŝǀĞ ĚĂƚĞ ĚƵƌŝŶŐ ƚŚĞ ĨŝƌƐƚ ĐĂůĞŶĚĂƌ ƋƵĂƌƚĞƌ ŽĨ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ϰϮ &Z ϰϯϬ͘ϮϬ͘ ď͘ ͺͺyͺͺͺ WƵďůŝĐ ŶŽƚŝĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ǁĂŝǀĞƌ ŽĨ ƉƵďůŝĐ ŶŽƚŝĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ƚŚĂƚ ǁŽƵůĚ ŽƚŚĞƌǁŝƐĞ ďĞ ĂƉƉůŝĐĂďůĞ ƚŽ ƚŚŝƐ ^W ƐƵďŵŝƐƐŝŽŶ͘ dŚĞƐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚŽƐĞ ƐƉĞĐŝĨŝĞĚ ŝŶ ϰϮ &Z ϰϰϬ͘ϯϴϲ ;ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐͿ͕ ϰϮ &Z ϰϰϳ͘ϱϳ;ĐͿ ;ƉƌĞŵŝƵŵƐ ĂŶĚ ĐŽƐƚ ƐŚĂƌŝŶŐͿ͕ ĂŶĚ ϰϮ &Z ϰϰϳ͘ϮϬϱ ;ƉƵďůŝĐ ŶŽƚŝĐĞ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ƐƚĂƚĞǁŝĚĞ ŵĞƚŚŽĚƐ ĂŶĚ ƐƚĂŶĚĂƌĚƐ ĨŽƌ ƐĞƚƚŝŶŐ ƉĂLJŵĞŶƚ ƌĂƚĞƐͿ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ Đ͘ y dƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŝŵĞůŝŶĞƐ ƐƉĞĐŝĨŝĞĚ ŝŶ ΀<ĂŶƐĂƐ΁DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŵŽĚŝĨŝĐĂƚŝŽŶƐ ƚŽ ƚŚĞ ƚŝŵĞůŝŶĞ͘ dŚĞ ^ƚĂƚĞ ǁŝůů ƌĞĚƵĐĞ ƚŚĞ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŽ njĞƌŽ ĚĂLJƐ ďĞĨŽƌĞ ƐƵďŵŝƐƐŝŽŶ ƚŽ D^͘ dŚĞ ^ƚĂƚĞ ǁŝůů ŶŽƚŝĨLJ ƚŚĞ ƚƌŝďĞƐ ƵƉŽŶ ƐƵďŵŝƐƐŝŽŶ ĂŶĚ ƌĞĐĞŝǀĞ ĐŽŵŵĞŶƚƐ ĨŽƌ ϭϰ ĚĂLJƐ ĂƐ ŶŽƚĞĚ ŝŶ ƚŚĞ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͘ ^ĞĐƚŝŽŶ  ʹ ůŝŐŝďŝůŝƚLJ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ Žƌ ϭϵϬϮ;ĂͿ;ϭϬͿ;ĐͿ ŽĨ ƚŚĞ Đƚ͘ dŚŝƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚĞ ŶĞǁ ŽƉƚŝŽŶĂů ŐƌŽƵƉ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƌŽǀŝĚŝŶŐ ĐŽǀĞƌĂŐĞ ĨŽƌ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ /ŶĐůƵĚĞ ŶĂŵĞ ŽĨ ƚŚĞ ŽƉƚŝŽŶĂů ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉ ĂŶĚ ĂƉƉůŝĐĂďůĞ ŝŶĐŽŵĞ ĂŶĚ ƌĞƐŽƵƌĐĞ ƐƚĂŶĚĂƌĚ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉŽƉƵůĂƚŝŽŶƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘Ϯϭϴ͗ Ă͘ ͺͺͺͺͺ ůů ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͲŽƌͲ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ ŽĨ ƚŚĞ Đƚ͗ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƉƉůŝĞƐ ůĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ďĂƐĞĚ ŽŶ ŵŽĚŝĨŝĞĚ ĂĚũƵƐƚĞĚ ŐƌŽƐƐ ŝŶĐŽŵĞ ;D'/Ϳ ĂƐ ĨŽůůŽǁƐ͘ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ŝŶĐŽŵĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ƌĞƐŽƵƌĐĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶƐŝĚĞƌƐ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĞǀĂĐƵĂƚĞĚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ůĞĂǀĞ ƚŚĞ ƐƚĂƚĞ ĨŽƌ ŵĞĚŝĐĂů ƌĞĂƐŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ Žƌ ǁŚŽ ĂƌĞ ŽƚŚĞƌǁŝƐĞ ĂďƐĞŶƚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĂŶĚ ǁŚŽ ŝŶƚĞŶĚ ƚŽ ƌĞƚƵƌŶ ƚŽ ƚŚĞ ƐƚĂƚĞ͕ ƚŽ ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ƌĞƐŝĚĞŶƚƐ ŽĨ ƚŚĞ ƐƚĂƚĞ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϰϬϯ;ũͿ;ϯͿ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ DĞĚŝĐĂŝĚ ĐŽǀĞƌĂŐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŝŶĚŝǀŝĚƵĂůƐ ůŝǀŝŶŐ ŝŶ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ĂƌĞ ŶŽŶͲƌĞƐŝĚĞŶƚƐ͗ ϲ͘ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ ĨŽƌ ĂŶ ĞdžƚĞŶƐŝŽŶ ŽĨ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĨŽƌ ŶŽŶͲ ĐŝƚŝnjĞŶƐ ĚĞĐůĂƌŝŶŐ ƚŽ ďĞ ŝŶ Ă ƐĂƚŝƐĨĂĐƚŽƌLJ ŝŵŵŝŐƌĂƚŝŽŶ ƐƚĂƚƵƐ͕ ŝĨ ƚŚĞ ŶŽŶͲĐŝƚŝnjĞŶ ŝƐ ŵĂŬŝŶŐ Ă ŐŽŽĚ ĨĂŝƚŚ ĞĨĨŽƌƚ ƚŽ ƌĞƐŽůǀĞ ĂŶLJ ŝŶĐŽŶƐŝƐƚĞŶĐĞƐ Žƌ ŽďƚĂŝŶ ĂŶLJ ŶĞĐĞƐƐĂƌLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ Žƌ ƚŚĞ ĂŐĞŶĐLJ ŝƐ ƵŶĂďůĞ ƚŽ ĐŽŵƉůĞƚĞ ƚŚĞ ǀĞƌŝĨŝĐĂƚŝŽŶ ƉƌŽĐĞƐƐ ǁŝƚŚŝŶ ƚŚĞ ϵϬͲĚĂLJ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ^ĞĐƚŝŽŶ  ʹ ŶƌŽůůŵĞŶƚ ϭ͘ ͺͺyͺͺͺ dŚĞ ĂŐĞŶĐLJ ĞůĞĐƚƐ ƚŽ ĂůůŽǁ ŚŽƐƉŝƚĂůƐ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚĚŝƚŝŽŶĂů ƐƚĂƚĞ ƉůĂŶ ƉŽƉƵůĂƚŝŽŶƐ͕ Žƌ ĨŽƌ ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ĂŶ ĂƉƉƌŽǀĞĚ ƐĞĐƚŝŽŶ ϭϭϭϱ ĚĞŵŽŶƐƚƌĂƚŝŽŶ͕ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϰϳͿ;Ϳ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϭϭϭϬ͕ ƉƌŽǀŝĚĞĚ ƚŚĂƚ ƚŚĞ ĂŐĞŶĐLJ ŚĂƐ ĚĞƚĞƌŵŝŶĞĚ ƚŚĂƚ ƚŚĞ ŚŽƐƉŝƚĂů ŝƐ ĐĂƉĂďůĞ ŽĨ ŵĂŬŝŶŐ ƐƵĐŚ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐͬƉŽƉƵůĂƚŝŽŶƐ ĂŶĚ ĂŶLJ ĐŚĂŶŐĞƐ ƚŽ ƌĞĂƐŽŶĂďůĞ ůŝŵŝƚĂƚŝŽŶƐ͕ ƉĞƌĨŽƌŵĂŶĐĞ ƐƚĂŶĚĂƌĚƐ Žƌ ŽƚŚĞƌ ĨĂĐƚŽƌƐ͘ dŚĞ ƐƚĂƚĞ ǁŝůů ĂůůŽǁ ƚǁŽ W ƉĞƌŝŽĚƐ ĚƵƌŝŶŐ Ă ƚǁĞůǀĞͲŵŽŶƚŚ ƉĞƌŝŽĚ ĚƵƌŝŶŐ ƚŚĞ WƵďůŝĐ ,ĞĂůƚŚ

ŵĞƌŐĞŶĐLJ ;W, Ϳ ;ŝŶĐƌĞĂƐĞ ĨƌŽŵ ŽŶĞ ĚƵƌŝŶŐ Ă ϭϮͲŵŽŶƚŚ ƉĞƌŝŽĚ ŝŶ ^W ϭϰͲϬϬϬϴͿ͘ dŚĞ W ƉĞƌŝŽĚ ďĞŐŝŶƐ ƚŚĞ ĨŝƌƐƚ ĚĂLJ ŽĨ ƚŚĞ ŵŽŶƚŚ ŽĨ ƚŚĞ ŝŶŝƚŝĂů W ƉĞƌŝŽĚ͘ dŚĞ ƐƚĂƚĞ ǁŝůů ůŝŵŝƚ ƚŚĞ ŶƵŵďĞƌ ŽĨ W

ƉĞƌŝŽĚƐ ĨŽƌ Wt ĨƌŽŵ ŽŶĞ ƉĞƌ ƉƌĞŐŶĂŶĐLJ ;ŝŶ <^ ϭϰͲϬϬϬϴͿ ƚŽ ƚǁŽ ƉĞƌ ƉƌĞŐŶĂŶĐLJ͘ Ϯ͘ ͺͺyͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ŝƚƐĞůĨ ĂƐ Ă ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚLJ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĂŶLJ ůŝŵŝƚĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ƉŽƉƵůĂƚŝŽŶƐ ŝŶĐůƵĚĞĚ Žƌ ƚŚĞ ŶƵŵďĞƌ ŽĨ ĂůůŽǁĂďůĞ W

ƉĞƌŝŽĚƐ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ dŚĞ ƐƚĂƚĞ ǁŝůů ĂůůŽǁ ƚǁŽ W ƉĞƌŝŽĚƐ ĚƵƌŝŶŐ Ă ƚǁĞůǀĞͲŵŽŶƚŚ ƉĞƌŝŽĚ ĚƵƌŝŶŐ ƚŚĞ WƵďůŝĐ ,ĞĂůƚŚ

ŵĞƌŐĞŶĐLJ ;W, Ϳ͘ dŚĞ W ƉĞƌŝŽĚ ďĞŐŝŶƐ ƚŚĞ ĨŝƌƐƚ ĚĂLJ ŽĨ ƚŚĞ ŵŽŶƚŚ ŽĨ ƚŚĞ ŝŶŝƚŝĂů W ƉĞƌŝŽĚ͘ dŚĞ ƐƚĂƚĞ ǁŝůů ƚŚĞ ůŝŵŝƚ ƚŚĞ ŶƵŵďĞƌ ŽĨ W ƉĞƌŝŽĚƐ ĨŽƌ Wt ƚŽ ƚǁŽ ƉĞƌ ƉƌĞŐŶĂŶĐLJ͘ Š‡ •–ƒ–‡ ™‹ŽŽ Ž‹‹– –Š‡ —„‡” ‘ˆ  ’‡”‹‘†• ‹†‹˜‹†—ƒŽ• ƒ› Šƒ˜‡ –‘ ‘ ‘”‡ –Šƒ –™‘ ™‹–Š‹ ƒ ͳʹǦ‘–Š ’‡”‹‘†ǡ •–ƒ”–‹‰ ™‹–Š –Š‡ ˆ‹”•– †ƒ› ‘ˆ –Š‡ ‘–Š ‘ˆ –Š‡ ‹‹–‹ƒŽ  ’‡”‹‘†Ǥ Š‡ ’‘’—Žƒ–‹‘•

‘˜‡”‡† ƒ”‡ WĂƌĞŶƚ Žƌ ĂƌĞƚĂŬĞƌ ZĞůĂƚŝǀĞƐ ĂŶĚ &ŽƌŵĞƌ &ŽƐƚĞƌ ĂƌĞ͕ WƌĞŐŶĂŶƚ tŽŵĞŶ͕ ĂŶĚ ŚŝůĚƌĞŶ͘ ϯ͘ ͺͺyͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĞŶƚŝƚŝĞƐ ĂƐ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ Žƌ ĂĚĚƐ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ /ŶĚŝĐĂƚĞ ŝĨ ĂŶLJ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ ĂƌĞ ƉĞƌŵŝƚƚĞĚ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽŶůLJ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ Žƌ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂŶĚ ĂŶLJ ůŝŵŝƚĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ Žƌ ŶƵŵďĞƌ ŽĨ ĂůůŽǁĂďůĞ W ƉĞƌŝŽĚƐ͘ o dŚĞ ƐƚĂƚĞ ĂůůŽǁƐ ƚŚĞ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ůŝƐƚĞĚ ŝŶ W ^W <^ ϭϰͲϬϬϬϮ ƚŽ ŵĂŬĞ W

ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ WĂƌĞŶƚ Žƌ ĂƌĞƚĂŬĞƌ ZĞůĂƚŝǀĞƐ ĂŶĚ &ŽƌŵĞƌ &ŽƐƚĞƌ ĂƌĞ͕ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ WƌĞŐŶĂŶƚ tŽŵĞŶ ĂŶĚ ŚŝůĚƌĞŶ͘ o dŚĞ ƐƚĂƚĞ ǁŝůů ŝŶĐƌĞĂƐĞ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ŶƵŵďĞƌ ŽĨ W ƉĞƌŝŽĚƐ ŝŶĚŝǀŝĚƵĂůƐ ŵĂLJ ŚĂǀĞ ƚŽ ŶŽ ŵŽƌĞ ƚŚĂŶ ƚǁŽ ;ĨƌŽŵ ŽŶĞ ŝŶ <^ ϭϰͲϬϬϮͿ ǁŝƚŚŝŶ Ă ϭϮͲ ŵŽŶƚŚ ƉĞƌŝŽĚ͕ ƐƚĂƌƚŝŶŐ ǁŝƚŚ ƚŚĞ ĨŝƌƐƚ ĚĂLJ ŽĨ ƚŚĞ ŵŽŶƚŚ ŽĨ ƚŚĞ ŝŶŝƚŝĂů W ƉĞƌŝŽĚ͘ o <^ ǁŝůů ŝŶĐƌĞĂƐĞ ƚŚĞ ŶƵŵďĞƌ ŽĨ W ƉĞƌŝŽĚƐ ĨŽƌ Wt ĨƌŽŵ ŽŶĞ ƉĞƌ ƉƌĞŐŶĂŶĐLJ ;ŝŶ <^ ϭϰͲϬϬϬϮͿ ƚŽ ƚǁŽ ƉĞƌ ƉƌĞŐŶĂŶĐLJ͘ ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚŽƉƚƐ Ă ƚŽƚĂů ŽĨ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ĐŽŶƚŝŶƵŽƵƐ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ĐŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ĞŶƚĞƌ ĂŐĞ ͺͺͺͺͺ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ĂŐĞ ϭϵͿ ƌĞŐĂƌĚůĞƐƐ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĞͿ;ϭϮͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϵϮϲ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶĚƵĐƚƐ ƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽĨ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ D'/Ͳ ďĂƐĞĚ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϲϬϯ;ũͿ ŽŶĐĞ ĞǀĞƌLJ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ϰϮ &Z ϰϯϱ͘ϵϭϲ;ďͿ͘ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ƚŽ ƐƵƉƉŽƌƚ ĞŶƌŽůůŵĞŶƚ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ Žƌ ĨŽƌ ĂĨĨĞĐƚĞĚ ŝŶĚŝǀŝĚƵĂůƐ ;Ă ĐŽƉLJ ŽĨ ƚŚĞ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ŚĂƐ ďĞĞŶ ƐƵďŵŝƚƚĞĚ ƚŽ D^Ϳ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ ĂƉƉůŝĐĂƚŝŽŶ͘ ď͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ͘ Đ͘ ͺͺͺͺͺ dŚĞ ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ Žƌ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ ŝƐ ŵĂĚĞ ĂǀĂŝůĂďůĞ ĨŽƌ ƵƐĞ ŝŶ ĐĂůůͲĐĞŶƚĞƌƐ Žƌ ŽƚŚĞƌ ƚĞůĞƉŚŽŶĞ ĂƉƉůŝĐĂƚŝŽŶƐ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ ^ĞĐƚŝŽŶ  ʹ WƌĞŵŝƵŵƐ ĂŶĚ ŽƐƚ ^ŚĂƌŝŶŐ ϭ͘ y ͺ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ ĂŶĚ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĂƐ ĨŽůůŽǁƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ǁŚĞƚŚĞƌ ƚŚĞ ƐƚĂƚĞ ƐƵƐƉĞŶĚƐ Ăůů ĐŽƐƚ ƐŚĂƌŝŶŐ Žƌ ƐƵƐƉĞŶĚƐ ŽŶůLJ ƐƉĞĐŝĨŝĞĚ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ Žƌ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ Žƌ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ϰϮ &Z ϰϰϳ͘ϱϮ;ĚͿ Žƌ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ŝŶĐŽŵĞ ůĞǀĞůƐ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ϰϮ &Z ϰϰϳ͘ϱϮ;ŐͿ͘ dŚĞ ƐƚĂƚĞ ǁĂŝǀĞƐ ĐŽƐƚͲƐŚĂƌŝŶŐ ĨŽƌ ƚĞƐƚŝŶŐ ƐĞƌǀŝĐĞƐ ;ŝŶĐůƵĚŝŶŐ ŝŶ ǀŝƚƌŽ ĚŝĂŐŶŽƐƚŝĐ ƉƌŽĚƵĐƚƐͿ͕ ƚĞƐƚŝŶŐ ƌĞůĂƚĞĚ ƐĞƌǀŝĐĞƐ ĂŶĚ ƚƌĞĂƚŵĞŶƚƐ ĨŽƌ Ks/Ͳϭϵ͕ ŝŶĐůƵĚŝŶŐ ǀĂĐĐŝŶĞƐ͕ ƐƉĞĐŝĂůŝnjĞĚ ĞƋƵŝƉŵĞŶƚ ĂŶĚ ƚŚĞƌĂƉŝĞƐ ĨŽƌ ĂŶLJ ƋƵĂƌƚĞƌ ŝŶ ǁŚŝĐŚ ƚŚĞ ƚĞŵƉŽƌĂƌLJ ŝŶĐƌĞĂƐĞĚ &DW ŝƐ ĐůĂŝŵĞĚ͘ Ϯ͘ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĞŶƌŽůůŵĞŶƚ ĨĞĞƐ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ͗ Ă͘ ͺͺͺͺͺ ůů ďĞŶĞĨŝĐŝĂƌŝĞƐ ď͘ dŚĞ ĨŽůůŽǁŝŶŐ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ͗ WůĞĂƐĞ ůŝƐƚ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ƉŽƉƵůĂƚŝŽŶƐ͘ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂůůŽǁƐ ǁĂŝǀĞƌ ŽĨ ƉĂLJŵĞŶƚ ŽĨ ƚŚĞ ĞŶƌŽůůŵĞŶƚ ĨĞĞ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ WůĞĂƐĞ ƐƉĞĐŝĨLJ ƚŚĞ ƐƚĂŶĚĂƌĚ;ƐͿ ĂŶĚͬŽƌ ĐƌŝƚĞƌŝĂ ƚŚĂƚ ƚŚĞ ƐƚĂƚĞ ǁŝůů ƵƐĞ ƚŽ ĚĞƚĞƌŵŝŶĞ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ ^ĞĐƚŝŽŶ  ʹ ĞŶĞĨŝƚƐ ĞŶĞĨŝƚƐ͗ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚĚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ŝŶ ŝƚƐ ƐƚĂƚĞ ƉůĂŶ ;ŝŶĐůƵĚĞ ƐĞƌǀŝĐĞ ĚĞƐĐƌŝƉƚŝŽŶƐ͕ ƉƌŽǀŝĚĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ůŝŵŝƚĂƚŝŽŶƐ ŽŶ ĂŵŽƵŶƚ͕ ĚƵƌĂƚŝŽŶ Žƌ ƐĐŽƉĞ ŽĨ ƚŚĞ ďĞŶĞĨŝƚͿ͗ Ϯ͘ ͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐƵƌƌĞŶƚůLJ ĐŽǀĞƌĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ ƉůĂŶ͗ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ŶĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ Žƌ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐŽŵƉůLJ ǁŝƚŚ Ăůů ĂƉƉůŝĐĂďůĞ ƐƚĂƚƵƚŽƌLJ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƐƚĂƚĞǁŝĚĞŶĞƐƐ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭͿ͕ ĐŽŵƉĂƌĂďŝůŝƚLJ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ͕ ĂŶĚ ĨƌĞĞ ĐŚŽŝĐĞ ŽĨ ƉƌŽǀŝĚĞƌ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϮϯͿ͘ ϰ͘ ͺͺͺͺͺ ƉƉůŝĐĂƚŝŽŶ ƚŽ ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐ ;WͿ͘ dŚĞ ƐƚĂƚĞ ĂĚŚĞƌĞƐ ƚŽ Ăůů W ƉƌŽǀŝƐŝŽŶƐ ŝŶ ϰϮ &Z WĂƌƚ ϰϰϬ͕ ^ƵďƉĂƌƚ ͘ dŚŝƐ ƐĞĐƚŝŽŶ ŽŶůLJ ĂƉƉůŝĞƐ ƚŽ ƐƚĂƚĞƐ ƚŚĂƚ ŚĂǀĞ ĂŶ ĂƉƉƌŽǀĞĚ W;ƐͿ͘ ƒǤ ̴̴̴̴̴ Š‡ ƒ‰‡ › ƒ••—”‡• –Šƒ– –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–• ™‹ŽŽ „‡ ƒ†‡ ƒ˜ƒ‹Žƒ„Ž‡ –‘ ‹†‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” •Ǥ „Ǥ ̴̴̴̴̴ †‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” • ™‹ŽŽ ‘– ”‡ ‡‹˜‡ –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–•ǡ ‘” ™‹ŽŽ ‘Ž› ”‡ ‡‹˜‡ –Š‡ ˆ‘ŽŽ‘™‹‰ •—„•‡–ǣ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ dĞůĞŚĞĂůƚŚ͗ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƚŝůŝnjĞƐ ƚĞůĞŚĞĂůƚŚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĂŶŶĞƌ͕ ǁŚŝĐŚ ŵĂLJ ďĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ͛Ɛ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ƌƵŐ ĞŶĞĨŝƚ͗ ϲ͘ ͺͺͺyͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ƚŚĞ ĚĂLJ ƐƵƉƉůLJ Žƌ ƋƵĂŶƚŝƚLJ ůŝŵŝƚ ĨŽƌ ĐŽǀĞƌĞĚ ŽƵƚƉĂƚŝĞŶƚ ĚƌƵŐƐ͘ dŚĞ ĂŐĞŶĐLJ ƐŚŽƵůĚ ŽŶůLJ ŵĂŬĞ ƚŚŝƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŝĨ ŝƚƐ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉĂŐĞƐ ŚĂǀĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ĂŵŽƵŶƚ ŽĨ ŵĞĚŝĐĂƚŝŽŶ ĚŝƐƉĞŶƐĞĚ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĐŚĂŶŐĞ ŝŶ ĚĂLJƐ Žƌ ƋƵĂŶƚŝƚŝĞƐ ƚŚĂƚ ĂƌĞ ĂůůŽǁĞĚ ĨŽƌ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ĂŶĚ ĨŽƌ ǁŚŝĐŚ ĚƌƵŐƐ͘ hƉ ƚŽ ϵϬͲĚĂLJƐ͛ ƐƵƉƉůLJ ŵĂLJ ďĞ ĂƉƉƌŽǀĞĚ ĨŽƌ ĚƌƵŐƐ ĐŽŶƐŝĚĞƌĞĚ ͞ŵĂŝŶƚĞŶĂŶĐĞ͟ ĚƌƵŐƐ͘ ϳ͘ ͺͺyͺͺͺ WƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĨŽƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝƐ ĞdžƉĂŶĚĞĚ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ͕ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ ϴ͘ ͺͺyͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĂLJŵĞŶƚ ĂĚũƵƐƚŵĞŶƚ ƚŽ ƚŚĞ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ǁŚĞŶ ĂĚĚŝƚŝŽŶĂů ĐŽƐƚƐ ĂƌĞ ŝŶĐƵƌƌĞĚ ďLJ ƚŚĞ ƉƌŽǀŝĚĞƌƐ ĨŽƌ ĚĞůŝǀĞƌLJ͘ ^ƚĂƚĞƐ ǁŝůů ŶĞĞĚ ƚŽ ƐƵƉƉůLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ƚŽ ũƵƐƚŝĨLJ ƚŚĞ ĂĚĚŝƚŝŽŶĂů ĨĞĞƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŵĂŶŶĞƌ ŝŶ ǁŚŝĐŚ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞƐ ĂƌĞ ĂĚũƵƐƚĞĚ Ŷ ŝŶĐƌĞĂƐĞ ŝŶ ƌĞŝŵďƵƌƐĞŵĞŶƚ ƐĞƌǀŝĐĞƐ ĨŽƌ ƉŚĂƌŵĂĐLJ ƐĞƌǀŝĐĞƐ ǁŝůů ďĞ ĐŽŵƉĞŶƐĂƚĞĚ ďLJ ŝŶĐƌĞĂƐŝŶŐ ƚŚĞ ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ďLJ ΨϬ͘ϱϬ ƉĞƌ ƉƌĞƐĐƌŝƉƚŝŽŶ͘ ϵ͘ ͺͺͺy dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞŝƌ ƉƵďůŝƐŚĞĚ WƌĞĨĞƌƌĞĚ ƌƵŐ >ŝƐƚ ŝĨ ĚƌƵŐ ƐŚŽƌƚĂŐĞƐ ŽĐĐƵƌ͘ dŚŝƐ ǁŽƵůĚ ŝŶĐůƵĚĞ ŽƉƚŝŽŶƐ ĨŽƌ ĐŽǀĞƌŝŶŐ Ă ďƌĂŶĚ ŶĂŵĞ ĚƌƵŐ ƉƌŽĚƵĐƚ ƚŚĂƚ ŝƐ Ă ŵƵůƚŝͲƐŽƵƌĐĞ ĚƌƵŐ ŝĨ Ă ŐĞŶĞƌŝĐ ĚƌƵŐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĂǀĂŝůĂďůĞ͘ ^ĞĐƚŝŽŶ ʹ WĂLJŵĞŶƚƐ KƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ͗ ϭ͘ ͺͺͺͺͺ EĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ  ĂƌĞ ƉĂŝĚ ƵƐŝŶŐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĞƚŚŽĚŽůŽŐLJ͗ ƒǤ ̴̴̴̴̴ —„Ž‹•Š‡† ˆ‡‡ • Š‡†—Ž‡• Ȃ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ „Ǥ ̴̴̴̴̴ –Š‡”ǣ ĞƐĐƌŝďĞ ŵĞƚŚŽĚŽůŽŐLJ ŚĞƌĞ͘ /ŶĐƌĞĂƐĞƐ ƚŽ ƐƚĂƚĞ ƉůĂŶ ƉĂLJŵĞŶƚ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ Ϯ͘ ͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŝŶĐƌĞĂƐĞƐ ƉĂLJŵĞŶƚ ƌĂƚĞƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ WůĞĂƐĞ ůŝƐƚ Ăůů ƚŚĂƚ ĂƉƉůLJ͘ Ă͘ ͺͺͺͺͺ WĂLJŵĞŶƚ ŝŶĐƌĞĂƐĞƐ ĂƌĞ ƚĂƌŐĞƚĞĚ ďĂƐĞĚ ŽŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐƌŝƚĞƌŝĂ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĐƌŝƚĞƌŝĂ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ ď͘ WĂLJŵĞŶƚƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ ƚŚƌŽƵŐŚ͗ ‹Ǥ ̴̴̴̴̴  •—’’Ž‡‡–ƒŽ ’ƒ›‡– ‘” ƒ††Ǧ‘ ™‹–Š‹ ƒ’’Ž‹ ƒ„Ž‡ —’’‡” ’ƒ›‡– Ž‹‹–•ǣ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ‹‹Ǥ ̴̴̴̴̴  ‹ ”‡ƒ•‡ –‘ ”ƒ–‡• ƒ• †‡• ”‹„‡† „‡Ž‘™Ǥ ZĂƚĞƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ͗ ͺͺͺͺ hŶŝĨŽƌŵůLJ ďLJ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌĐĞŶƚĂŐĞ͗ ͺͺͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ dŚƌŽƵŐŚ Ă ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ƉƵďůŝƐŚĞĚ ĨĞĞ ƐĐŚĞĚƵůĞƐ ʹ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ hƉ ƚŽ ƚŚĞ DĞĚŝĐĂƌĞ ƉĂLJŵĞŶƚƐ ĨŽƌ ĞƋƵŝǀĂůĞŶƚ ƐĞƌǀŝĐĞƐ͘ ͺͺͺͺͺ LJ ƚŚĞ ĨŽůůŽǁŝŶŐ ĨĂĐƚŽƌƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ WĂLJŵĞŶƚ ĨŽƌ ƐĞƌǀŝĐĞƐ ĚĞůŝǀĞƌĞĚ ǀŝĂ ƚĞůĞŚĞĂůƚŚ͗ ϯ͘ ͺͺͺͺͺ &Žƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ƐƚĂƚĞ ĂƵƚŚŽƌŝnjĞƐ ƉĂLJŵĞŶƚƐ ĨŽƌ ƚĞůĞŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŚĂƚ͗ ƒǤ ̴̴̴̴̴ ”‡ ‘– ‘–Š‡”™‹•‡ ’ƒ‹† —†‡” –Š‡ ‡†‹ ƒ‹† •–ƒ–‡ ’ŽƒǢ „Ǥ ̴̴̴̴̴ ‹ˆˆ‡” ˆ”‘ ’ƒ›‡–• ˆ‘” –Š‡ •ƒ‡ •‡”˜‹ ‡• ™Š‡ ’”‘˜‹†‡† ˆƒ ‡ –‘ ˆƒ ‡Ǣ

Ǥ ̴̴̴̴ ‹ˆˆ‡” ˆ”‘ —””‡– •–ƒ–‡ ’Žƒ ’”‘˜‹•‹‘• ‰‘˜‡”‹‰ ”‡‹„—”•‡‡– ˆ‘” –‡Ž‡Š‡ƒŽ–ŠǢ ĞƐĐƌŝďĞ ƚĞůĞŚĞĂůƚŚ ƉĂLJŵĞŶƚ ǀĂƌŝĂƚŝŽŶ͘ †Ǥ ̴̴̴̴̴  Ž—†‡ ’ƒ›‡– ˆ‘” ƒ ‹ŽŽƒ”› ‘•–• ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ †‡Ž‹˜‡”› ‘ˆ ‘˜‡”‡† •‡”˜‹ ‡• ˜‹ƒ –‡Ž‡Š‡ƒŽ–Šǡ ȋ‹ˆ ƒ’’Ž‹ ƒ„Ž‡Ȍǡ ƒ• ˆ‘ŽŽ‘™•ǣ ‹Ǥ ̴̴̴̴̴  ‹ŽŽƒ”› ‘•– ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ ‘”‹‰‹ƒ–‹‰ •‹–‡ ˆ‘” –‡Ž‡Š‡ƒŽ–Š ‹• ‹ ‘”’‘”ƒ–‡† ‹–‘ ˆ‡‡Ǧˆ‘”Ǧ•‡”˜‹ ‡ ”ƒ–‡•Ǥ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ ‹‹Ǥ ̴̴̴̴̴  ‹ŽŽƒ”› ‘•– ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ ‘”‹‰‹ƒ–‹‰ •‹–‡ ˆ‘” –‡Ž‡Š‡ƒŽ–Š ‹• •‡’ƒ”ƒ–‡Ž› ”‡‹„—”•‡† ƒ• ƒ ƒ†‹‹•–”ƒ–‹˜‡ ‘•– „› –Š‡ •–ƒ–‡ ™Š‡ ƒ ‡†‹ ƒ‹† •‡”˜‹ ‡ ‹• †‡Ž‹˜‡”‡†Ǥ KƚŚĞƌ͗ ϰ͘ ͺͺͺͺͺ KƚŚĞƌ ƉĂLJŵĞŶƚ ĐŚĂŶŐĞƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ^ĞĐƚŝŽŶ & ʹ WŽƐƚͲ ůŝŐŝďŝůŝƚLJ dƌĞĂƚŵĞŶƚ ŽĨ /ŶĐŽŵĞ ͳǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• –‘ ‘†‹ˆ› –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ˆ‘” ‹•–‹–—–‹‘ƒŽ‹œ‡† ‹†‹˜‹†—ƒŽ•Ǥ Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ‹• ‡“—ƒŽ –‘ ‘‡ ‘ˆ –Š‡ ˆ‘ŽŽ‘™‹‰ ƒ‘—–•ǣ ƒǤ ̴̴̴̴ Š‡ ‹†‹˜‹†—ƒŽǯ• –‘–ƒŽ ‹ ‘‡ „Ǥ ̴̴̴̴̴ ͵ͲͲ ’‡” ‡– ‘ˆ –Š‡  ˆ‡†‡”ƒŽ „‡‡ˆ‹– ”ƒ–‡

Ǥ ̴̴̴̴̴ –Š‡” ”‡ƒ•‘ƒ„Ž‡ ƒ‘—–ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• ƒ ‡™ ˜ƒ”‹ƒ ‡ –‘ –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡Ǥ ȋ‘–‡ǣ Ž‡ –‹‘ ‘ˆ –Š‹• ‘’–‹‘ ‹• ‘– †‡’‡†‡– ‘ ƒ •–ƒ–‡ ‡Ž‡ –‹‰ –Š‡ ‘’–‹‘ †‡• ”‹„‡† –Š‡ ‘’–‹‘ ‹ ǤͳǤ ƒ„‘˜‡ǤȌ dŚĞ ƐƚĂƚĞ ƉƌŽƚĞĐƚƐ ĂŵŽƵŶƚƐ ĞdžĐĞĞĚŝŶŐ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ŚĂǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ŐƌĞĂƚĞƌ ƉĞƌƐŽŶĂů ŶĞĞĚƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ ŐƌĞĂƚĞƌ ŶĞĞĚƐ ĂŶĚ ƚŚĞ ĂŵŽƵŶƚ;ƐͿ ƉƌŽƚĞĐƚĞĚ ĨŽƌ ĞĂĐŚ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ͘ ^ĞĐƚŝŽŶ ' ʹ KƚŚĞƌ WŽůŝĐŝĞƐ ĂŶĚ WƌŽĐĞĚƵƌĞƐ ŝĨĨĞƌŝŶŐ ĨƌŽŵ ƉƉƌŽǀĞĚ DĞĚŝĐĂŝĚ ^ƚĂƚĞ WůĂŶ ͬĚĚŝƚŝŽŶĂů /ŶĨŽƌŵĂƚŝŽŶ WZ ŝƐĐůŽƐƵƌĞ ^ƚĂƚĞŵĞŶƚ ĐĐŽƌĚŝŶŐ ƚŽ ƚŚĞ WĂƉĞƌǁŽƌŬ ZĞĚƵĐƚŝŽŶ Đƚ ŽĨ ϭϵϵϱ͕ ŶŽ ƉĞƌƐŽŶƐ ĂƌĞ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞƐƉŽŶĚ ƚŽ Ă ĐŽůůĞĐƚŝŽŶ ŽĨ ŝŶĨŽƌŵĂƚŝŽŶ ƵŶůĞƐƐ ŝƚ ĚŝƐƉůĂLJƐ Ă ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ͘ dŚĞ ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ĨŽƌ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ϬϵϯϴͲϭϭϰϴ ; džƉŝƌĞƐ ϬϯͬϯϭͬϮϬϮϭͿ͘ dŚĞ ƚŝŵĞ ƌĞƋƵŝƌĞĚ ƚŽ ĐŽŵƉůĞƚĞ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ĞƐƚŝŵĂƚĞĚ ƚŽ ĂǀĞƌĂŐĞ ϭ ƚŽ Ϯ ŚŽƵƌƐ ƉĞƌ ƌĞƐƉŽŶƐĞ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƚŝŵĞ ƚŽ ƌĞǀŝĞǁ ŝŶƐƚƌƵĐƚŝŽŶƐ͕ ƐĞĂƌĐŚ ĞdžŝƐƚŝŶŐ ĚĂƚĂ ƌĞƐŽƵƌĐĞƐ͕ ŐĂƚŚĞƌ ƚŚĞ ĚĂƚĂ ŶĞĞĚĞĚ͕ ĂŶĚ ĐŽŵƉůĞƚĞ ĂŶĚ ƌĞǀŝĞǁ ƚŚĞ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ <ĂŶƐĂƐ dE͗ ͺ<^ͲϮϬͲϬϬϭϮͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ͘ zŽƵƌ ƌĞƐƉŽŶƐĞ ŝƐ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞĐĞŝǀĞ Ă ǁĂŝǀĞƌ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ͘ ůů ƌĞƐƉŽŶƐĞƐ ĂƌĞ ƉƵďůŝĐ ĂŶĚ ǁŝůů ďĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ŽŶ ƚŚĞ D^ ǁĞď ƐŝƚĞ͘ /Ĩ LJŽƵ ŚĂǀĞ ĐŽŵŵĞŶƚƐ ĐŽŶĐĞƌŶŝŶŐ ƚŚĞ ĂĐĐƵƌĂĐLJ ŽĨ ƚŚĞ ƚŝŵĞ ĞƐƚŝŵĂƚĞ;ƐͿ Žƌ ƐƵŐŐĞƐƚŝŽŶƐ ĨŽƌ ŝŵƉƌŽǀŝŶŐ ƚŚŝƐ ĨŽƌŵ͕ ƉůĞĂƐĞ ǁƌŝƚĞ ƚŽ͗ D^͕ ϳϱϬϬ ^ĞĐƵƌŝƚLJ ŽƵůĞǀĂƌĚ͕ ƚƚŶ͗ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞƌ͕ DĂŝů ^ƚŽƉ ϰͲϮϲͲϬϱ͕ ĂůƚŝŵŽƌĞ͕ DĂƌLJůĂŶĚ ϮϭϮϰϰͲϭϴϱϬ͘ ΎΎΎD^ ŝƐĐůŽƐƵƌĞΎΎΎ WůĞĂƐĞ ĚŽ ŶŽƚ ƐĞŶĚ ĂƉƉůŝĐĂƚŝŽŶƐ͕ ĐůĂŝŵƐ͕ ƉĂLJŵĞŶƚƐ͕ ŵĞĚŝĐĂů ƌĞĐŽƌĚƐ Žƌ ĂŶLJ ĚŽĐƵŵĞŶƚƐ ĐŽŶƚĂŝŶŝŶŐ ƐĞŶƐŝƚŝǀĞ ŝŶĨŽƌŵĂƚŝŽŶ ƚŽ ƚŚĞ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞ͘ WůĞĂƐĞ ŶŽƚĞ ƚŚĂƚ ĂŶLJ ĐŽƌƌĞƐƉŽŶĚĞŶĐĞ ŶŽƚ ƉĞƌƚĂŝŶŝŶŐ ƚŽ ƚŚĞ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ďƵƌĚĞŶ ĂƉƉƌŽǀĞĚ ƵŶĚĞƌ ƚŚĞ ĂƐƐŽĐŝĂƚĞĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ůŝƐƚĞĚ ŽŶ ƚŚŝƐ ĨŽƌŵ ǁŝůů ŶŽƚ ďĞ ƌĞǀŝĞǁĞĚ͕ ĨŽƌǁĂƌĚĞĚ͕ Žƌ ƌĞƚĂŝŶĞĚ͘ /Ĩ LJŽƵ ŚĂǀĞ ƋƵĞƐƚŝŽŶƐ Žƌ ĐŽŶĐĞƌŶƐ ƌĞŐĂƌĚŝŶŐ ǁŚĞƌĞ ƚŽ ƐƵďŵŝƚ LJŽƵƌ ĚŽĐƵŵĞŶƚƐ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂŝĚ Θ ,/W ^ĞƌǀŝĐĞƐ Ăƚ ϰϭϬͲϳϴϲͲϯϴϳϬ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ϱͬϭϭͬϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Table of Contents State/Territory Name: Kansas State Plan Amendment (SPA) #: 20-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENTOFHEALTH & HUMANSERVICES CentersforMedicare & MedicaidServices 601East12thStreet, Suite355 KansasCity, Missouri64106-2898 MedicaidandCHIPOperationsGroup July1, 2020 ChristianeSwartz, InterimMedicaidDirector KansasDepartmentofHealthandEnvironment DivisionofHealthCareFinance LandonStateOfficeBuilding 900SWJackson, Suite900N Topeka, KS66612-1220 DearMs. Swartz: OnApril21, 2020, theCentersforMedicare & MedicaidServices (CMS) receivedKansas’ State PlanAmendment (SPA) transmittal #20-0003, whichaddsservicesavailableinState’sHealth HomesprogramtoenrolleesinKansas’ WorkingHealthyProgram(analternativebenefit program). ThestatewithdrewSPA20-0003tocorrecterrorsinthepublicnoticeforit, and resubmittedtheSPAas20-0013onMay29, 2020. Basedupontheinformationreceived, wearenowreadytoapproveSPA #20-0013asofJuly16, 2020, withaneffectivedateofApril1, 2020, asrequestedbythestate. EnclosedisacopyoftheCMS-179form, aswellastheapprovedpage, forincorporationintothe KansasStatePlan. Ifyouhaveanyquestionsregardingthisamendment,pleasecontactMichalaWalkerofmystaff, atMichala.walker@cms.hhs.govor (816) 426-5925. 7/17/2020 Sincerely, X JamesG. Scott, Director DivisionofProgramOperations Signedby: JamesG. Scott -S Enclosure cc: BobbieGraff-Hendrixson, KDHE WilliamStelzner, KDHE KimTjelmeland, KDHE JasonFrandson

KS.5040.R00.00 -Apr01, 2020Page1of2 MedicaidAlternativeBenefitPlan: SummaryPage (CMS179) State/Territoryname: Kansas TransmittalNumber: PleaseentertheTransmittalNumber (TN) intheformatST-YY-0000whereST= thestateabbreviation, YY = thelasttwodigitsof thesubmissionyear, and0000 = afourdigitnumberwithleadingzeros. Thedashesmustalsobeentered. KS-20-0013 ProposedEffectiveDate 04/01/2020 mm/dd/yyyy) FederalStatute/RegulationCitation 1937 FederalBudgetImpact FederalFiscalYearAmount FirstYear 20 174769.00 SecondYear 21 520645.00 SubjectofAmendment ThisamendmentaddsHealthHomestotheABP5. Thefiscalimpactprojectionis10percentofthetotalcostoftheHealthHomeprogram. Governor'sOfficeReview Governor'sofficereportednocomment CommentsofGovernor'sofficereceived Describe: Noreplyreceivedwithin45daysofsubmittal Other, asspecified Describe: SignatureofStateAgencyOfficial SubmittedBy: BobbieGraff-Hendrixson LastRevisionDate: May29, 2020 SubmitDate: May29, 2020 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New https://wms-mmdl.cms.gov/MMDL/faces/protected/abp/d01/print/PrintSelector.js06112020 p//

