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LOUISIANA TITLE XXI PROGRAM FACT SHEET

Name of Plan: LaCHIP

Date Plan Submitted:

July 31, 1998 Date Plan Approved:

October 20, 1998 Effective Date:

November 1, 1998

Date First Amendment Submitted: June 30, 1999 Date First Amendment Approved: August 27, 1999 Effective Date of First Amendment: October 1, 1999

Date Second Amendment Submitted: December 18, 2000 Date Second Amendment Approved: June 6, 2001 Effective Date of Second Amendment: January 1, 2001

Date Third Amendment Submitted: November 27, 2002 Date Third Amendment Approved: February 24, 2003

Date Fourth Amendment Submitted: January 25, 2007 Date Fourth Amendment Approved: April 4, 2007 Effective Date of Fourth Amendment: April 1