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 AlternativeBenefitPlanPopulationsABP1 IdentifyanddefinethepopulationthatwillparticipateintheAlternativeBenefitPlan. AlternativeBenefitPlanPopulationName:WorkingHealthy/WORK IdentifyeligibilitygroupsthatareincludedintheAlternativeBenefitPlan'spopulation, andwhichmaycontainindividualsthatmeetany targetingcriteriausedtofurtherdefinethepopulation. EligibilityGroupsIncludedintheAlternativeBenefitPlanPopulation: Enrollmentis AddEligibilityGroup: mandatoryorRemove voluntary? AddRemove TickettoWorkBasicGroupVoluntary AddRemove TickettoWorkMedicalImprovementsGroupVoluntary Enrollmentisavailableforallindividualsintheseeligibilitygroup(s). No TargetingCriteriaselectallthatapply): IncomeStandard. Disease/Condition/Diagnosis/Disorder. Other. OtherTargetingCriteria (Describe): Individualswhosefunctionallimitationsandneedforassistanceissimilartoindividualsmeetinganinstitutionallevelofcare. GeographicArea TheAlternativeBenefitPlanpopulationwillincludeindividualsfromtheentirestate/territory. Yes Anyotherinformationthestate/territorywishestoprovideaboutthepopulation (optional) ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page1of2

AlternativeBenefitPlan PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20181119 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page2of2

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 VoluntaryEnrollmentAssurancesforEligibilityGroupsotherthantheAdultGroupunder ABP2b Section1902(a)(10)(A)(i)( VIII) oftheAct Theseassurancesmustbemadebythestate/territoryiftheABPPopulationincludesanyeligibilitygroupsotherthanorinadditiontothe Adulteligibilitygroup. WhenofferingvoluntaryenrollmentinanAlternativeBenefitPlan (BenchmarkorBenchmark-Equivalent), priortoenrollment: Thestate/territorymustinformtheindividualtheyareexemptandthestate/territorymustcomplywithallrequirementsrelatedto voluntaryenrollment. Thestate/territoryassuresitwilleffectivelyinformindividualswhovoluntaryenrollofthefollowing: a)Enrollmentisvoluntary; b)TheindividualmaydisenrollfromtheAlternativeBenefitPlanatanytimeandregainimmediateaccesstofullstandardstate/ territoryplancoverage; c)Whattheprocessisfordisenrolling. Thestate/territoryassuresitwillinformtheindividualof: a)ThebenefitsavailableundertheAlternativeBenefitPlan; and b)ThecostsofthedifferentbenefitpackagesandacomparisonofhowtheAlternativeBenefitPlandiffersfromtheapproved Medicaidstate/territoryplan. Howwillthestate/territoryinformindividualsaboutvoluntaryenrollment? (Checkallthatapply.) Letter Email Other: Describe: TheStatehasBenefitsSpecialistslocatedregionallywhomeetindividuallywithperspectiveWorkingHealthy/WORK enrolleestoprovideinformationabouttheprogram, provideacomparisontoHomeandCommunityBasedwaiverprograms, andtoexplainthattheprogramisvoluntaryandparticipantscandis-enrollatanytime. (SeeattachedTalkingPoints) Provideacopyoftheletter, emailtextorothercommunicationtextthatwillbeusedtoinformindividualsaboutvoluntaryenrollment. Anattachmentissubmitted. Whendid/willthestate/territoryinformtheindividuals? Individualsareprovidedwithprograminformation, includingtheabilitytovoluntarilyenrollordis-enroll, followingeitheraself referral, orareferralbyanotherentity. Pleasedescribethestate/territory'sprocessforallowingvoluntarilyenrolledindividualstodisenroll. Whenaparticipantchoosestodis-enoll, StateprogramstaffandMCOCaseManagersassistthemtotransitiontootherMedicaid ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 Page1of2 SupersedesTN: New Date:

AlternativeBenefitPlan servicesforwhichtheyareeligible. Thestate/territoryassuresitwilldocumentintheexemptindividual'seligibilityfilethattheindividual: a)Wasinformedinaccordancewiththissectionpriortoenrollment; b)Wasgivenampletimetoarriveataninformedchoice; and c)VoluntarilyandaffirmativelychosetoenrollintheAlternativeBenefitPlan. Wherewilltheinformationbedocumented? (Checkallthatapply.) Intheeligibilitysystem. Inthehardcopyofthecaserecord. Other: Describe: TherecordswillbemaintainedbytheKansasDepartmentofHealthandEnvironment (KDHE), thestateagencythatmanages theWORKprogram. Recordsincludedemographicinformation, WORKAssessments, IndividualizedBudgets, Consumer ChoiceForms, andEmergencyBack-UpPlansinhardcopyaswellasinanAccessDataBase. Whatdocumentationwillbemaintainedintheeligibilityfile? (Checkallthatapply.) Copyofcorrespondencesenttotheindividual. SigneddocumentationfromtheindividualconsentingtoenrollmentintheAlternativeBenefitPlan. Other: Thestate/territoryassuresthatitwillmaintaindatathattracksthetotalnumberofindividualswhohavevoluntarilyenrolledinan AlternativeBenefitPlanandthetotalnumberwhohavedisenrolled. OtherInformationRelatedtoEnrollmentAssuranceforVoluntaryParticipants (optional): PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 ApprovalDate: 07/16/2020EffectiveDate: 04/01/2020 TransmittalNumber (TN): 20-0013 Page2of2 SupersedesTN: New

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 SelectionofBenchmarkBenefitPackageorBenchmark-EquivalentBenefitPackageABP3.1 Selectoneofthefollowing: Thestate/territoryisamendingoneexistingbenefitpackageforthepopulationdefinedinSection1. Thestate/territoryiscreatingasinglenewbenefitpackageforthepopulationdefinedinSection1. Nameofbenefitpackage:WorkOpportunitiesRewardKansans (WORK) SelectionofEHB-BenchmarkPlan Thestate/territorymustselectanEHB-benchmarkplanasthebasisforprovidingEssentialHealthBenefitsinits BenchmarkorBenchmark-EquivalentPackage. BC/BSofKSComprehensiveMaj. Medical-BlueChoi EHB-benchmarkplanname: o N TheEHB-benchmarkplanisthesameastheSection1937Coverageoption: IndicatetheEHB-benchmarkoptionasdescribedat45CFR156.111(b)(2)(B) thestate/territorywilluseasitsEHB- benchmarkplan: State/TerritoryisselectingoneofthebelowoptionstodesignanEHBpackagethatcomplieswiththerequirementsfor theindividualinsurancemarketunder45CFR156.100through156.125. State/TerritoryisselectingtheEHB-benchmarkplanusedbythestate/territoryforthe 2017planyear. State/TerritoryisselectingoneoftheEHB-benchmarkplansusedforthe2017planyearbyanother state/territory. State/ TerritoryselectsthefollowingEHB-benchmarkplanusedforthe2017planyearbutwill replacecoverageofoneormoreofthecategoriesofEHBwithcoverageofthesamecategoryfrom the2017EHB-benchmarkplanofoneormoreotherstates Selectasetofbenefitsconsistentwiththe10EHBcategoriestobecomethenewEHB-benchmark plan. (CompleteandsubmittheABP5: BenefitsDescriptionformtodescribethesetofbenefits.) TypeofEHB-benchmarkplan: Largestplanbyenrollmentofthethreelargestsmallgroupinsuranceproductsinthestate's smallgroupmarket. Anyofthelargestthreestateemployeehealthbenefitplansbyenrollment. AnyofthelargestthreenationalFEHBPplanoptionsopentoFederalemployeesinall geographiesbyenrollment. Largestinsuredcommercialnon-MedicaidHMO. ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New 1of3

AlternativeBenefitPlan Assurances Thestate/territoryassurestheEHBplanmeetsthescopeofbenefitsstandardsat45CFR156.111(b), doesnotexceed generosityofmostgenerousamongasetofcomparisonplans, providesappropriatebalanceofcoverageamong10 EHBcategories, andthescopeofbenefitsisequalto, orgreaterthan, thescopeofbenefitsprovidedunderatypical employerplanasdefinedat45CFR156.111(b)(2). Thestate/territoryassuresthatallservicesintheEHB-benchmarkplanhavebeenaccountedforthroughoutthebenefit chartfoundinABP5. Thestate/territoryassurestheaccuracyofallinformationinABP5depictingamount, durationandscopeparametersof servicesauthorizedinthecurrentlyapprovedMedicaidStatePlan. SelectionoftheSection1937CoverageOption Thestate/territoryselectsasitsSection1937CoverageoptionthefollowingtypeofBenchmarkBenefitPackageorBenchmark- EquivalentBenefitPackageunderthisAlternativeBenefitPlan (checkone): BenchmarkBenefitPackage. Benchmark-EquivalentBenefitPackage. Thestate/territorywillprovidethefollowingBenchmarkBenefitPackage (checkonethatapplies): TheStandardBlueCross/BlueShieldPreferredProviderOptionofferedthroughtheFederalEmployeeHealthBenefit Program (FEHBP). Stateemployeecoveragethatisofferedandgenerallyavailabletostateemployees (StateEmployeeCoverage): AcommercialHMOwiththelargestinsuredcommercial, non-Medicaidenrollmentinthestate/territory (Commercial HMO): Secretary-ApprovedCoverage. Thestate/territoryoffersbenefitsbasedontheapprovedstateplan. Thestate/territoryoffersanarrayofbenefitsfromthesection1937coverageoptionand/orbasebenchmarkplan benefitpackages, ortheapprovedstateplan, orfromacombinationofthesebenefitpackages. Pleasebrieflyidentifythebenefits, thesourceofbenefitsandanylimitations: Benefitsincludeallthoseprovidedintheapprovedstateplanplusadditionalbenefits. TheStateassuresthatall servicesinthebasebenchmarkhavebeenaccountedforthroughoutthebenefitchartfoundinABP5. TheState assurestheaccuracyofallinformationinABP5depictingamount, durationandscopeparametersofservices authorizedinthecurrentlyapprovedMedicaidStatePlan. OtherInformationRelatedtoSelectionoftheSection1937CoverageOptionandtheEHB-BenchmarkPlan (optional): ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New 2of3

AlternativeBenefitPlan PRADisclosureStatement CentersforMedicare & MedicaidServices (CMS) collectsthismandatoryinformationinaccordancewith (42U.S.C. 1396a) forthe purposeofstandardizingdata. TheinformationwillbeusedtomonitorandanalyzeperformancemetricsrelatedtotheMedicaidand Children’sHealthInsuranceProgramineffortstoboostprogramintegrityefforts, improveperformanceandaccountabilityacrossthe programs. UnderthePrivacyActof1974anypersonallyidentifyinginformationobtainedwillbekeptprivatetotheextentofthelaw. AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1188. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20190813 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New 3of3

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 AlternativeBenefitPlanCost-SharingABP4 AnycostsharingdescribedinAttachment4.18-AappliestotheAlternativeBenefitPlan. Attachment4.18-AmayberevisedtoincludecostsharingforABPservicesthatarenototherwisedescribedinthestateplan.Anysuch costsharingmustcomplywithSection1916oftheSocialSecurityAct. TheAlternativeBenefitPlanforindividualswithincomeover100% FPLincludescost-sharingotherthanthatdescribedin No Attachment4.18-A. OtherInformationRelatedtoCostSharingRequirements (optional): PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New 1of1

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 BenefitsDescriptionABP5 Thestate/territoryproposesa “Benchmark-Equivalent” benefitpackage.No BenefitsIncludedinAlternativeBenefitPlan Enterthespecificnameofthebasebenchmarkplanselected: BlueCrossBlueShieldofKansasComprehensiveMajorMedical-BlueChoice Enterthespecificnameofthesection1937coverageoptionselected, ifotherthanSecretary-Approved. Otherwise, enter Secretary-Approved.” Secretary-Approved ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page1of36

AlternativeBenefitPlan 1.EssentialHealthBenefit: AmbulatorypatientservicesCollapseAll BenefitProvided: Source: Remove Physicians' Services StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove OutpatientHospitalServices StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove OtherLicensedPractitionersServices StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: oneone NN ScopeLimit: one N ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page2of36

AlternativeBenefitPlan Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Priorauthorizationmayberequiredforsomeservices. Notauniversalrequirement. BenefitProvided: Source: Remove ClinicServices StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove HospiceCare StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: HospiceNoticeofElectionstatementmustbeonfile. Inaccordancewithsection2302oftheACA, individualsundertheageof21, willreceivehospicecareconcurrentlywithcurativecare. BenefitProvided: Source: Remove CertifiedPediatricorFamilyNursePract. Srvcs StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page3of36

AlternativeBenefitPlan ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove PersonalServices - WORK/SelfDirection StatePlan1915(j) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: oneone NN ScopeLimit: SeeOtherbelow Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: ii.ServicePackage TheStateelectstohavethefollowingincludedasSelf-DirectedPersonalAssistanceServices: A._X_ StatePlanPersonalCareandRelatedServices, tobeself-directedbyindividualseligibleunder theStatePlan. iv.UseofCash A._X_ TheStateelectstodisbursecashprospectivelytoparticipantsself-directingpersonalassistance services. TheStateassuresthatallInternalRevenueService (IRS) requirementsregardingpayroll/taxfiling functionswillbefollowed, includingwhenparticipantsperformthepayroll/taxfilingfunctionsthemselves. viii.GeographicLimitationsandComparability A._X_ TheStateelectstoprovideself-directedpersonalassistanceservicesonastatewidebasis. D._X_ TheStateelectstoprovideself-directedpersonalassistanceservicestotargetedpopulations. Pleasedescribe: Individualswhosefunctionallimitationsandneedforassistanceissimilartoindividualsmeetingan institutionallevelofcare. E._X_ TheStateelectstoprovideself-directedpersonalassistanceservicestoanunlimitednumberof participants. xii.RiskManagement A.Theriskassessmentmethodsusedtoidentifypotentialriskstoparticipantsaredescribedbelow. 1.Duringtheinitialandannualassessments, participantsneedforpersonalassistanceisaddressedina personcenteredprocess. Participantsreceivethenumberofhoursthattheyareassessedasneeding. Once needsaredetermined, hoursofpersonalassistanceareassigned. Hoursofservicearethentranslatedinto dollars, andamonthlyallocationdetermined. Participants, withthehelpofIndependentLiving (IL) Counselorsandanyoneelsetheywishtoincludeintheplanningprocess, developanIndividualizedBudget designedtoaddresstheirneeds. TheIndividualizedBudgetincludespersonalassistance, alternative assistance, anduseofanycarryoverfunds. BoththeneedsassessmentandtheIndividualizedBudgetare reviewedbytheManagedCareOrganization (MCO) CaseManagertodeterminethattheIndividualized Budgetaddressestheneedsofparticipantsidentifiedintheneedsassessment. 2.Inadditiontoaddressingactivitiesofdailylivingthatposeariskwithoutassistance, theassessorand participantcompleteaHealthRelatedInformationassessment, whichincludesanassessmentofhomeand ApprovalDate: 07/16/2020 TransmittalNumber (TN): 20-0013 EffectiveDate: 04/01/2020 SupersedesTN: New Page4of36

AlternativeBenefitPlan neighborhoodsafety. 3.Participants, withtheassistanceoftheassessor, andothersignificantpersonsifdesired, developan emergencyback-upplan, documentthisplanontheEmergencyBack-UpPlanform, andsubmitthistothe ManagedCareOrganization (MCO) CaseManagerforapproval. TheEmergencyBack-upPlanisusedto identifywhowillprovideassistanceinhigh-riskandemergencysituations. MCOCaseManagersreview theEmergencyBack-UpPlantodeterminewhetheritincludesthenecessarysafeguards, andeither approvestheplan, orreturnsittotheconsumerandassessorwithrecommendations. Consumers, MCO CaseManagers, IndependentLivingCounselorsandStateprogramstaffmaintainacopyoftheEmergency Back-UpPlanandmakeitavailableasappropriate. 4.StateprogramstaffreviewtheNeedsAssessment, theHealthRelatedform, theEmergencyBack-Up Plan, theConsumerAgreementformandtheIndividualizedBudgettoassesswhethertheyappeartomeet theneedsoftheparticipant, thatallinformationiscomplete, andthatformsaresignedbytheparticipantor representative. 5.Assistivetechnologyandhome/vehiclemodificationsareavailabletoparticipantswhodemonstratea needfortheseforhealthandsafetyreasons. WiththeassistanceoftheirILCounselors, participants completeanAssistiveServicesRequestForm, whichissenttotheirMCOCaseManagerforapproval. 6.Assessors, ILCounselorsandMCOCaseManagersarerequiredtoreportanyconcernsregarding consumerslivingsituations, emotionalandphysicalabuse, neglect, exploitationandfiduciaryabuseto KDHEandtheDepartmentofChildrenandFamilies (DCF). DCFisresponsibleforfollow-upand investigation. B.Thetoolsorinstrumentsusedtomitigateidentifiedrisksaredescribedbelow. 1.TheNeedsAssessmenttoolisanassessmentoffunctionallimitationsandisdesignedtoidentifysupport needsforActivitiesofDailyLiving (ADL), InstrumentalActivitiesofDailyLiving (IADL), and EmploymentSupports. TheNeedsAssessmenttoolrequiresaface-to-facemeeting, anddiscussionwith participants/representativesandanyoneelsetheychoosetoincludeintheprocess, suchasIndependent LivingCounselors (ILCs), otherfamilymembers, andfriends. Theprogramisdevelopedtoprovide neededsupportandyetencourageasmuchindependenceaspossible. ThetoollooksatthefollowingforeachADLandIADL: oCanthememberperformthesetasksindependently? oHowmuchtimedoesitrequireforthemembertoperformthesetasksindependently? oDoesthememberneedassistancebutcurrentlyuseunpaidnaturalsupporttoperformthetask? oIfnaturalsupportiscurrentlyusedtoaccomplishthesetasks, describethenatureofthenaturalsupport. oIsassistivetechnologyorhomemodificationscurrentlyused, orneeded, toincreaseindependence? oIfassistivetechnologyisusedorneeded, describethetypeofassistivetechnologyorthehome modifications. oWouldpersonalassistanceorassistiveservicesreducetheamountoftime? oHowmuchpersonalassistanceisneeded, orwhatassistivetechnologyisneeded, toincreasesafetyand independence. 2.TheHealthRelatedInformationwithintheNeedsAssessmenttoolincludesanassessmentof: ohomeandneighborhoodsafety osafetyequipmentsuchascarbonmonoxideandsmokedetectors ofunctionalityofutilities ohealthandphysicalsafety oegresssafety, and oquestionsrelatedtoabuse, neglectandexploitation. Participantsmayusetheirmonthlyallocationtopurchasesafetyequipmentsuchassmokeandcarbon monoxidedetectors. Theintenttopurchasesafetyitemsaredocumentedontheparticipant'sIndividualized Budget. 3.TheEmergencyBack-upPlanprovidesthefollowinginformation: owhoshouldbecontactedintheeventapersonalassistantdoesnotcome owhotocontactintheeventofanemergency ocontactswhowillprovideassistanceinanemergency/naturaldisaster ocontactstocareforservicepetintheeventofanemergency, and TransmittalNumber (TN): 20-0013 EffectiveDate: 04/01/2020 ApprovalDate: 07/16/2020 SupersedesTN: New Page5of36

AlternativeBenefitPlan ocontactwhoisauthorizedtomakedecisionsorsigndocuments. 4.TheIndividualizedBudgetdocuments owhowillbepaidtoprovidepersonalassistanceservices owhatalternativeserviceswillbepurchased, and ohowcarry-overfundswillbeusedtoincreasehealth, safetyorindependence. 5.TheAssistiveServicesRequestform odescribestheneedforassistivetechnologyorhome/vehiclemodifications, and odocumentsthemedicalnecessityfortheseservices. 6.BackgroundCheckformsallowtheFiscalManagementServiceprovidertoperformbackgroundchecks onpersonalassistants. Backgroundcheckswillbepaidbytheparticipant'sMCOandnoneofthecostof thebackgroundcheckwillbedeductedfromtheparticipant'sIndividualizedBudget. 7.TheIndependentLivingCounselorasaMandatedReporterexplainsthatKansaslawconsidersIL Counselorsmandatedreportersofabuse, neglect, exploitation, andfiduciaryabuse, anddefinestheseterms. xiii.QualificationsofProvidersofPersonalAssistance A._X_ TheStateelectstopermitparticipantstohirelegallyliablerelatives, aspaidprovidersofthe personalassistanceservicesidentifiedintheserviceplanandbudget. xv.PermissiblePurchases A._X _ TheStateelectstopermitparticipantstousetheirservicebudgetstopayforitemsthatincreasea participant'sindependenceorsubstituteforaparticipant'sdependenceonhumanassistance. xvi.FinancialManagementServices A._X_ TheStateelectstoemployaFinancialManagementEntitytoprovidefinancialmanagement servicestoparticipantsself-directingpersonalassistanceservices, withtheexceptionofthoseparticipants utilizingthecashoptionandperformingthosefunctionsthemselves. ii._X_ TheStateelectstoprovidefinancialmanagementservicesthroughvendororganizationsthathave thecapabilitiestoperformtherequiredtasksinaccordancewithsection3504oftheIRSCodeandRevenue Procedure70-6. (Whenprivateentitiesfurnishfinancialmanagementservices, theprocurementmethod mustmeettherequirementssetforthFederalregulationsin45CFRsection74.40 - section74.48.) iii._X_ TheStateelectstoprovidefinancialmanagementservicesusing "agencywithchoice" organizationsthathavethecapabilitiestoperformtherequiredtasksinaccordancewiththeprinciplesof self-directionandwithFederalandStateMedicaidrules. BenefitProvided: Source: Remove AssistiveServices - WORK StatePlan1915(i) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: 7,500peryearone N ScopeLimit: Servicesarelimitedtoindividualprogramcriteriaandarebasedonapersoncenteredplanningprocess. Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Individualsmusthaveamedicalandfunctionalneedfortheassistivetechnologyorservicesinorderto improvehealthandsafetyand/orincreasetheabilitytomaintainemployment. AssistiveServicesincludes items, equipment, productsystems, andhomeorvehiclemodifications, notcoveredundertheMedicaid StatePlan, butwhichcontributetotheindividual'shealthandsafetyand/orabilitytomaintainemployment andindependence. AssistiveServicesmayalsoincludeserviceswhichdirectlyassistindividualswitha disabilityintheselection, acquisition, oruseofassistivetechnology. TheAssistiveServicerequestedmust bepriorauthorizedandmustberelatedtotheindividual'sdisabilityandfunctionallimitations, medically ApprovalDate: 07/16/2020EffectiveDate: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page6of36

AlternativeBenefitPlan necessaryanddocumentedbyappropriatemedicalpersonnel, andcannotgobeyondthescopeofthe Medicaidprogramandsubsumeanemployer'sresponsibilitiesunderTitleIoftheAmericanswith DisabilitiesAct (ADA), andtheKansasActAgainstDiscrimination. ForanyHomeandCommunityBasedServicesbenefitsaspermittedin1915(i) inABP5, thestateassures that: 1.Theservice(s) areprovidedinsettingsthatmeetHCBsettingrequirements; 2.Theservice(s) meettheperson-centeredserviceplanningrequirements; 3.Individualsreceivingtheseservicesmeetthestate-establishedneeds-basedcriteriathatarenotrelated solelytoage, disability, ordiagnosis, andarelessstringentthancriteriaforentryintoinstitutions. Services canbeaccessedasneeded, eveniftheindividualshaveneedsthatarebelowinstitutionallevelofcare. The $7500.00annuallimitmaybeexceededbasedonmedicalnecessity. ProviderQualifications: CommunityorganizationseligibletoenrollasprovidersofAssistiveServicesmust beprovidersofDME, orthoticsandprostheticsorbeoneofthefollowing: CDDOorCDDOAffiliate, CIL, orlicensedHomeHealthAgency. BenefitProvided: Source: Remove IndependentLivingCounseling - WORK StatePlan1915(j) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: 40units (quarterhour) permonth. one N ScopeLimit: Servicesarelimitedtoindividualprogramcriteriaandarebasedonapersoncenteredplanningprocess. Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: IndependentLivingCounselingisprovidedforWORKparticipantsbyIndependentLivingCounselors workingforcommunityorganizationssuchasCentersforIndependentLiving, CommunityDevelopmental DisabilityOrganizations, andlicensedHomeHealthagencies. IndependentLivingCounselor responsibilitiesincludeconveyingWORKprogrampoliciesandprocedurestoparticipantandassisting participantsto: completetheWORKChoiceForm accesstrainingandsupportsneededtodeveloptheskillstoself-directservices, managetheirmonthly allocation, organizeworkplaceaccommodations, andotherwisemeetgoalsforindependentliving developanIndividualizedBudget determineandlocatealternate, cost-effectivemethodsforpurchasingservices planfortheuseofcarry-overfunds developanEmergencyBack-UpPlanandlocateemergencyback-upcareandemergencyassistance recruitprovidersofpersonalassistanceservices interview, hire, supervise, andterminatepersonalassistants obtainagency-directedservices, ifthatistheirpreference documenttheneedforandapplyforassistiveservices, aswellaslocateproviders completeandsubmitrequiredpaperworkforthefiscalintermediary dis-enrollfromtheprogram. IndependentLivingCounselorsarealsoresponsibleforcommunicatinganychangesinstatus, needs, problems, etc., totheparticipant'sMCOCaseManager, reportemotionalabuse, physicalabuse, exploitation, fiduciaryabuse, maltreatmentand/orneglecttotheprogramstaffand/orAdultProtective Services. Extraunitsmaybeaddedbasedonmedicalnecessity. ApprovalDate: 07/16/2020EffectiveDate: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page7of36

AlternativeBenefitPlan ForanyHomeandCommunityBasedServicesbenefitsaspermittedin1915(i) inABP5, thestateassures that: 1.Theservice(s) areprovidedinsettingsthatmeetHCBsettingrequirements; 2.Theservice(s) meettheperson-centeredserviceplanningrequirements; 3.Individualsreceivingtheseservicesmeetthestate-establishedneeds-basedcriteriathatarenotrelated solelytoage, disability, ordiagnosis, andarelessstringentthancriteriaforentryintoinstitutions. Services canbeaccessedasneeded, eveniftheindividualshaveneedsthatarebelowinstitutionallevelofcare. ProviderQualifications: 1.BeemployedbyaCenterforIndependentLiving, CommunityDevelopmentalDisabilityOrganizationor itsaffiliate, oralicensedHomeHealthAgencythatisenrolledasaproviderofindependentliving counselingservices; 2.Haveaminimumofoneyearofprofessionalexperienceprovidingdirectservices, includingcase management; 3.Haveaminimumof6-monthsexperienceworkingwithapersonwithadisabilityasrecognizedbythe RehabilitationActof1973; 4.Haveattendeda2-hourWORKpresentation; 5.Haveatleast12hoursofstandardizedtrainingannually; and 6.Havecompletedtheon-lineWORKIndependentLivingCounselingtrainingandreceivedthecertificate ofcompletion. BenefitProvided: Source: Remove SupportedEmployment - IndEmpSupSer StatePlan1915(i) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: oneone NN ScopeLimit: Servicesarelimitedtoindividualprogramcriteriaandarebasedonapersoncenteredplanningprocess. Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: IndividualsmusthaveamedicalandfunctionalneedfortheSupportedEmployment - Individual EmploymentSupportservicesinordertoimprovehealthandsafetyand/orincreasetheabilitytomaintain employment. SupportedEmployment - IndividualEmploymentSupportServicesaretheongoingsupports toparticipantswho, becauseoftheirdisabilities, needintensiveon-goingsupporttomaintainanindividual jobincompetitiveorcustomizedemployment, orself-employment, inanintegratedworksettinginthe generalworkforceforwhichanindividualiscompensatedatorabovetheminimumwage, butnotlessthan thecustomarywageandlevelofbenefitspaidbytheemployerforthesameorsimilarworkperformedby individualswithoutdisabilities. Theoutcomeofthisserviceissustainedpaidemploymentatorabovethe minimumwageinanintegratedsettinginthegeneralworkforce. Supportedemploymentservicesare individualizedandmayincludesupporttolearnneworevolvingandchangingjobresponsibilities, to exhibitappropriateworkbehavior, tointeractappropriatelywithotheremployeesandthegeneralpublic, to practicesafetymeasuresatwork, andtransportationtoandfromwork. Itmayalsoincludejobcoaching andconsultationwiththeemployertodealwithemploymentrelatedissuesand/orjobrelatedadaptationsor modifications. SupportedEmployment - IndividualEmploymentSupportsdonotincludepaymentfor supervision, training, supportandadaptationstypicallyavailabletootherworkerswithoutdisabilitiesfilling similarpositionsinthebusiness. Forthosewhoareself-employed, SupportedEmployment - Individual SupportMedicaidisnotprovidedtodefraytheexpensesassociatedwithstartinguporoperatingabusiness. ProvidersofSupportedEmployment - IndividualSupportarecommunityserviceproviders, selectedbythe ApprovalDate: 07/16/2020 TransmittalNumber (TN): 20-0013 EffectiveDate: 04/01/2020 SupersedesTN: New Page8of36

AlternativeBenefitPlan individual, whohavetrainedstaffsuchasjobspecialists, jobdevelopers, supportedemploymentspecialists, etc. Individualswhoareself-directingmayusecommunityserviceprovidersorestablishtheirownprovider qualificationsfortheprovisionofindividua1employmentsupports. ForanyHomeandCommunityBasedServicesbenefitsaspermittedin1915(i) inABP5, thestateassures that: 1.Theservice(s) areprovidedinsettingsthatmeetHCBsettingrequirements; 2.Theservice(s) meettheperson-centeredserviceplanningrequirements; 3.Individualsreceivingtheseservicesmeetthestate-establishedneeds-basedcriteriathatarenotrelated solelytoage, disability, ordiagnosis, andarelessstringentthancriteriaforentryintoinstitutions. Services canbeaccessedasneeded, eveniftheindividualshaveneedsthatarebelowinstitutionallevelofcare. Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page9of36

AlternativeBenefitPlan 2.EssentialHealthBenefit: EmergencyservicesCollapseAll BenefitProvided: Source: Remove EmergencyHospitalServices - OutpatientHospital StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove EmergencyTransportation - OutpatientHospital StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page10of36

AlternativeBenefitPlan 3.EssentialHealthBenefit: HospitalizationCollapseAll BenefitProvided: Source: Remove InpatientHospitalServices StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove Physicians' Services - Inpatient StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove HospiceServices - Inpatient StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page11of36

AlternativeBenefitPlan Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Forsymptomsmanagementofthehospicediagnosis. Inaccordancewithsection2302ofthe ACA,individualsundertheageof21, willreceivehospicecareconcurrentlywithcurativecare. Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page12of36

AlternativeBenefitPlan 4.EssentialHealthBenefit: MaternityandnewborncareCollapseAll BenefitProvided: Source: Remove urse-MidwifeServices N StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove AmbulatoryPrenatalCare-Physicians StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove InpatientHospital - Maternity StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page13of3

AlternativeBenefitPlan Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page14of36

AlternativeBenefitPlan CollapseAll 5.EssentialHealthBenefit: Mentalhealthandsubstanceusedisorderservicesincluding behavioralhealthtreatment Thestate/territoryassuresthatitdoesnotapplyanyfinancial requirementortreatmentlimitationtomentalhealthor substanceusedisorderbenefitsinanyclassificationthatismorerestrictivethanthepredominantfinancialrequirementor treatmentlimitationofthattypeappliedtosubstantially allmedical/surgicalbenefitsinthesameclassification. BenefitProvided: Source: Remove CommunityPsychiatricSupportandTreatment-Rehab. StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove MentalHealthIn-patientServices StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Individualsassessedtobeadmittedforinpatientacutecarerelatedtopsychiatricservicesinwhichthe psychiatricplanofcareisdirectedbyapsychiatristandinwhichpsychotherapyisprovidedonadaily basis. TheseservicesarenotprovidedinanIMD. BenefitProvided: Source: Remove SubstanceAbuseOut-patientServices-Rehab StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN TransmittalNumber (TN): 20-0013 ApprovalDate: 07/16/2020EffectiveDate: 04/01/2020 SupersedesTN: New Page15of36

AlternativeBenefitPlan ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: OutpatientSubstanceAbuseServicesincludesanarrayofconsumercenteredoutpatientandintensive outpatientservicesconsistentwiththeindividual'sassessedtreatmentneeds, witharehabilitationand recoveryfocusdesignedtopromoteskillsforcopingwithandmanagingsubstanceabusesymptomsand behaviors. BenefitProvided: Source: Remove SubstanceAbuseIn-patientHospitalServices StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: Acutemedicaldetoxificationhospitallevelofcare. Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: TheseservicesarenotprovidedinanIMD. Residentialtreatmentalsocovered. BenefitProvided: Source: Remove PsychosocialRehabilitation-Rehabilitation StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page16of36

AlternativeBenefitPlan 6.EssentialHealthBenefit: Prescriptiondrugs Thestate/territoryassuresthattheABPprescriptiondrugbenefitplanisthesameasundertheapprovedMedicaid StatePlanforprescribeddrugs. BenefitProvided: CoverageisatleastthegreaterofonedrugineachU.S. Pharmacopeia (USP) categoryandclassorthe samenumberofprescriptiondrugsineachcategoryandclassasthebasebenchmark. Authorization: ProviderQualifications: PrescriptionDrugLimits (Checkallthatapply.): Statelicensed Yes Limitondayssupply Limitonnumberofprescriptions Limitonbranddrugs Othercoveragelimits Preferreddruglist Coveragethatexceedstheminimumrequirementsorother: TheStateofKansasABPprescriptiondrugbenefitisthesameasundertheapprovedMedicaidstateplan forprescribeddrugs. KSMedicaidcoversallfederallyrebateddrugs. ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page17of36

AlternativeBenefitPlan 7.EssentialHealthBenefit: RehabilitativeandhabilitativeservicesanddevicesCollapseAll Thestate/territoryassuresthatitisnotimposinglimitsonhabilitativeservicesanddevicesthataremorestringentthan limitsonrehabilitativeservices (45CFR156.115(a)(5)(ii)). Further, thestate/territoryunderstandsthatseparatecoverage limitsmustalsobeestablishedforrehabilitativeandhabilitativeservicesanddevices. Combinedrehabilitativeand habilitativelimitsareallowed, iftheselimitscanbeexceededbasedonmedicalnecessity. BenefitProvided: Source: Remove PhysicalTherapyandRelatedServices: PT StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: NoneAdult6mosperillnessorinjury/childrennone ScopeLimit: None Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: ServicesprovidedinaccordancewithCFR440.110. Usedtodefinebothrehabilitativeandhabilitative services. Sixmonthlimitforadultscanbeextendedwithmedicalnecessitydocumentation. BenefitProvided: Source: Remove PhysicalTherapyandRelatedServices: OT StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: NoneAdult6mosperillnessorinjury/childrennone. ScopeLimit: None Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: ServicesprovidedinaccordancewithCFR440.110. Usedtodefinebothrehabilitativeandhabilitative services. Sixmonthlimitforadultscanbeextendedwithmedicalnecessitydocumentation. BenefitProvided: Source: Remove PhysicalTherapyandRelatedServices: ST StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: NoneAdult6mosperillnessorinjury/childrennone. ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page18of36

AlternativeBenefitPlan ScopeLimit: None Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: ServicesprovidedinaccordancewithCFR440.110. Usedtodefinebothrehabilitativeandhabilitative services. Includesaudiologicaltestingandevaluationbyanaudiologist. Sixmonthlimitforadultscanbe extendedwithmedicalnecessitydocumentation. BenefitProvided: Source: Remove HomeHealthServices: Medicalsupplies, equipment StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: None Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: BenefitProvided: Source: Remove HomeHealthServices StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: None Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page19of36

AlternativeBenefitPlan 8.EssentialHealthBenefit: LaboratoryservicesCollapseAll BenefitProvided: Source: Remove OtherLaboratoryandX-RayServices StatePlan1905(a) ProviderQualifications: Authorization: oneMedicaidStatePlan N AmountLimit: DurationLimit: oneone NN ScopeLimit: one N Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page20of36

AlternativeBenefitPlan 9.EssentialHealthBenefit: PreventiveandwellnessservicesandchronicdiseasemanagementCollapseAll Thestate/territorymustprovide, ataminimum, abroadrangeofpreventiveservicesincluding: “A” and “B” servicesrecommended bytheUnitedStatesPreventiveServicesTaskForce; AdvisoryCommitteeforImmunizationPractices (ACIP) recommended vaccines; preventivecareandscreeningforinfants, childrenandadultsrecommendedbyHRSA’sBrightFuturesprogram/project; andadditionalpreventiveservicesforwomenrecommendedbytheInstituteofMedicine (IOM). BenefitProvided: Source: Remove Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page21of36

AlternativeBenefitPlan 10.EssentialHealthBenefit: PediatricservicesincludingoralandvisioncareCollapseAll BenefitProvided: Source: Remove Medicaid StatePlanEPSDTBenefits StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: None Otherinformationregardingthisbenefit, includingthespecificnameofthesourceplanifitisnotthebase benchmarkplan: PAmayberequiredforservicesinexcessofadultbenefitlimitations. Medicalnecessitydocumentation mayberequired. Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page22of36

AlternativeBenefitPlan 11.OtherCoveredBenefitsfromBaseBenchmarkCollapseAll ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page23of36

AlternativeBenefitPlan 12.BaseBenchmarkBenefitsNotCoveredduetoSubstitutionorDuplicationCollapseAll BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Prim. CareVisittoTreatInjuryorIllness - dup BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: PrimaryCareVisittoTreatanInjuryorIllnessismappedtoEHB1, Physicians' Servicesand1905(a). The servicesareaduplicationofphysicians' servicesundertheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SpecialistVisit - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: SpecialistVisitismappedtoEHB1, OtherLicensedPractitioners' Servicesand1905(a). Theservicesarea duplicationofotherpractitioners' servicesundertheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OtherPractitionerOfficeVisit - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: OtherPractitionerOfficeVisitismappedtoEHB1, OtherLicensedPractitioners' Servicesand1905(a). Theservicesareaduplicationofotherpractitioners' servicesundertheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutPtFac. Fee(e.g., Amb. Surg. Ctr.) - duplicate BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: OutpatientFacilityFee (e.g., Amb. SurgeryCtr.) ismappedtoEHB1, OutpatientHospitalServicesand ClinicServicesand1905(a). Theservicesareaduplicationofoutpatienthospitalandclinicservicesfrom theapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutPtSurg. Phys./Surg. Svs. - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: OutpatientSurgeryPhysician/SurgicalServicesaremappedtoEHB1, OutpatientHospitalServicesand ClinicServicesand1905(a). Theservicesareaduplicationofoutpatienthospitalandclinicservicesfrom theapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutPtFac. Fee/Abortion - duplication BaseBenchmark TransmittalNumber (TN): 20-0013 ApprovalDate: 07/16/2020EffectiveDate: 04/01/2020 SupersedesTN: New Page24of36

AlternativeBenefitPlan Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: OutPtFac. Fee/AbortionismappedtoEHB1, OutpatientHospitalServicesandClinicServicesand 1905(a). Theservicesareaduplicationofoutpatienthospitalandclinicservicesfromtheapproved MedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutPt. Surg. Phys./Surg. Ser./Abortion - duplicat BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: OutPt. Surg. Phys./Surg. Ser. (Abortion) ismappedtoEHB1, OutpatientHospitalServicesandClinic Servicesand1905(a). Theservicesareaduplicationofoutpatienthospitalandclinicservicesfromthe approvedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Urgt. CareOutPt. CtrsorFac. - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: UrgentCareOutPt. CentersorFacilitiesaremappedtoEHB1, OutpatientHospitalServicesandClinic Servicesand1905(a). Theservicesareaduplicationofoutpatienthospitalandclinicservicesfromthe approvedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove HospiceCare - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: HospiceCareismappedtoEHB1, HospiceCareand1905(a), andEHB3, HospiceServices-Inpatientand 1905(a). TheservicesareaduplicationofhospicecareservicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove RoutineFootCare - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: RoutineFootCareismappedtoEHB1, OtherLicensedPractitioners' Servicesand1905(a). Theservices areaduplicationofotherpractitioners' servicesundertheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove HomeHealthCareServices - duplication BaseBenchmark ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page25of36

AlternativeBenefitPlan Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: HomeHealthCareServicesismappedtoEHB7, HomeHealthServicesand1905(a). Theservicesarea duplicationofhomehealthservicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove EmergencyRoomServices - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: EmergencyRoomServicesaremappedtoEHB2, EmergencyHospitalServicesand1905(a). Theservices areaduplicationofoutpatienthospitalservicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove EmrgncyTrans./Ambulance - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: EmergencyTransportation/AmbulanceismappedtoEHB2, EmergencyTransportationand1905(a). The servicesareaduplicationofoutpatienthospitalservicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InPt. Hosp. Svc (e.g., HospitalStay)- duplicati BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: InPt. HospitalServices (e.g., HospitalStay) ismappedtoEHB3, InpatientHospitalservicesand1905(a). TheservicesareaduplicationofinpatienthospitalservicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InPt. Phys. andSurg. Srvcs - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: InPt. PhysicianandSurg. ServicesismappedtoEHB3, Physicians' Services-Inpatientand1905(a). The servicesareaduplicationofinpatienthospitalservicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InPt. Hosp. Svcs (e.g. Hosp. Sty) Abortion - dupl BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: InPt. Hosp. Services (e.g., Hosp. Stay) AbortionismappedtoEHB3, InpatientHospitalServicesand 1905(a). TheservicesareaduplicationofinpatienthospitalservicesfromtheapprovedMedicaidState Plan. EffectiveDate: 04/01/2020 TransmittalNumber (TN): 20-0013 ApprovalDate: 07/16/2020 SupersedesTN: New Page26of36

AlternativeBenefitPlan BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InPt. Phys. andSurg. Srvcs (Abortion) - duplicat BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: InPt. PhysicianandSurg. Services (Abortion) ismappedtoEHB3, Physicians' Services-Inpatientand 1905(a). TheservicesareaduplicationofinpatienthospitalservicesfrmtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove PrenatalandPostnatalCare - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: PrenatalandPostnatalCareismappedtoEHB4, AmbulatoryPrenatalCare-Physiciansand1905(a). The servicesareaduplicationofphysicians' servicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Dlvry & allInPt. SrvcsforMat. Care - duplicat BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Delivery & allInPt. ServicesforMaternityCareismappedtoEHB4, InpatientHospital-Maternityand 1905(a). Theservicesareaduplicationofphysicians' servicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Ment/BehavHlthOutPt. Srvcs - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Mental/BehavioralHealthOutPt. ServicesismappedtoEHB5, CommunityPsychiatricSupportand Treatment-Rehabilitation, PsychosocialRehabilitation-Rehabilitation, and1905(a). Theservicesarea duplicationofCommunityPsychiatricSupportandTreatmentservicesandPsychosocialRehabilitation fromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Ment/BehavHlthInPt. Services - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: Mental/BehavioralHealthInPt. ServicesismappedtoEHB5, MentalHealthIn-patientServicesand 1905(a). Theservicesareaduplicationofinpatientacutecarerelatedtopsychiatricservicesfromthe approvedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SubstanceAbuseDis. OutPt. Srvcs - duplication BaseBenchmark ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page27of36

AlternativeBenefitPlan Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: SubstanceAbuseDisorderOutPt. ServicesismappedtoEHB5, SubstanceAbuseOut-patientServices- Rehaband1905(a). TheservicesareaduplicationofoutpatientSubstanceAbuseServicesfromthe approvedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove SubstanceAbuseDis. InPt. Srvcs - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: SubstanceAbuseDisorderInPt. ServicesismappedtoEHB5, SubstanceAbuseIn-patientHospital Servicesand1905(a). Theservicesareaduplicationofacutemedicaldetoxificationhospitalservicesfrom theapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove PrescriptionDrugs - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: PrescriptionDrugsaremappedtoEHB6, PrescriptionDrugsand1905(a). Theservicesareaduplication ofprescriptiondrugsservicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove OutPt. RehabilitationServices - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: OutPt. RehabilitationServicesismappedtoEHB7, PhysicalTherapyandRelatedServicesand1905(a). TheservicesareaduplicationofPT, OT, STunder440.110andcoveredbytheapprovedMedicaidState Plan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DurableMedicalEquipment - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: DurableMedicalEquipmentismappedtoEHB7, HomeHealthServices: Medicalsupplies, equipmentand 1905(a). TheservicesareaduplicationofhomehealthservicescoveredbytheapprovedMedicaidState Plan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DiagnosticTest (X-rayandLabwork) - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: DiagnosticTest (X-rayandLabwork) servicesaremappedtoEHB8, OtherLaboratoryandX-Ray TransmittalNumber (TN): 20-0013 Date: 07/16/2020 Approval EffectiveDate: 04/01/2020 Page28of36 SupersedesTN: New

AlternativeBenefitPlan Servicesand1905(a). Theservicesareaduplicationofotherlaboratoryandx-rayservicescoveredbythe approvedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove RoutineEyeExam (Pediatric) - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: RoutineEyeExamismappedtoEHB10, EPSDTand1905(a). Theservicesareaduplicationofthe optometrists' servicescoveredbytheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove PreventiveCare/Screening/Immunization - duplicati BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: PreventiveCare/Screening/ImmunizationismappedtoEHB9, Preventiveandwellnessservicesand chronicdiseasemanagementand1905(a). Theservicesareaduplicationofpreventiveandwellness servicesandchronicdiseasemanagementundertheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InfertilityTreatment - substitution BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: PersonalServices-WORK/SelfDirectioninEHB1issubstitutedforInfertilityTreatment. Actuarieshave determinedthecostofPersonalServices-WORK/SelfDirectionexceedsthecostofInfertilityTreatment. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Donorsearch - substitution BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: IndependentLivingCounseling-WORKinEHBlissubstitutedforDonorSearch. Actuarieshave determinedthecostofIndependentLivingCounseling-WORKexceedsthecostofDonorSearch. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Biofeedbackforurinaryincontinence - substituted BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: AssistiveServices-WORKinEHB1issubstitutedforBiofeedbackforUrinaryIncontinence. Actuaries havedeterminedthecostofAssistiveServices-WORKexceedsthecostofBiofeedbackforUrinary Incontinence. ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page29of36

AlternativeBenefitPlan BaseBenchmarkBenefitthatwasSubstituted: Source: Remove DiabetesEducation - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: DiabetesEducationismappedtoEHB9, Preventiveandwellnessservicesandchronicdisease managementand1905(a). Theservicesareaduplicationofpreventiveandwellnessservicesandchronic diseasemanagementundertheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove CertifiedPediatricorFamilyNursePractioner-dup BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: CertifiedPediatricorFamilyNursePractionerismappedtoEHB1, CertifiedPediatricorFamilyNurse Pract. Srvcsand1905(a). TheservicesareaduplicationofpediatricservicesundertheapprovedMedicaid StatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove PhysicianServices - Inpatient - duplication BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: PhysicianServices-InpatientismappedtoEHB3, Physicians' Services-Inpatientand1905(a). The servicesareaduplicationofinpatientphysicianservicesfromtheapprovedMedicaidStatePlan. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove InfertilityTreatment - Substitution BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: SupportedEmployment - IndividualEmploymentSupportServicesinEHBlissubstitutedforInfertility Treatment. ActuarieshavedeterminedthecostofSupportedEmployment - IndividualEmployment SupportServicesexceedsthecostofInfertilityTreatment. BaseBenchmarkBenefitthatwasSubstituted: Source: Remove Delivery/Inpat. Ser. forMaternityCare - dup BaseBenchmark Explainthesubstitutionorduplication, includingindicatingthesubstitutedbenefit(s) ortheduplicate section1937benchmarkbenefit(s) includedaboveunderEssentialHealthBenefits: DeliveryandAllInpatientServicesforMaternityCareismappedtoEHB4, Nurse-MidwifeServicesand 1905(a). Theservicesareaduplicationofnurse-midwifeservicesintheapprovedMedicaidStatePlan. Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page30of36

AlternativeBenefitPlan 13.OtherBaseBenchmarkBenefitsNotCoveredCollapseAll BaseBenchmarkBenefitnotIncludedintheAlternativeBenefitPlan: Source: Remove on-EmergencyCareWhenTravelingOutsideUS N BaseBenchmark Explainwhythestate/territorychosenottoincludethisbenefit: KansasMedicaiddoesnotcoveranyservicesoutsideoftheUnitedStates. Add ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page31of36

AlternativeBenefitPlan 14.Other1937CoveredBenefitsthatarenotEssentialHealthBenefitsCollapseAll ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page32of36

AlternativeBenefitPlan CollapseAll 15.AdditionalCoveredBenefits (Thiscategoryofbenefitsisnotapplicabletotheadultgroup undersection1902(a)(10)(A)(i)( VIII) oftheAct.) BenefitProvided: Source: Remove ursingFacilityServices N StatePlan1905(a) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: ServicesasspecifiedintheMedicaidStatePlan. Other: Providedtobeneficiariesassessedforthelevelofneedfornursingfacility. Thiscanbeeitherrehabilitation orlongtermcare. BenefitProvided: Source: Remove PeerSupport-Rehabilitation StatePlan1905(a) ProviderQualifications: Authorization: PriorAuthorizationMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: ServicesasspecifiedintheMedicaidStatePlan. Other: Activitiesincludedmustbeintendedtoachievetheidentifiedgoalsorobjectivesassetforthinthe consumer'sindividualizedtreatmentplan. BenefitProvided: Source: Remove CrisisIntervention-Rehabilitation StatePlan1905(a) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: ServicesasspecifiedintheMedicaidStatePlan. Other: oPAisrequiredforcrisisservices. Thelanguageinthe "Limitations/Exclusionsisasfollows "Re- N evaluationfortheneedofcrisisservicesistobecompletedbyaQMHPevery72hoursormorefrequently EffectiveDate: 04/01/2020 TransmittalNumber (TN): 20-0013 ApprovalDate: 07/16/2020 SupersedesTN: New Page33of36

AlternativeBenefitPlan asneeded." BenefitProvided: Source: Remove ExtendedServicesforPregnantWomen StatePlan1905(a) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: None60dayspostpartumcoverage ScopeLimit: ServicesasspecifiedintheMedicaidStatePlan. Pregnancyrelatedandpostpartumservicesfora60day periodafterthepregnancyendsandanyremainingdaysinthemonthinwhichthe60thdayfalls. Other: Servicesforanyothermedicalconditionsthatmaycomplicatepregnancy. BenefitProvided: Source: Remove RoutineEyeExam (Adult) StatePlan1905(a) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: OneexamperyearNone ScopeLimit: ServicesasspecifiedintheMedicaidStatePlan. Other: BenefitProvided: Source: Remove DentalServices StatePlan1905(a) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: ServicesmustbemedicallynecessaryandarelimitedtothosespecifiedintheMedicaidStatePlan. Other: Inaddition, theMCOsofferprophylacticcleaningsatleastonceperyear. EffectiveDate: 04/01/2020 TransmittalNumber (TN): 20-0013 ApprovalDate: 07/16/2020 SupersedesTN: New Page34of36

AlternativeBenefitPlan BenefitProvided: Source: Remove Eyeglasses StatePlan1905(a) ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: Yes, seeOtherbelow. None ScopeLimit: Yes, seeOtherbelow. Other: Onepair (lensesandframes) foradultsperyear. BenefitProvided: Source: Remove HealthHome - SeriousMentalIllness StatePlan1945 ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: ServicesasspecifiedinMedicaidStatePlan Other: MeetHealthHome - SMI (OneCareKansas) eligibilitycriteriaasdescribedinMedicaidStatePlan BenefitProvided: Source: Remove HealthHome - Asthma StatePlan1945 ProviderQualifications: Authorization: OtherMedicaidStatePlan AmountLimit: DurationLimit: NoneNone ScopeLimit: ServicesasspecifiedintheMedicaidStatePlan Other: MeetHealthHome - Asthma (OneCareKansas) eligibilitycriteria: Asthmaandatriskofdeveloping anotherchroniccondition - Diabetes, Hypertension, Cardiovasculardisease, COPD, MetabolicSyndrome, Mentalillness, Substanceusedisorder, MorbidObesity, TobaccoUseorexposuretosecondhandsmoke. ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page35of36

AlternativeBenefitPlan Add PRADisclosureStatement CentersforMedicare & MedicaidServices (CMS) collectsthismandatoryinformationinaccordancewith (42U.S.C. 1396a) forthe purposeofstandardizingdata. TheinformationwillbeusedtomonitorandanalyzeperformancemetricsrelatedtotheMedicaidand Children’sHealthInsuranceProgramineffortstoboostprogramintegrityefforts, improveperformanceandaccountabilityacrossthe programs. UnderthePrivacyActof1974anypersonallyidentifyinginformationobtainedwillbekeptprivatetotheextentofthelaw. AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1188. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20190808 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page36of36

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 BenefitsAssurancesABP7 EPSDTAssurances Ifthetargetpopulationincludespersonsunder21, pleasecompletethefollowingassurancesregardingEPSDT. Otherwise, skiptothe PrescriptionDrugCoverageAssurancesbelow. Thealternativebenefitplanincludesbeneficiariesunder21yearsofage.Yes Thestate/territoryassuresthatthenoticetoanindividualincludesadescriptionofthemethodforensuringaccesstoEPSDTservices 42CFR440.345). Thestate/territoryassuresEPSDTserviceswillbeprovidedtoindividualsunder21yearsofagewhoarecoveredunderthestate/ territoryplanundersection1902(a)(10)(A) oftheAct. IndicatewhetherEPSDTserviceswillbeprovidedonlythroughanAlternativeBenefitPlanorwhetherthestate/territorywillprovide additionalbenefitstoensureEPSDTservices: ThroughanAlternativeBenefitPlan. ThroughanAlternativeBenefitPlanwithadditionalbenefitstoensureEPSDTservicesasdefinedin1905(r). OtherInformationregardinghowESPDTbenefitswillbeprovidedtoparticipantsunder21yearsofage (optional): Themajorityofchildrenages0 - 21willcontinuetoreceiveEPSDTthroughtheKSMedicaidStatePlan. Averysmallnumberof childrenages16to21maybeemployedandeligiblefortheKSMedicaidBuy-Inprogram, WorkingHealthy, inwhichcasetheymay receiveallEPSDTservicesaswellastheservicesavailablethroughtheAlternativeBenefitPlan. PrescriptionDrugCoverageAssurances Thestate/territoryassuresthatitmeetstheminimumrequirementsforprescriptiondrugcoverageinsection1937oftheActand implementingregulationsat42CFR440.347. CoverageisatleastthegreaterofonedrugineachUnitedStatesPharmacopeia (USP) categoryandclassorthesamenumberofprescriptiondrugsineachcategoryandclassasthebasebenchmark. Thestate/territoryassuresthatproceduresareinplacetoallowabeneficiarytorequestandgainaccesstoclinicallyappropriate prescriptiondrugswhennotcovered. Thestate/territoryassuresthatwhenitpaysforoutpatientprescriptiondrugscoveredunderanAlternativeBenefitPlan, itmeetsthe requirementsofsection1927oftheActandimplementingregulationsat42CFR440.345, exceptforthoserequirementsthatare directlycontrarytoamount, durationandscopeofcoveragepermittedundersection1937oftheAct. Thestate/territoryassuresthatwhenconductingpriorauthorizationofprescriptiondrugsunderanAlternativeBenefitPlan, it complieswithpriorauthorizationprogramrequirementsinsection1927(d)(5) oftheAct. OtherBenefitAssurances Thestate/territoryassuresthatsubstitutedbenefitsareactuariallyequivalenttothebenefitstheyreplacedfromthebasebenchmark plan, andthatthestate/territoryhasactuarialcertificationforsubstitutedbenefitsavailableforCMSinspectionifrequestedbyCMS. Thestate/territoryassuresthatindividualswillhaveaccesstoservicesinRuralHealthClinics (RHC) andFederallyQualifiedHealth Centers (FQHC) asdefinedinsubparagraphs (B) and (C) ofsection1905(a)(2) oftheSocialSecurityAct. ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New 1of2

AlternativeBenefitPlan Thestate/territoryassuresthatpaymentforRHCandFQHCservicesismadeinaccordancewiththerequirementsofsection 1902(bb) oftheSocialSecurityAct. Thestate/territoryassuresthatitwillcomplywiththerequirementofsection1937(b)(5) oftheActbyproviding, effectiveJanuary1, 2014, toallAlternativeBenefitPlanparticipantsatleastEssentialHealthBenefitsasdescribedinsection1302(b) ofthePatient ProtectionandAffordableCareAct. Thestate/territoryassuresthatitwillcomplywiththementalhealthandsubstanceusedisorderparityrequirementsofsection 1937(b)(6) oftheActbyensuringthatthefinancialrequirementsandtreatmentlimitationsapplicabletomentalhealthorsubstance usedisorderbenefitscomplywiththerequirementsofsection2705(a) ofthePublicHealthServiceActinthesamemannerassuch requirementsapplytoagrouphealthplan. Thestate/territoryassuresthatitwillcomplywithsection1937(b)(7) oftheActbyensuringthatbenefitsprovidedtoAlternative BenefitPlanparticipantsinclude, foranyindividualdescribedinsection1905(a)(4)(C), medicalassistanceforfamilyplanning servicesandsuppliesinaccordancewithsuchsection. Thestate/territoryassurestransportation (emergencyandnon-emergency) forindividualsenrolledinanAlternativeBenefitPlanin accordancewith42CFR431.53. Thestate/territoryassures, inaccordancewith45CFR156.115(a)(4) and45CFR147.130, thatitwillprovideasEssentialHealth Benefitsabroadrangeofpreventiveservicesincluding: “A” and “B” servicesrecommendedbytheUnitedStatesPreventiveServices TaskForce; AdvisoryCommitteeforImmunizationPractices (ACIP) recommendedvaccines; preventivecareandscreeningfor infants, childrenandadultsrecommendedbyHRSA'sBrightFuturesprogram/project; andadditionalpreventiveservicesforwomen recommendedbytheInstituteofMedicine (IOM). PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New 2of2

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 ServiceDeliverySystemsABP8 Providedetailonthetypeofdeliverysystem(s) thestate/territorywillusefortheAlternativeBenefitPlan'sbenchmarkbenefitpackageor benchmark-equivalentbenefitpackage, includinganyvariationbytheparticipants' geographicarea. Typeofservicedeliverysystem(s) thestate/territorywilluseforthisAlternativeBenefitPlan(s). Selectoneormoreservicedeliverysystems: Managedcare. ManagedCareOrganizations (MCO). PrepaidInpatientHealthPlans (PIHP). PrepaidAmbulatoryHealthPlans (PAHP). PrimaryCareCaseManagement (PCCM). Fee-for-service. Otherservicedeliverysystem. ManagedCareOptions ManagedCareAssurance Thestate/territorycertifiesthatitwillcomplywithallapplicableMedicaidlawsandregulations, includingbutnotlimitedtosections 1903(m), 1905(t), and1932oftheActand42CFRPart438, inprovidingmanagedcareservicesthroughthisAlternativeBenefit Plan. ThisincludestherequirementforCMSapprovalofcontractsandratespursuantto42CFR438.6. ManagedCareImplementation PleasedescribetheimplementationplanfortheAlternativeBenefitPlanundermanagedcareincludingmember, stakeholder, and provideroutreachefforts. TheStatereceivedapprovaltoimplement "KanCare", managedcareforthemajorityofitsMedicaidenrollees, includingindividuals enrolledintheBenchmarkBenefitPlanWORK. KanCarewasauthorizedbyCMSunderthe1115authority, andbeganJanuary2013. Priortosubmittingthe1115waiverapplication, theAdministrationsoughtpublicinputthroughanopenprocessthatincludedaRequest forInformationinFebruary2011, andanopen-doorpolicywithstakeholdersandadvocates. Inthesummerof2011, theStateofKansas facilitatedaMedicaidpublicinputandstakeholderconsultationprocess, duringwhichmorethan1,700participantsengagedin discussionsonhowtoreformtheKansasMedicaidsystem. Participantsproducedmorethan2,000commentsandrecommendationsfor reform. AfterthreepublicforumsinTopeka, WichitaandDodgeCity, webteleconferenceswereheldwithstakeholdersrepresenting Medicaidpopulationgroupsandproviders. TheStatealsomadeanonlinecommenttoolavailable, andafourth, wrap-up publicforumwasconductedinOverlandParkinAugust2011. TheStatecarefullyconsideredtheinputfromthisprocessandfrom meetingswithadvocatesandproviderassociations. InNovember2011, KansasannouncedacomprehensiveMedicaidreformplanthat incorporatedthethemesthathademergedfromthepublicprocess, includingintegrated, whole-personcare; preservingandcreating pathstoindependence; alternativeaccessmodels; andenhancingcommunity-basedservices. TheStatereleasedaRequestfor Proposals (RFP) onNovember8, 2011, andsubmittedtoCMSaSection1115DemonstrationProjectproposalintheformofaconcept paperonJanuary26, 2012. AdvancenoticeoftheDemonstrationProjectwasdistributedtotribalrepresentatives, andaninitialtribal consultationmeetingwithrepresentativesofeachtribalgovernmentwasconductedonFebruary22, 2012. Statewideeducationaltours wherestakeholdersprovidedadditionalinputwereconductedfromAugust2012throughFebruary2013. Inaddition, weekly "Rapid Response" callswereheldwithconsumers, providersandotherstakeholdersfromJanuarythroughJune2013inordertoaddress concernsasquicklyaspossible. ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page1of3

AlternativeBenefitPlan MCO: ManagedCareOrganization Themanagedcaredeliverysystemisthesameasanalreadyapprovedmanagedcareprogram. Yes Themanagedcareprogramisoperatingunder (selectone): Section1915(a) voluntarymanagedcareprogram. Section1915(b) managedcarewaiver. Section1932(a) mandatorymanagedcarestateplanamendment. Section1115demonstration. Section1937Alternative (Benchmark) BenefitPlanstateplanamendment. IdentifythedatethemanagedcareprogramwasapprovedbyCMS: Januar1, 2013 y Describeprogrambelow: KanCareisdeliveringwhole-person, integratedcaretomorethan360,000consumersacrossthestate. Kansashascontracts withthreehealthplans, ormanagedcareorganizations (MCOs), tocoordinatehealthcarefornearlyallMedicaidbeneficiaries. TheKansasDepartmentofHealthandEnvironment (KDHE) andtheKansasDepartmentforAgingandDisabilityServices KDADS) administersKanCarewithintheStateofKansas. KDHEmaintainsfinancialmanagementandcontractoversightof theKanCareprogramwhileKDADSadministerstheMedicaidwaiverprogramsfordisabilityservices, mentalhealthand substanceabuse, aswellasoperatesthestatehospitalsandinstitutions. EachMedicaidconsumerhasachoiceatapplicationfor benefitsregardingfromwhichMCOtheywanttoreceiveservices. Iftheydonotchooseatapplication, theywillberandomly assignedtoanMCO. ConsumersinKanCarereceiveallthesameservicesprovidedunderthepreviousMedicaiddelivery system, plusadditionalservices. HowevertheinclusionofservicesprovidedthroughtheHomeandCommunityBasedServices waiverforconsumerswithintellectualordevelopmentaldisabilities (I/DD) wasdelayedforoneyearandbecamepartof KanCareonJanuary1, 2014. InadditiontotheservicesthatwereavailabletoMedicaidconsumerpriorto2013, thethree healthplansoffernewservicestotheirmembers, suchaspreventivedentalcareforadults, heart/lungtransplantsandbariatric surgery. ConsumershavetheoptionduringopenenrollmentseasononceayeartochangetoadifferentKanCarehealthplanif theyprefertodoso. Theopenseasoncorrespondswiththeiranniversarymonthofenrollmentintheprogram. Allpre-2013 MedicaidservicesareprovidedthroughtheKanCarehealthplans. Theseincludephysicalhealthservicessuchasdoctor appointmentsandhospitalvisits, behavioralhealthservices, dentalandvisioncare, pharmacy, transportation, andnursing facilitycare. AlltheservicesofferedthroughtheState'sHomeandCommunityBasedServiceswaiversarepartofKanCare withtheexceptionofthepreviouslynotedwaiverservicesforpeoplewithI/DD, whichbecamepartofKanCareFebruary1, 2014). TheKSMedicaidBuy-Inprogram, WorkingHealthy, andthesupplementalBenchmarkBenefitWORK, arealsoin KanCare. KanCarehealthplansarerequiredtocoordinateallofthedifferenttypesofcareaconsumerreceives. Thegoalsof theKanCareprogramaretoimproveoverallhealthoutcomeswhileslowingtherateofcostgrowthovertime. Thiswillbe accomplishedbyprovidingtherightcare, intherightamount, intherightsetting, attherighttime. Thehealthplansfocuson ensuringthatconsumersreceivethepreventiveservicesandscreeningstheyneedandongoinghelpwithmanagingchronic conditions. TheAlternativeBenefitPlanwillbeprovidedthroughprimarycarecasemanagement (PCCM) consistentwithapplicablemanaged carerequirements (42CFRPart438, section1903(m) oftheSocialSecurityAct, andsection1932oftheSocialSecurityAct). MCOProcurementorSelectionMethod IndicatethemethodusedtoselectMCOs: Competitiveprocurementmethod (RFP, RFA). Otherprocurement/selectionmethod. ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page2of3

AlternativeBenefitPlan Describethemethodusedbythestate/territorytoprocureorselecttheMCOs: OtherMCO-BasedServiceDeliverySystemCharacteristics OneormoreoftheAlternativeBenefitPlanbenefitsorserviceswillbeprovidedapartfromthemanagedcareorganization. No MCOservicedeliveryisprovidedonlessthanastatewidebasis. No MCOParticipationExclusions IndividualsareexcludedfromMCOparticipationintheAlternativeBenefitPlan:No GeneralMCOParticipationRequirements Indicateifparticipationinthemanagedcareismandatoryorvoluntary: Mandatoryparticipation. Voluntaryparticipation. Indicatethemethodforeffectuatingenrollment: DescribemethodofenrollmentinMCOs: ParticipantsaredefaultedtoanMCO, butgiven90daystomakeachange. Yearly, duringtheopenenrollmentprocess, participantsaregiven90daystomakeanewMCOchoiceortoremainwiththecurrentMCO. Participantsarealsoabletochange MCOsoutsideofOpenEnrollmentforagoodcausereasonasdefinedin42CFR438(d)(2). NativeAmericanscanoptoutof ManagedCareatanytime. AdditionalInformation: MCO (Optional) Provideanyadditionaldetailsregardingthisservicedeliverysystem (optional): PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20181119 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New Page3of3

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 EmployerSponsoredInsuranceandPaymentofPremiumsABP9 Thestate/territoryprovidestheAlternativeBenefitPlanthroughthepaymentofemployersponsoredinsurancefor participants withsuchcoverage, withadditionalbenefitsandservicesprovidedthroughaBenchmarkorBenchmark-EquivalentBenefit Yes Package. Provideadescriptionofemployersponsoredinsurance, includingthepopulationcovered, theamountofpremiumassistanceby population, employersponsoredinsuranceactivitiesincludingrequiredcontribution, cost-effectivenesstestrequirements, and benefitinformation: Thestateassuresthatemployersponsoredinsurance (ESI) coverageisestablishedinsections3.2and4.22(h) ofthestate'sapproved Medicaidstateplan. Thebeneficiarywillreceiveabenefitpackagethatincludesawrapofbenefitsaroundtheemployersponsored insuranceplanthatequalsthebenefitpackageinthealternativebenefitsplanknownastheKSWorkingHealthy/Workplan. The beneficiarywillnotberesponsibleforpaymentofpremiumsorothercostsharingthatexceedsnominallevelsasestablishedat42 CFRpart447subpartA. Thestate/territoryotherwiseprovidesforpaymentofpremiums. No OtherInformationRegardingEmployerSponsoredInsuranceorPaymentofPremiums: PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New 1of1

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 GeneralAssurancesABP10 EconomyandEfficiencyofPlans Thestate/territoryassuresthatAlternativeBenefitPlancoverageisprovidedinaccordancewithFederalupperpaymentlimit requirementsandothereconomyandefficiencyprinciplesthatwouldotherwisebeapplicabletotheservicesordeliverysystem throughwhichthecoverageandbenefitsareobtained. EconomyandefficiencywillbeachievedusingthesameapproachasusedforMedicaidstateplanservices. Yes CompliancewiththeLaw Thestate/territorywillcontinuetocomplywithallotherprovisionsoftheSocialSecurityActintheadministrationofthestate/ territoryplanunderthistitle. Thestate/territoryassuresthatAlternativeBenefitPlanbenefitsdesignsshallconformtothenon-discriminationrequirementsat42 CFR430.2and42CFR440.347(e). Thestate/territoryassuresthatallprovidersofAlternativeBenefitPlanbenefitsshallmeettheproviderqualificationrequirementsof theBaseBenchmarkPlanand/ortheMedicaidstateplan. PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New of1

AlternativeBenefitPlan OMBControlNumber: 09381148 StateName:Kansas Attachment3.1-L- TransmittalNumber:KS-20-0013 PaymentMethodologyABP11 AlternativeBenefitPlans - PaymentMethodologies Thestate/territoryprovidesassurancethat, foreachbenefitprovidedunderanAlternativeBenefitPlanthatisnotprovidedthrough managedcare, itwillusethepaymentmethodologyinitsapprovedstateplanorherebysubmitsstateplanamendmentAttachment 4.19a, 4.19bor4.19d, asappropriate, describingthepaymentmethodologyforthebenefit. Anattachmentissubmitted. PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage5hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC4-26-05, Baltimore, Maryland21244-1850. V.20160722 ApprovalDate: 07/16/2020Effective Date: 04/01/2020 TransmittalNumber (TN): 20-0013 SupersedesTN: New 1of1

Table of Contents

State/Territory Name: Kansas State Plan Amendment (SPA) #: 21-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages




 

 

   

 

    

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Table of Contents State/Territory Name: kansas State Plan Amendment (SPA) #: 21-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th Street Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services July 24, 2023 Sarah Fertig State Medicaid Director Kansas Department of Health and Environment, Division of Health Care Finance 900 SW Jackson, Suite 900 N Topeka, KS Topeka, KS 66612 Re: Approval of State Plan Amendment KS-21-0013 Dear Sarah Fertig, The Centers for Medicare & Medicaid Services (CMS) has completed its review of Kansas’ State Plan Amendment (SPA) 21-0013, Presumptive Eligibility (PE) and Hospital Presumptive Eligibility (HPE). This amendment proposes to expand PE to include the Parents and other Caretaker Relatives, Former Foster Care and Breast and Cervical Cancer groups, in addition to Children and Pregnant Women, and to allow the state-designated Qualified Entities to complete PE determinations for all groups covered in PE. This amendment additionally includes the online PE application/portal in both the state’s PE and HPE programs. CMS has reviewed screenshots of the online PE application, provider training materials, and the Reviewable Units that were submitted with this SPA. We approve Kansas State Plan Amendment (SPA) KS-21-0013 with an effective date(s) of July 01, 2021. If you have any questions regarding this amendment, please contact Michala Walker at michala.walker@cms.hhs.gov Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services - MS CENTEIIS JOR MEDICARE & MEDICAID SERVICIS

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 CMS-10434 OMB 0938-1188 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID N/A SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date N/A State Information State/Territory Name: Kansas Medicaid Agency Name: Kansas Department of Health and Environment, Division of Health Care Finance Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID N/A SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date N/A SPA ID and Effective Date SPA ID KS-21-0013 Reviewable Unit Proposed Effective Date Superseded SPA ID Presumptive Eligibility 7/1/2021 New Presumptive Eligibility for Children under Age 19 7/1/2021 KS14-0019 Parents and Other Caretaker Relatives - Presumptive Eligibility 7/1/2021 New Presumptive Eligibility for Pregnant Women 7/1/2021 KS14-0019 Former Foster Care Children - Presumptive Eligibility 7/1/2021 New Presumptive Eligibility by Hospitals 7/1/2021 KS-14-0008 Individuals Needing Treatment for Breast or Cervical Cancer - Presumptive Eligibility 7/1/2021 New Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID N/A SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The Kansas Department of Health and Environment, Division of Health Care Finance, KDHE-DHCF, is amending the Kansas Medicaid State Plan to revise the Presumptive Eligibility (PE) online application. The state is expanding PE to include Parents and other Caretaker Relatives, Former Foster Care and Breast and Cervical Cancer (in addition to children and Pregnant Women); and to include the online PE application/portal in both hospital presumptive eligibility and presumptive eligibility. The PE Tool is being enhanced to use a single application for Medicaid/CHIP and presumptive eligibility. Presumptive eligibility is being expanded to allow all Qualified Entities (QE) to complete PE determinations. This will expand all Qualified Entities’ ability to complete PE determinations for parents and caretaker relatives, former foster care children and individuals seeking treatment for breast or cervical cancer in addition to the pregnant woman and children. The portal allows individuals to apply for PE using an online PE-only application, and may also elect to submit both a PE and a full online Medicaid/CHIP application. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2021 $0 Second 2022 $0 Federal Statute / Regulation Citation 42 CFR 435 Subpart L Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID N/A SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/25/2023 1:36 PM EDT No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 CMS-10434 OMB 0938-1188 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 The state provides Medicaid services to individuals during a presumptive eligibility period following a determination by a qualified entity. Presumptive eligibility covered in the state plan includes: Eligibility Groups Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Presumptive Eligibility for Children under Age 19 APPROVED Parents and Other Caretaker Relatives - Presumptive Eligibility APPROVED Presumptive Eligibility for Pregnant Women APPROVED Adult Group - Presumptive Eligibility NEW Individuals above 133% FPL under Age 65 - Presumptive Eligibility NEW Individuals Eligible for Family Planning Services - Presumptive Eligibility NEW Former Foster Care Children - Presumptive Eligibility APPROVED Individuals Needing Treatment for Breast or Cervical Cancer - Presumptive Eligibility APPROVED Hospitals Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Presumptive Eligibility by APPROVED

□ □ 0 0 0 0 0 0 0 0 0

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Hospitals

Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/25/2023 2:03 PM EDT

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility for Children under Age 19 MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity. CMS-10434 OMB 0938-1188 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS14-0019 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 Presumptive eligibility for children is determined under the following provisions: A. Presumptive Eligibility Income Standard 1. The income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child's age. B. Presumptive Eligibility Age Limit Children under the following age may be determined presumptively eligible: Under age: 19

Presumptive Eligibility for Children under Age 19 MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS14-0019 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 C. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: 1. a. The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or 2. b. 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. 3. Periods of presumptive eligibility are limited as follows: a. No more than one period within a calendar year. b. No more than one period within two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. e. Other reasonable limitation: 0 0 0 0 0

Presumptive Eligibility for Children under Age 19 MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS14-0019 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 D. Application for Presumptive Eligibility Name Date Created PE Application Pages 4/27/2023 3:16 PM EDT 5. Describe the presumptive eligibility screening process: The Entity will conduct presumptive eligibility determinations for Medicaid based on information provided by applicants. As part of conducting such determinations, the Entity will interview individuals for completion of the presumptive eligibility application, make presumptive eligibility determinations, provide applicants with their eligibility results, and help individuals complete the KanCare application for ongoing coverage. The Entity will conduct these activities in accordance with all applicable laws, rules, regulations, and policies for Medicaid presumptive eligibility determinations. E. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. Household income must not exceed the applicable income standard for the child's age, described in Section A. 1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses the single streamlined paper and/or online application for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is attached. 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. 4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. a. A reasonable estimate of MAGI-based income is used to determine household income. b. Gross income is used to determine household size. 2. State residency 3. Citizenship, status as a national, or satisfactory immigration status □ ~ 0 0 Ea ~ I

Presumptive Eligibility for Children under Age 19 MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS14-0019 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 F. Qualified Entities 1. The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements. 2. The following qualified entities are used to determine presumptive eligibility for this eligibility group: Name of entity Description Qualified Clinics Qualified clinic means an entity that is determined by the State to be capable of making determinations of presumptive eligibility for children, pregnant women, parents and caretakers, former foster care, breast, or cervical cancer recipients, and that meets at least one of the following characteristics — (1) Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan. (2) Is authorized to determine eligibility of a child to participate in a Head Start program under the Head Start Act. (3) Is authorized to determine eligibility of a child to receive childcare services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990. (4) Is authorized to determine eligibility of an infant or child to receive assistance under the special nutrition program for women, infants, and children (WIC) under section 17 of the Child Nutrition Act of 1966. (5) Is authorized to determine eligibility of a child for medical assistance under the Medicaid State plan, or eligibility of a child for child health assistance under the State Children's Health Insurance Program. (6) 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). (7) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs. (8) Is a State or Tribal child support enforcement agency. (9) Is an organization that— (i) Provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act. (ii) Is a State or Tribal office or entity involved in enrollment in the program under title XIX, Part A of title IV, or title XXI; or (iii) Determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.). (10) Is a health facility operated by the Indian Health Service, a Tribe or Tribal organization under the Indian Self Determination and Education Assistance Act (25 U.S.C. 450 et seq.), or an Urban Indian Organization under title V of the Indian Health Care Improvement Act (25 U.S.C. 1651 et seq.). Other entity the agency determines is capable of making presumptive eligibility determinations ~

4. A copy of the training materials has been uploaded for review during the submission process. Name Date Created Presumptive Eligibility Policy 4/28/2023 9:49 AM EDT Presumptive Eligibility Approval.Denial 4/28/2023 9:49 AM EDT Presumptive Eligibility Approval 4/28/2023 9:49 AM EDT Presumptive Eligibility Denial 4/28/2023 9:49 AM EDT Immigrant Eligibility Worksheet 4/28/2023 9:49 AM EDT 1 – 5 of 5 3. The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included. I I I I I

Presumptive Eligibility for Children under Age 19 MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS14-0019 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 G. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/25/2023 2:05 PM EDT

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Medicaid State Plan Eligibility Presumptive Eligibility Parents and Other Caretaker Relatives - Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 The state covers parents and other caretaker relatives when determined presumptively eligible by a qualified entity. CMS-10434 OMB 0938-1188 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 The state covers parents and other caretaker relatives when determined presumptively eligible by a qualified entity. A. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: a. The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or b. 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. 3. Periods of presumptive eligibility are limited as follows: a. No more than one period within a calendar year. b. No more than one period within two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. e. Other reasonable limitation: 0 0 0 0 0

Parents and Other Caretaker Relatives - Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 B. Application for Presumptive Eligibility Name Date Created PE Application Pages 4/27/2023 3:29 PM EDT 5. Describe the presumptive eligibility screening process: The Entity will conduct presumptive eligibility determinations for Medicaid based on information provided by applicants. As part of conducting such determinations, the Entity will interview individuals for completion of the presumptive eligibility application, make presumptive eligibility determinations, provide applicants with their eligibility results, and help individuals complete the KanCare application for ongoing coverage. The Entity will conduct these activities in accordance with all applicable laws, rules, regulations, and policies for Medicaid presumptive eligibility determinations. C. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The individual must be a caretaker relative, as described at 42 CFR 435.110. 2. Household income must not exceed the applicable income standard described at 42 CFR 435.110. 1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses the single streamlined paper and/or online application for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is attached. a. Paper - A copy of the application form is included. b. Online - A copy of the application form is included. 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. 4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. a. A reasonable estimate of MAGI-based income is used to determine household income. b. Gross income is used to determine household income. 3. State residency 4. Citizenship, status as a national, or satisfactory immigration status □ □ 0 0 I

Parents and Other Caretaker Relatives - Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 D. Qualified Entities 1. The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements. 2. The following qualified entities are used to determine presumptive eligibility for this eligibility group: Name of entity Description Qualified Clinics Qualified clinic means an entity that is determined by the State to be capable of making determinations of presumptive eligibility for children, pregnant women, parents and caretakers, former foster care, breast, or cervical cancer recipients, and that meets at least one of the following characteristics — (1) Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan. (2) Is authorized to determine eligibility of a child to participate in a Head Start program under the Head Start Act. (3) Is authorized to determine eligibility of a child to receive childcare services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990. (4) Is authorized to determine eligibility of an infant or child to receive assistance under the special nutrition program for women, infants, and children (WIC) under section 17 of the Child Nutrition Act of 1966. (5) Is authorized to determine eligibility of a child for medical assistance under the Medicaid State plan, or eligibility of a child for child health assistance under the State Children's Health Insurance Program. (6) 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). (7) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs. (8) Is a State or Tribal child support enforcement agency. (9) Is an organization that— (i) Provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act. (ii) Is a State or Tribal office or entity involved in enrollment in the program under title XIX, Part A of title IV, or title XXI; or (iii) Determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.). (10) Is a health facility operated by the Indian Health Service, a Tribe or Tribal organization under the Indian Self Determination and Education Assistance Act (25 U.S.C. 450 et seq.), or an Urban Indian Organization under title V of the Indian Health Care Improvement Act (25 U.S.C. 1651 et seq.). Other entity the agency determines is capable of making presumptive eligibility determinations ~

4. A copy of the training materials has been uploaded for review during the submission process. Name Date Created Presumptive Eligibility Policy 4/28/2023 9:52 AM EDT Presumptive Eligibility Approval.Denial 4/28/2023 9:52 AM EDT Presumptive Eligibility Approval 4/28/2023 9:52 AM EDT Presumptive Eligibility Denial 4/28/2023 9:52 AM EDT Immigrant Eligibility Worksheet 4/28/2023 9:52 AM EDT 1 – 5 of 5 3. The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. I I I I I

Parents and Other Caretaker Relatives - Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 E. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/25/2023 2:06 PM EDT

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility for Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 CMS-10434 OMB 0938-1188 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS14-0019 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 The state covers ambulatory prenatal care for individuals qualifying as pregnant women under 42 CFR 435.116 when determined presumptively eligible by a qualified entity. A. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: a. The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or b. 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. 3. There may be no more than one period of presumptive eligibility per pregnancy. B. Application for Presumptive Eligibility Name Date Created PE Application Pages 4/27/2023 3:34 PM EDT 5. Describe the presumptive eligibility screening process: The Entity will conduct presumptive eligibility determinations for Medicaid based on information provided by applicants. As part of conducting such determinations, the Entity will interview individuals for completion of the presumptive eligibility application, make presumptive eligibility determinations, provide applicants with their eligibility results, and help individuals complete the KanCare application for ongoing coverage. The Entity will conduct these activities in accordance with all applicable laws, rules, regulations, and policies for Medicaid presumptive eligibility determinations. C. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The woman must be pregnant. 2. Household income must not exceed the applicable income standard at 42 CFR 435.116. 1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses the single streamlined paper and/or online application for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is attached. a. Paper - A copy of the application form is included. b. Online - A copy of the application form is included. 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. 4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. a. A reasonable estimate of MAGI-based income is used to determine household income. □ □ 0 D D I

b. Gross income is used to determine household size. 3. State residency 4. Citizenship, status as a national, or satisfactory immigration status

Presumptive Eligibility for Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS14-0019 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 D. Qualified Entities 1. The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements. 2. The following qualified entities are used to determine presumptive eligibility for this eligibility group: Name of entity Description Qualified Clinics Qualified clinic means an entity that is determined by the State to be capable of making determinations of presumptive eligibility for children, pregnant women, parents and caretakers, former foster care, breast, or cervical cancer recipients, and that meets at least one of the following characteristics — (1) Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan. (2) Is authorized to determine eligibility of a child to participate in a Head Start program under the Head Start Act. (3) Is authorized to determine eligibility of a child to receive childcare services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990. (4) Is authorized to determine eligibility of an infant or child to receive assistance under the special nutrition program for women, infants, and children (WIC) under section 17 of the Child Nutrition Act of 1966. (5) Is authorized to determine eligibility of a child for medical assistance under the Medicaid State plan, or eligibility of a child for child health assistance under the State Children's Health Insurance Program. (6) 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). (7) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs. (8) Is a State or Tribal child support enforcement agency. (9) Is an organization that— (i) Provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act. (ii) Is a State or Tribal office or entity involved in enrollment in the program under title XIX, Part A of title IV, or title XXI; or (iii) Determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.). (10) Is a health facility operated by the Indian Health Service, a Tribe or Tribal organization under the Indian Self Determination and Education Assistance Act (25 U.S.C. 450 et seq.), or an Urban Indian Organization under title V of the Indian Health Care Improvement Act (25 U.S.C. 1651 et seq.). Other entity the agency determines is capable of making presumptive eligibility determinations ~

4. A copy of the training materials has been uploaded for review during the submission process. Name Date Created Presumptive Eligibility Policy 4/28/2023 9:54 AM EDT Presumptive Eligibility Approval.Denial 4/28/2023 9:54 AM EDT Presumptive Eligibility Approval 4/28/2023 9:54 AM EDT Presumptive Eligibility Denial 4/28/2023 9:54 AM EDT Immigrant Eligibility Worksheet 4/28/2023 9:54 AM EDT 1 – 5 of 5 3. The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. I I I I I

Presumptive Eligibility for Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS14-0019 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 E. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/25/2023 2:07 PM EDT

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Medicaid State Plan Eligibility Presumptive Eligibility Former Foster Care Children - Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 The state covers former foster care children when determined presumptively eligible by a qualified entity. CMS-10434 OMB 0938-1188 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 A. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: a. The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or b. 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. 3. Periods of presumptive eligibility are limited as follows: a. No more than one period within a calendar year. b. No more than one period within two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. e. Other reasonable limitation: 0 0 0 0 0

Former Foster Care Children - Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 B. Application for Presumptive Eligibility Name Date Created PE Application Pages 4/27/2023 3:50 PM EDT 5. Describe the presumptive eligibility screening process: The Entity will conduct presumptive eligibility determinations for Medicaid based on information provided by applicants. As part of conducting such determinations, the Entity will interview individuals for completion of the presumptive eligibility application, make presumptive eligibility determinations, provide applicants with their eligibility results, and help individuals complete the KanCare application for ongoing coverage. The Entity will conduct these activities in accordance with all applicable laws, rules, regulations, and policies for Medicaid presumptive eligibility determinations. C. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The individual must meet the categorical requirements of 42 CFR 435.150. 1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses the single streamlined paper and/or online application for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is attached. a. Paper - A copy of the application form is included. b. Online - A copy of the application form is included. 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. 4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. 2. State residency 3. Citizenship, status as a national, or satisfactory immigration status □ □ I

Former Foster Care Children - Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 D. Qualified Entities 1. The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements. 2. The following qualified entities are used to determine presumptive eligibility for this eligibility group: Name of entity Description Qualified Clinics Qualified clinic means an entity that is determined by the State to be capable of making determinations of presumptive eligibility for children, pregnant women, parents and caretakers, former foster care, breast, or cervical cancer recipients, and that meets at least one of the following characteristics — (1) Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan. (2) Is authorized to determine eligibility of a child to participate in a Head Start program under the Head Start Act. (3) Is authorized to determine eligibility of a child to receive childcare services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990. (4) Is authorized to determine eligibility of an infant or child to receive assistance under the special nutrition program for women, infants, and children (WIC) under section 17 of the Child Nutrition Act of 1966. (5) Is authorized to determine eligibility of a child for medical assistance under the Medicaid State plan, or eligibility of a child for child health assistance under the State Children's Health Insurance Program. (6) 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). (7) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs. (8) Is a State or Tribal child support enforcement agency. (9) Is an organization that— (i) Provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act. (ii) Is a State or Tribal office or entity involved in enrollment in the program under title XIX, Part A of title IV, or title XXI; or (iii) Determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.). (10) Is a health facility operated by the Indian Health Service, a Tribe or Tribal organization under the Indian Self Determination and Education Assistance Act (25 U.S.C. 450 et seq.), or an Urban Indian Organization under title V of the Indian Health Care Improvement Act (25 U.S.C. 1651 et seq.). Other entity the agency determines is capable of making presumptive eligibility determinations ~

4. A copy of the training materials has been uploaded for review during the submission process. Name Date Created Presumptive Eligibility Policy 4/28/2023 9:56 AM EDT Presumptive Eligibility Approval.Denial 4/28/2023 9:56 AM EDT Presumptive Eligibility Approval 4/28/2023 9:56 AM EDT Presumptive Eligibility Denial 4/28/2023 9:56 AM EDT Immigrant Eligibility Worksheet 4/28/2023 9:56 AM EDT 1 – 5 of 5 3. The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. I I I I I

Former Foster Care Children - Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID New User-Entered SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 E. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/25/2023 2:08 PM EDT

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 CMS-10434 OMB 0938-1188 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS-14-0008 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 A. Qualifications of Hospitals A qualified hospital is a hospital that: 1. Participates as a provider under the state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. 2. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. 3. Assists individuals in completing and submitting the full application and understanding any documentation requirements. The state provides an assurance that it has policies and procedures in place to enable qualified hospitals to determine presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: Yes No 0 0

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS-14-0008 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 B. Eligibility Groups or Populations Included The eligibility groups or populations for which hospitals determine eligibility presumptively are: 1. Pregnant Women 2. Infants and Children under Age 19 3. Parents and Other Caretaker Relatives 4. Adult Group, if covered by the state 5. Individuals above 133% FPL under Age 65, if covered by the state 6. Individuals Eligible for Family Planning Services, if covered by the state 7. Former Foster Care Children 8. Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state The state limits qualified hospitals for this group to providers who conduct screenings for breast and cervical cancer under the state’s Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program. Yes No 9. Other Medicaid state plan eligibility groups: 10. Demonstration populations covered under section 1115 0 0 □ □

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS-14-0008 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 C. Standards for Participating Hospitals The state establishes reasonable standards for qualified hospitals making presumptive eligibility determinations. Percentage of individuals submitting a regular application: 98.00% Percentage of individuals found eligible for Medicaid 85.00% Description 95.00% of Presumptive Eligibility determinations are completed accurately. D. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. 3. Periods of presumptive eligibility are limited as follows: Yes No The state has a standard requiring that a percentage of individuals who are determined presumptively eligible submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. The state has a standard requiring that a percentage of individuals who are determined presumptively eligible be determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. The state has elected one or more other reasonable standard(s). a. No more than one period within a calendar year. b. No more than one period within two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. e. Other reasonable limitation: 0 0 ~ 0 0 0 0 0

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS-14-0008 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 E. Application for Presumptive Eligibility Name Date Created PE Application Pages 4/27/2023 3:45 PM EDT 5. Describe the presumptive eligibility screening process: The Entity will conduct presumptive eligibility determinations for Medicaid based on information provided by applicants. As part of conducting such determinations, the Entity will interview individuals for completion of the presumptive eligibility application, make presumptive eligibility determinations, provide applicants with their eligibility results, and help individuals complete the KanCare application for ongoing coverage. The Entity will conduct these activities in accordance with all applicable laws, rules, regulations, and policies for Medicaid presumptive eligibility determinations. F. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) 2. Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. 1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses the single streamlined paper and/or online application form for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is included. 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. 4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. a. A reasonable estimate of MAGI-based income is used to determine household income. b. Gross income is used to determine household size. c. Other income methodology 3. State residency 4. Citizenship, status as a national, or satisfactory immigration status □ Iii 0 0 0 Iii Iii I

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | KS2021MS0001O | KS-21-0013 Package Header Package ID KS2021MS0001O Submission Type Official Approval Date 07/24/2023 Superseded SPA ID KS-14-0008 System-Derived SPA ID KS-21-0013 Initial Submission Date 7/30/2021 Effective Date 7/1/2021 G. Qualified Entity Requirements 2. A copy of the training materials has been uploaded for review during the submission process. Name Date Created Presumptive Eligibility Policy 4/28/2023 9:59 AM EDT Presumptive Eligibility Approval.Denial 4/28/2023 9:59 AM EDT Presumptive Eligibility Approval 4/28/2023 9:59 AM EDT Presumptive Eligibility Denial 4/28/2023 9:59 AM EDT Immigrant Eligibility Worksheet 4/28/2023 9:59 AM EDT 1 – 5 of 5 H. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/25/2023 2:10 PM EDT 1. The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. I I I I I

Records / Submission Packages - View All KS - Submission Package - KS2021MS0001O - (KS-21-0013) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions Reviewable Units Print Preview Select a reviewable unit below to view in a printer friendly format. To view all the package components in a consolidated print preview, click the "View Consolidated Print Preview" button at the bottom of the page. After generating the consolidated print preview, you may use your browser to print or save the content. The preview will automatically terminate after 5 minutes. Spell Check Instructions | Request System Help Should Package Information be included in the consolidated report? Should Approval/Disapproval notice be included in the consolidated report? Should RAI data be included in the consolidated report? Please select reviewable units that need to be present in the consolidated report. If none are selected, all of the reviewable units will be present in the consolidated report by default. Also, on click of an individual reviewable unit name, printer friendly format of that reviewable unit data can be viewed. Submission Form - Reviewable Units Reviewable Unit Updated By Updated Date Sta Submission - Summary William Stelzner 4/27/2023 3:13 PM EDT Submission - Public Comment William Stelzner 7/30/2021 4:03 PM EDT Submission - Tribal Input William Stelzner 7/30/2021 4:04 PM EDT Medicaid Eligibility SPA - Reviewable Units Yes No Yes No Yes No 0 0 0 0 0 0 □ □ □ □

Reviewable Unit Proposed Effective Date Effective Date Updated By Updated Date Other Approve Version Sta Presumptive Eligibility 7/1/2021 7/1/2021 William Stelzner 7/30/2021 4:04 PM EDT Presumptive Eligibility for Children under Age 19 7/1/2021 7/1/2021 William Stelzner 5/17/2023 9:36 AM EDT Parents and Other Caretaker Relatives - Presumptive Eligibility 7/1/2021 7/1/2021 William Stelzner 5/17/2023 9:38 AM EDT Presumptive Eligibility for Pregnant Women 7/1/2021 7/1/2021 William Stelzner 5/17/2023 9:39 AM EDT Former Foster Care Children - Presumptive Eligibility 7/1/2021 7/1/2021 William Stelzner 5/17/2023 9:41 AM EDT Presumptive Eligibility by Hospitals 7/1/2021 7/1/2021 William Stelzner 4/28/2023 11:15 AM EDT Individuals Needing Treatment for Breast or Cervical Cancer - Presumptive Eligibility 7/1/2021 7/1/2021 William Stelzner 5/17/2023 9:43 AM EDT 1 – 7 of 7 CANCEL VIEW CONSOLIDATED PRINT PREVIEW □ □ 4 C □ 4 C □ 4 C 4 C 4 C 4 C 4 C D

Table of Contents

State/Territory Name: Kansas State Plan Amendment (SPA) #: 22-0029 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 September 16, 2022 Sarah Fertig, State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Suite 900 N Topeka, KS 66612-1220 Re: Kansas State Plan Amendment (SPA) 22-0029 Dear Ms. Fertig: The Centers for Medicare & Medicaid Services (CMS) reviewed the proposed Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 22-0029. This amendment proposes to temporarily implement a disregard of income that would have otherwise been part of an individual’s liability for institutional or home and community-based waiver services based on application of the post-eligibility treatment-of income (PETI) rules, but which became countable resources on or after March 18, 2020. CMS conducted our review of your submittal according to statutory requirements in Title XIX of the Act and implementing regulations. This letter is to inform you that Kansas’ Medicaid SPA Transmittal Number 22-0029 is approved effective the day after the end of the COVID-19 public health emergency. If you have any questions, please contact Michala Walker at 816-426-6503 or via email at michala.walker@cms.hhs.gov. Sincerely, Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2022.09.16 07:58:10 -04'00'

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED ‘OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

1. TRANSMITTAL NUMBER 2. STATE 22. _— _0029 KS

3. PROGRAM IDENTIFICATION: TITLE _XIXOF THE SOCIAL SECURITY ACT

TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE

The first date after the end of the PHE

5. FEDERAL STATUTE/REGULATION CITATION FFCRA

6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2022 g_0 b. FFY__2023 $_0

7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Section 7.4.c , page 1

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

New

9. SUBJECT OF AMENDMENT

Temporary 12-month Post-PHE Disregard of Post-Eligibility Treatment of Income (PETI) rules.

10. GOVERNOR'S REVIEW (Check One)

[_|covernor's OFFICE REPORTED NO COMMENT | COMMENTS OF GOVERNOR'S OFFICE ENCLOSED E] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED:

Sarah Fertig is the Governor's Designee

AGENCY OFFICIAL

“12. TYPED NAME Sarah Fertig

13. TITLE State Medicaid Director

14. DATE SUBMITTED August 16, 2022

15. RETURN TO

Sarah Fertig, State Medicaid Director KDHE, Division of Health Care Finance Landon State Office Building

900 SW Jackson, Room 900-N Topeka, KS 66612-1220

FOR CMS USE ONLY

16. DATE RECEIVED August 16, 2022

17. DATE APPROVED

September 16, 2022

PLAN APPROVED - ONE COPY ATTACHED

18. EFFECTIVE DATE OF APPROVED MATERIAL the first day after the end of the PHE

19. SIGNATURE OF ARRROYINS OFF Oidiblly signed by Alissa

M. Deboy -S Date: 2022 09.16 07.5834 04'00"

Deboy -S

20. TYPED NAME OF APPROVING OFFICIAL Alissa Mooney DeBoy

21. TITLE OF APPROVING OFFICIAL On Behalf of Anne Marie Costello, Deputy Director, CMCS

22. REMARKS

FORM CMS-179 (09/24)

Box 7: State authorized pen and ink change on 9/13/22

Instructions on Back

State/Territory: Kansas Page 1 TN: KS-22-0029

Approval Date: 9/16/2022 Supersedes TN: NEW

Effective Date: the first day after the end of the PHE This SPA is in addition to all previous approved Disaster Relief SPAs, and does not supersede anything approved in those SPAs. Section 7 General Provisions 7.4.C. Temporary Policies in effect following the COVID-19 National Emergency Effective the day after the end of the PHE until twelve months after, the agency temporarily implements the following changes to the state plan: Income that would have otherwise been part of an individual’s liability for his or her institutional or home and community-based waiver services based on application of the post-eligibility treatment-of income (PETI) rules, but which became countable resources on or after March 18, 2020. Such resources will be disregarded through the twelve months following the end of the month in which the COVID-19 public health emergency ends.

Table of Contents

State/Territory Name: Kansas State Plan Amendment (SPA) #: 22-0030 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 October 14, 2022 Sarah Fertig, State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Suite 900 N Topeka, KS 66612-1220 Re: Kansas State Plan Amendment (SPA) 22-0030 Dear Ms. Fertig: We have reviewed the proposed amendment to add section 7.4.A. Rescissions to the State’s Disaster Relief Policies for the COVID-19 National Emergency to Kansas’ Medicaid state plan, as submitted under transmittal number (TN) 22-0030. This amendment proposes to rescind temporary policies, in section 7.4. Medicaid Disaster Relief for the National Emergency. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Social Security Act and implementing regulations. Section 7.4 of the Medicaid state plan provides temporary authority for these provisions and is intended to be in effect only for the duration of the COVID-19 public health emergency. Due to the temporary nature of this provision, Medicaid SPA Transmittal Number 22-0030 is approved effective July 1, 2022. Enclosed is a copy of the CMS-179 summary form and the approved state plan page. Please contact Michala Walker at 816-426-6503 or by email at michala.walker@cms.hhs.gov if you have any questions about this approval. Sincerely, Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2022.10.14 08:18:34 -04'00'

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED ‘OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

1. TRANSMITTAL NUMBER 2. STATE 22 _— _0030 KS

3. PROGRAM IDENTIFICATION: TITLE _XIXOF THE SOCIAL SECURITY ACT

TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE July 1, 2022

5. FEDERAL STATUTE/REGULATION CITATION 42 CFR 44% Subpart L

6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY_2022 $_0 b. FFY__2023 $_0

7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Section 7.4.A. page 2

8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION

None

9. SUBJECT OF AMENDMENT

A rescission to a Disaster Recovery SPA, regarding the authority granted to allow for two Presumptive Eligibility (PE) periods during a twelve-month period. The agency rescinds he elections at B.1, B 2, and B 3 of section 7.4 (approved on 05/11/2020 in SPA Number KS-20-0012) of the state plan. This will revert the State back to the practice of one PE period for parents or caretaker relatives, children, former foster care children, and one presumptive eligibility period per pregnancy per a 12 month period; remove the state as a qualified entity; and eliminate the ability for qualified providers to determine eligibility for Parents/Caretaker Relatives and Former Foster Care Children.

10. GOVERNOR'S REVIEW (Check One)

[_|covernor's OFFICE REPORTED NO COMMENT | COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Eq NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED:

Sarah Fertig is the Governor's Designee

15. RETURN TO Sarah Fertig, State Medicaid Director KDHE, Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220

GENCY OFFICIAL

12. TYPED NAME Sarah Fertig

13. TITLE State Medicaid Director

14. DATE SUBMITTED September 7, 2022

FOR CMS USE ONLY 17. DATE APPROVED

16. DATE RECEIVED

September 7, 2022 October 14, 2022

PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 19. SIGNATURE OF APPRPSSEGNAFFICLAP Oaly signed by Alissa Date: 2022.10.14 July 1, 2022 Deboy -S 0819-11 0400" 20. TYPED NAME OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL

Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director, CMCS

22. REMARKS

FORM CMS-179 (09/24) Instructions on Back

Boxes 5 and 7: State authorized pen and ink changes on 10/5/22.

State/Territory: __Kansas____

Page 2

TN: KS-22-0030 Approval Date: 10/14/2022 Supersedes TN No. NEW

Effective Date: 7/1/2022 7.4.A. Rescissions to the State’s Disaster Relief Policies for the COVID-19 National Emergency

Effective 7/1/2022, the agency rescinds the elections at B.1, B.2 and B.3 of section 7.4 (approved on 05/11/2020 in SPA Number KS-20-0012) of the state plan, including the following provisions: x B1 - The state will allow two PE periods during a twelve-month period during the Public Health Emergency (PHE) (increase from one during a 12-month period in SPA 14-0008). The PE period begins the first day of the month of the initial PE period. The state will limit the number of PE periods for PW from one per pregnancy (in KS 14-0008) to two per pregnancy. x B2 - The state will allow two PE periods during a twelve-month period during the Public Health Emergency (PHE). The PE period begins the first day of the month of the initial PE period. The state will the limit the number of PE periods for PW to two per pregnancy. The state will limit the number of PE periods individuals may have to no more than two within a 12-month period, starting with the first day of the month of the initial PE period. The populations covered are Parent or Caretaker Relatives and Former Foster Care, Pregnant Women, and Children. x B3 – o The state allows the qualified entities listed in PE SPA KS14-0002 to make PE determinations for Parent or Caretaker Relatives and Former Foster Care in addition to Pregnant Women and Children. o The state will increase the reasonable limits on the number of PE periods individuals may have to no more than two (from one in KS14-002) within a 12-month period, starting with the first day of the month of the initial PE period. o KS will increase the number of PE periods for PW from one per pregnancy (in KS 14- 0002) to two per pregnancy.

Table of Contents

State/Territory Name: Kansas State Plan Amendment (SPA) #: 23-0011 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

March 17, 2023

Sarah Fertig, State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220

Re: Kansas State Plan Amendment (SPA) 23-0011

Dear Ms. Fertig:

The Centers for Medicare & Medicaid Services (CMS) reviewed the proposed Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 23-0011. This amendment proposes to temporarily implement a disregard of income that would have otherwise been part of an individual’s liability for institutional or home and community-based waiver services based on application of the post-eligibility treatment of income (PETI) rules, but which became countable resources on or after March 18, 2020. This disregard was originally approved in Disaster Relief SPA 22-0029 and is now being approved with the following modification: changing the effective date from the day after the COVID-19 public health emergency ends to April 1, 2023.

CMS conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations. This letter is to inform you that Kansas’ Medicaid SPA Transmittal Number 23-0011 is approved effective April 1, 2023.

If you have any questions, please contact Michala Walker at 816-426-6503 or via email at Michala.Walker@cms.hhs.gov.

Sincerely,

Alissa Mooney DeBoy

On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services

Enclosures

Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2023.03.17 07:48:01 -04'00'

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED ‘OMB No. 0938-0193

1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 23 __ 0011 KS STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES __ | 3. PROGRAM IDENTIFICATION: TITLE _XIXOF THE SOCIAL SECURITY ACT TO: CENTER DIRECTOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICAID & CHIP SERVICES April 1. 2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES pi’. 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) FFCRA, Consolidated Appropriations Act (CAA), 2023 a FFY_2023 $_0 b. FFY_2024 $_0

7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Section 7.4.C., Page 1

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

Section 7.4.C., Page 1

9. SUBJECT OF AMENDMENT

The proposed effective date of Section 7.4.C., Page 1 is changed to April 1, 2023.

10. GOVERNOR'S REVIEW (Check One)

[_]covernor's OFFICE REPORTED NO COMMENT | COMMENTS OF GOVERNOR'S OFFICE ENCLOSED LC] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED: Sarah Fertig is the Governor's Designee

GENCY OFFICIAL

Sarah Fertig

13. TITLE State Medicaid Director

14. DATE SUBMITTED February 21, 2023

15. RETURN TO Sarah Fertig, State Medicaid Director KDHE, Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220

FOR CMS

USE ONLY

16. DATE RECEIVED February 21, 2023

17. DATE APPROVED March 17, 2023

PLAN APPROVED - ONE COPY ATTACHED

18. EFFECTIVE DATE OF APPROVED MATERIAL April 1, 2023

Digitally signed by Alissa M. Deboy -S

Date: 2023.03.17 07:48:18 -04°00"

19. SIGNATURE OF APPROVAVIS Qa A\GIAL Deboy -S

20. TYPED NAME OF APPROVING OFFICIAL

Alissa Mooney DeBoy )

21. TITLE OF APPROVING OFFICIAL nm Behalf of Anne Marie Costello, Deputy Director, CMCS

22. REMARKS

FORM CMS-179 (09/24)

Instructions on Back

State/Territory: Kansas Page 1 TN: KS-23-0011

Approval Date: March 17, 2023 Supersedes TN: KS-22-0029

Effective Date: April 1, 2023

Section 7 General Provisions 7.4.C. Temporary Policies in effect following the COVID-19 National Emergency Effective April 1, 2023, the agency temporarily implements the following changes to the state plan: The agency applies less restrictive resource methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows: Income that would have otherwise been part of an individual’s liability for his or her institutional or home and community-based waiver services based on application of the post-eligibility treatment-of income (PETI) rules, but which became countable resources on or after March 18, 2020. Such resources will be disregarded through the twelve months following the end of the continuous enrollment requirement enacted by section 6008(b)(3) of the Families First Coronavirus Response Act and amended by section 5131(a)(2)(C) of the Consolidated Appropriations Act, 2023.

Table of Contents State/Territory Name: Kansas State Plan Amendment (SPA) #: 23-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMA.1'1 SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group May 19, 2023 Saral1 Fe1tig, St.ate Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Suite 900 N Topeka, KS 66612-1220 Re: Kansas State Plan Amendment (SPA) 23-0015 Dear Ms. Fertig: CENTERS FOR MEOICARE & MEOICAIO SloRVICES CENTER FOR MEDIC41D & CHIP SERVICES The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 23-0015. This amendment proposes to align premium rates for the Working Healthy program with recent changes to the protected income level for Kansas Home- and Community-Based Services waivers, which eliminates premiums for most beneficiaries. We conducted our review of your submittal according to statuto1y requirements in Title XIX of the Social Security Act and implementing regulations 42 CFR 447.50-57. This letter is to inform you that Kansas Medicaid SPA 23-0015 was approved on May 19, 2023 with an effective date of May 1, 2023. If you have any questions, please contact Michala Walker at 816-426-6503 or via email at Michala. Walker@cms.hhs.gov. Enclosures cc: Bobbie Graff-Hendrixson William Stelzner William Thompson James G. Scott, Director Division of Program Operations

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2.STATE FORM APPROVED 0MB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 23 0015 KS - STA TE PLAN MATERIAL ---- -------- ---- FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIXOF THE SOCIAL SECURITY ACT TO: CENTER DIRECTOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES May 1, 2023 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) 4:;! GFR 447 Sections 1916 and 1916A of the SSA; 42 CFR447.50-57 a FFY 2023 $ 0 b. FFY 2024 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 2.6-A, Page 120 Attachment 2.6-A, Page 120 9. SUBJECT OF AMENDMENT The Working Healthy premium rates are being realigned with the recent changes to the protected income limit for HCBS waivers. 10. GOVERNOR'S REVIEW (Check One) !~ !GOVERNOR'S OFFICE REPORTED NO COMMENT D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED □ NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 11 . SIGNATURE OF STATE AGENCY OFFICIAL 12. TYPED NAME Sarah Fertig 13. TITLE State Medicaid Director 14. DATE SUBMITTED April 12, 2023 El OTHER, AS SPECIFIED: Sarah Fertig is the Governor's Designee 15. RETURN TO Sarah Fertig, State Medicaid Director KDHE, Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220 FOR CMS USE ONLY 16. DATE RECEIVED 17. DATE APPROVED April 12, 2023 May 19, 2023 PLAN APPROVED- ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MA TE RIAL May 1, 2023 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS 21. TITLE OF APPROVING OFFICIAL Director, Division of Program Operations Box 5: State authorized pen and ink change on 04/25/2023. FORM CMS-179 (09/24) Instructions on Back

KANSAS MEDICAID STATE PLAN

ATTACHMENT 2.6-A PAGE 12o

Citation

Condition or Requirement Sections 1902(a)(I0)(A) (ii)(XV), (XVI), and 1916 (g) of the Act (cont.) Premiums and Other Cost-Sharing Charges

For the Basic Coverage Group and the Medical Improvement Group, the agency's premium or other cost-sharing charges, and how they are applied, are described below.

For each individual whose monthly applicable income* is at least 226% for an individual or a two person household, or 179% for a three person household, but not greater than 300% of the official Federal Poverty level income guidelines for the appropriate family size, a monthly premium amount shall be assessed. The premium amount cannot exceed 7.5% of the poverty level indicated for the appropriate family size. Failure to pay the premium shall result in ineligibility.

Premiums For Individuals: $124 per month for incomes between 226% and 250% of FPL $138 per month for incomes between 251% and 275% of FPL $152 per month for incomes between 276% and 300% of FPL

Premiums For Two Person Households: $168 per month for incomes between 226% and 250% of FPL $186 per month for incomes between 251% and 275% of FPL $205 per month for incomes between 276% and 300% of FPL

Premiums For Three Person Households: $168 per month for incomes between 179% and 199% of FPL $186 per month for incomes between 200% and 219% of FPL $205 per month for incomes between 220% and 300% of FPL

* Monthly applicable income is all countable monthly income according to 1902(r)(2) of the Act as described in the Kansas Medicaid State Plan. Kansas is an SSI-criteria state. Except where the state is more liberal, the SSI income counting rules are followed. Those who receive an SSI federal benefit are not eligible for the Basic Coverage Group and the Medical Improvement Group.

KS 23-0015 Approval Date 05/19/2023 Effective Date 05/01/2023 Supersedes MS 01-13

Table of Contents State/Territory Name: Kansas State Plan Amendment (SPA) #: 24-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group April 4, 2024

Christine Osterlund, Acting State Medicaid Director Kansas Department of Health and Environment Division of Health Care Finance Landon State Office Building 900 SW Jackson, Room 900-N Topeka, KS 66612-1220

Re: Kansas State Plan Amendment (SPA) 24-0002

Dear Christine Osterlund:

The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0002. This amendment proposes to abolish copayments for Medicaid fee-for-service beneficiaries within the state.

We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act. This letter is to inform you that Kansas Medicaid SPA 24-0002 was approved on April 4, 2024, with an effective date of January 1, 2024.

Enclosed are copies of Form CMS-179 and approved SPA page to be incorporated into the Kansas State Plan.

If you have any questions, please contact Helenita Augustus at 410-786-8902 or via email at Helenita.Augustus@cms.hhs.gov .

Sincerely,

James G. Scott, Director Division of Program Operations

Enclosures

cc: Bobbie Graff-Hendrixson

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

Medicaid Premiums and Cost Sharing: Summary Page (CMS 179) State/Territory name: Kansas Transmittal Number: Enter tl,e Transmittal Number (TN), i11cl11di11g dashes, i11 tl,eformat SS-YY-NNNN or SS-YY-NNNN-xxxx (with ."\:XXX being optio11al to specific SPA types), wl,ere SS = 2-character state abbreviation, YY = last 2 digits of sub111issio11 year, NNNN = 4-digit 1111111ber with leading zeros, and=~~, = OPTIONAL, 1- to 4-cl,aracter alpha/numeric suffix. I KS-24-0002 I Proposed Effective Date 10110112024 I (mm/dd/yyyy) Federal Statute/Regulation Citation I Sections of 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447.57 (excluding 447.55) Federal Budget Impact Federal Fiscal Year First Year 12024 Second Year 12025 Subject of Amendment I Removal of Co-pays Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: ~ 2020.00 ~ 2811 .00 Signature of State Agency Official Submitted By: Last Revision Date: Bobbie Graff-Hendrixson Feb 22, 2024 Submit Date: Jan 16, 2024 Amount

Medicaid Premiums and Cost Sharing State Name:~IK_an _ s_as ________________ ~ 0MB Control Number: 09381148 Transmittal Number: KS - 24 - 0002 Cost Sharing Requirements Gl 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. ~ 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 0MB control number. The valid 0MB control number for this information collection is 0938 1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. Transmittal Number: KS-24-0002 Supersedes Transmittal Number: NEW Approval Date April 4 2024 V.20160722 Effective Date: January 1 2024 Page 1 of 1

Table of Contents State/Territory Name: Kansas State Plan Amendment (SPA) #: 24-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All KS - Submission Package - KS2024MS0001O - (KS-24-0003) - Eligibility Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operation Group (MCOG) 7500 Security Boulevard Baltimore, MD 21244-1850 Center for Medicaid & CHIP Services March 15, 2024 Christine Osterlund Medicaid Director Kansas Department of Health and Environment, Division of Health Care Finance 900 SW Jackson, Suite 900 N Topeka, KS Topeka, KS 66612 Re: Approval of State Plan Amendment KS-24-0003 Dear Director Osterlund, On February 26, 2024, the Centers for Medicare and Medicaid Services (CMS) received Kansas State Plan Amendment (SPA) KS-24-0003. This amendment seeks to streamline the process of integrating the state's compliance with continuous eligibility (CE) authority into the Medicaid and Chip Program (MACPro) Portal. We approve Kansas State Plan Amendment (SPA) KS-24-0003 with an effective date(s) of January 01, 2024. If you have any questions regarding this amendment, please contact Helenita Augustus at 410-786-8902 or via email at Helenita.Augustus@cms.hhs.gov. Sincerely, James G. Scott Director Center for Medicaid & CHIP Services

Records / Submission Packages - View All KS - Submission Package - KS2024MS0001O - (KS-24-0003) - Eligibility Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2024MS0001O | KS-24-0003 CMS-10434 OMB 0938-1188 Package Header Package ID KS2024MS0001O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID N/A SPA ID KS-24-0003 Initial Submission Date 2/26/2024 Effective Date N/A State Information State/Territory Name: Kansas Medicaid Agency Name: Kansas Department of Health and Environment, Division of Health Care Finance Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2024MS0001O | KS-24-0003 Package Header Package ID KS2024MS0001O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID N/A SPA ID KS-24-0003 Initial Submission Date 2/26/2024 Effective Date N/A SPA ID and Effective Date SPA ID KS-24-0003 Reviewable Unit Proposed Effective Date Superseded SPA ID Continuous Eligibility for Children 1/1/2024 New Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2024MS0001O | KS-24-0003 Package Header Package ID KS2024MS0001O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID N/A SPA ID KS-24-0003 Initial Submission Date 2/26/2024 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Federal legislation, Section 5112 of the Consolidated Appropriations Act, 2023 (CAA, 2023), amended Medicaid to require that states provide twelve months of continuous eligibility (CE) for children under the age of 19. Since 2006, children under age 19 have had twelve months of continuous eligibility in Kansas Medicaid. The current SPA attests the twelve-month CE in MACPro. The SPA also extends CE for hospitalized children in Medicaid who are still in the hospital on their 19th birthday. They will remain in Medicaid until the completion of their hospitalization. (March 7, 2024) Per the request by CMS, the attestation email sent to CMS by the state on 12/11/2023, with Att. 2.2a, has been attached to this page. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2024 $0 Second 2025 $0 Federal Statute / Regulation Citation Section 5112 of the Consolidated Appropriations Act, 2023 (CAA, 2023) Supporting documentation of budget impact is uploaded (optional). Name Date Created RE_ Continuous Eligibility (CE) -State of Kansas Attestation 12.23.2023 3/7/2024 11:39 AM EST Att 2.2a - Mandatory Coverage, Page 23a, 21 3/7/2024 11:39 AM EST

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | KS2024MS0001O | KS-24-0003 Package Header Package ID KS2024MS0001O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID N/A SPA ID KS-24-0003 Initial Submission Date 2/26/2024 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/20/2024 12:43 PM EDT No comment Comments received No response within 45 days Other

Records / Submission Packages - View All KS - Submission Package - KS2024MS0001O - (KS-24-0003) - Eligibility Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Children MEDICAID | Medicaid State Plan | Eligibility | KS2024MS0001O | KS-24-0003 CMS-10434 OMB 0938-1188 Package Header Package ID KS2024MS0001O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID New User-Entered SPA ID KS-24-0003 Initial Submission Date 2/26/2024 Effective Date 1/1/2024 The state provides continuous eligibility for children in accordance with the following provisions: A. Mandatory Continuous Eligibility for Hospitalized Children The state provides Medicaid to a child eligible for and enrolled under the Infants and Children under Age 19 (42 CFR 435.118) eligibility group until the end of an inpatient stay for which inpatient services are covered, if the child: 1. Was receiving inpatient services covered by Medicaid on the date the child becomes ineligible under the eligibility group based on the child's age; and 2. Would remain eligible but for attaining such age. B. Mandatory Continuous Eligibility for Children The state provides continuous eligibility to all children under age 19 and that: 1. The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends the last day of the earlier of the following periods: a. The month that the child turns 19 years old; b. 12 months. 2. Continuous eligibility is provided to children eligible under all mandatory and optional eligibility groups (excluding Medically Needy) who would otherwise lose eligibility because of any change in circumstances, unless: a. The child dies; b. The child or the child's representative voluntarily requests a termination of the child's eligibility; c. The child ceases to be a resident of the state; d. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or e. The child attains the maximum age specified in B. C. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

This view was generated on 3/20/2024 12:44 PM EDT

This amendment allows EMS providers to receive reimbursement for treatment rendered in response to an emergency call to a member’s home or other location, when transportation to the hospital emergency room (ER) is not provided.

Approval Document

This plan amendment updates the Indirect Medical Education factor to include large public Kansas teaching hospitals.

Approval Document

This amends the State Plan to revise the definitions for school-based services under the Early and Periodic Screening, Diagnosis and Treatment Limitations.

Approval Document

This amendment covers and reimbursement of Targeted Case Management (TCM) services for eligible juveniles who are inmates of a public institution post adjudication of charges in accordance with Section 1902(a)(84) of the Social Security Act (the Act).

Approval Document

This amendment adds mandatory coverage for eligible juveniles who are inmates of a public institution post adjudication of charges in accordance with Section 1902(a)(84) of the Social Security Act (the Act).

Approval Document

This amendment removes the end date for coverage of medication-assisted treatment (MAT) in accordance with the Consolidated Appropriations Act (CAA) of 2024.

Approval Document

This plan amendment updates the DMEPOS Annual Preventive Maintenance services.

Approval Document

This updated coverage for clinic services of the “four walls” of Indian Health Service (HIS)/Tribal clinics to implement the exception for rural counties.

Approval Document

This plan amendment updates the nursing facility rates for state fiscal year 2026.

Approval Document

This plan amendment adds the definition of “Rural Emergency Hospital” (REH).

Approval Document

This Amendment income disregard, under the authority of section 1902(r)(2) of the Social Security Act, for its medically needy eligibility groups to effectively raise the medically needy income standard to one hundred percent of the supplemental security income (SSI) federal benefit rate (FBR).

Approval Document

This plan amendment updates the Physician services and reimbursement rates.

Approval Document

This plan amendment updates the Dental Services reimbursement rate.

Approval Document

This plan amendment updates the definition for Carve Out Drugs.

Approval Document

This plan amendment updates the Physician services and reimbursement rates.

Approval Document

This plan amendment adds the reimbursement rate for Women, Infants and Children (WIC) supplement.

Approval Document

This plan amendment reflects the repair rates for maintenance of the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) equipment which will be increased to 80% of the Medicare fee schedule.

Approval Document

This plan amendment updates the Physician services and reimbursement rates.

Approval Document

This amendment assures coverage for clinic services outside of the "four walls" of Indian Health Service (IHS)/ Tribal clinics.

Approval Document

This plan amendment updates the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) reimbursement rates for select audiology services.

Approval Document

This plan amendment will reimburse pharmacists for Medication Therapy Management (MTM) intervention services.

Approval Document

This plan amendment updates Psychiatric Collaborative Care services.

Approval Document

This amendment allows Partial Hospitalization Program (PHP) and Intensive Outpatient Treatment (IOP) of mental health disorders related to Eating Disorder Care.

Approval Document

This SPA allows Kansas to enter into Value/Outcomes-Based Agreements with drug manufacturers on a voluntary basis.

Approval Document

This plan amendment updates the Critical Access Hospital (CAH) cost report settlements. These funds will be split between inpatient CAH Adjustment Factor (CAF) settlements and outpatient CAF settlements using the same percentage split as the inpatient and outpatient CAF settlements in 2013.

Approval Document

This plan amendment excludes select pharmaceuticals from the DRG reimbursement system.

Approval Document

This plan amendment updates the nursing facility rates for state fiscal year 2025.

Approval Document

The purpose of this SPA is to remove health homes language from Attachment 3.1F, due to the termination of the Health Homes Asthma and the Health Homes SMI programs.

Approval Document

This SPA allows coverage of medically necessary prescribed drugs that are not covered outpatient drugs, including drugs authorized for import by the U.S. Food and Drug Administration (FDA), during drug shortages. Additionally, this SPA authorizes reimbursement of prescribed drugs that are not considered covered outpatient drugs, with the same reimbursement methodologies as covered outpatient drugs.

Approval Document

This amendment discontinues health homes from the alternative benefit plan.

Approval Document

This amendment discontinues health homes from the Supports and Training for Employing People Successfully (STEPS) program alternative benefit plan.

Approval Document

This Amendment to discontinue the OneCare Kansas, Health Home SMI, program as a covered service.

Approval Document

This Amendment to discontinue the OneCare Kansas, Health Home Asthma, program as a covered service.

Approval Document

This amendment adds an additional 2-year renewal of exemption from the Recovery Audit Contractor (RAC) program, from January 1, 2025, to December 31, 2026.

Approval Document

This amendment is to add Elevated Blood Lead (EBL) level education visits for children under 21 years of age, and Lead Hazard Risk Assessments for children under 21 years of age.

Approval Document

This amendment is to add Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) to the FQHC and RHC sections of its Medicaid State Plan to be in compliance with CAA 2023.

Approval Document

This amendment provides the required assurances regarding the reporting of mandatory Core Set measures by Health Home providers in accordance with 42 CFR §§ 437.10 and 437.15. This amendment also updates state plan assurances in accordance with federally mandated quality reporting requirements for the Child Core Set and the behavioral health quality measures on the Adult Core Set outlined in 42 CFR 431.16 and 437.10 through 437.15.

Approval Document

This amendment provides the required assurances regarding the reporting of mandatory Core Set measures by Health Home providers. In accordance with 42 CFR §§ 437.10 and 437.15.

Approval Document

This plan amendment updates the select Certified Midwife (CNM) reimbursement rates.

Approval Document

This plan amendment updates the Family Service Coordination Targeted Case Management (TCM) reimbursement rate.

Approval Document

This plan amendment updates the Outpatient Hospital reimbursement rates.

Approval Document

This plan amendment updates the Physician Provider reimbursement rates.

Approval Document

This amendment allow providers outside of the Community Mental Health Center (CMHC) network to employ Mobile Crisis Intervention providers and to be reimbursed for providing mobile crisis intervention services.

Approval Document

This amendment proposes adds adult dental benefits to the STEPS Alternative Benefit Plan (ABP) due to the expanded dental services in the Kansas Medicaid Plan.

Approval Document

This amendment adds adult dental benefits to the Working Healthy Alternative Benefit Plan (ABP) population due to the expanded dental services in the Kansas Medicaid Plan.

Approval Document

This amendment will expand dental services to cover Medicaid participants over 20 years of age.

Approval Document

This plan amendment updates the reimbursement rates for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).

Approval Document

This plan amendment updates the reimbursement rates for the Community Health Worker (CHW) services.

Approval Document

This plan amendment updates the Global Pregnancy reimbursement rates.

Approval Document

This plan amendment updates the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) reimbursement rates.

Approval Document

This plan amendment updates the reimbursement rates for Sleep Study Services.

Approval Document

This plan amendment updates the Hospice Nursing Facility Room and Board reimbursement rate.

Approval Document

This amendment is to add Doula as a provider type for pregnancy and postpartum services.

Approval Document

This amendment abolishes copayments for Medicaid fee-for-service beneficiaries within the state.

Approval Document

This amendment streamlines the process of integrating the state's compliance with continuous eligibility (CE) authority into the Medicaid and Chip Program (MACPro) Portal.

Approval Document

This amendment covers the Continuous Glucose Monitors (CGM) under the Durable Medical Equipment (DME) benefit.

Approval Document

This amendment adds the Management of Self-Monitoring Blood Pressure (SMBP) treatment plans as a preventive outpatient service for persons using SMBP devices as part of their care.

Approval Document

This amendment is to update the state plan to indicate that, in accordance with Section 12006 of the 21^st^ Century Cures Act, the state complies with the Electronic Visit Verification System (EVV) requirements for home health services.

Approval Document

This plan amendment updates the Hospice Rate Change.

Approval Document

This plan amendment updates the Radiology Reimbursement Rates.

Approval Document

This plan amendment moves the payment for bath and toilet aids to the durable medical equipment benefit.

Approval Document

This amendment is to add the Alternative Benefit Plan (ABP) for the Supports and Training for Employing People Successfully (STEPS) program.

Approval Document

The purpose of this state plan amendment is to enroll Medicaid eligible beneficiaries on a mandatory basis into managed care organizations.

Approval Document

This amendment is to amend the Working Healthy Alternative Benefit Plan (ABP) to change the Medicaid authority from the 1115 waiver for managed care to the 1915(b) waiver.

Approval Document

This plan amendment has established payment methodologies for Alternative Benefit Plan (ABP) benefits that are not provided through managed care.

Approval Document

This amendment adds Diabetes Self-Management Training (DSMT) benefits to the Kansas Medicaid State Plan as a preventive outpatient service for persons diagnosed with diabetes.

Approval Document

The ICF-IID Levels of Care structure and administration per diem rates are being revised.

Approval Document

This amendment updates Nursing Facility provider enrollment and increases Nursing Facility Rates for State Fiscal Year (SFY) 2024.

Approval Document

The reimbursement rates for lactation counseling services will be increased.

Approval Document

This amendment adds Children Behavioral Interventionist (CBI) Service, which will provide children/youth with neuro developmental activities for individuals/families that are struggling with behavior and emotional management issues as established in a person-centered treatment plan.

Approval Document

This amendment adds coverage and reimbursement of pharmacists as providers, and to authorize pharmacy technicians and interns to administer vaccines.

Approval Document

The Brain Injury Rehabilitation Facility (BIRF) rate will be increased from $700 per day to $1,400 and include non-traumatic as well as traumatic brain injury.

Approval Document

This SPA proposes to update the language on the state’s Prescribed Drugs Limitations list on the Pharmacy state plan coverage pages.

Approval Document

This amendment expands Peer Support Services, which allows providers outside of the Community Mental Health Center (CMHC) network to employ Peer Support providers and to be reimbursed for providing Peer Support Services.

Approval Document

Per Legislative allocation, select procedure codes will be increased by 3% for physicians.

Approval Document

This amendment increased reimbursement for targeted case management, and replaces the phrase “mental retardation and other developmental disabilities” with the phrase “intellectual or developmental disabilities” on the submitted pages.

Approval Document

This amendment is to establish coverage of dentures and partials for adults who meet medical necessity criteria.

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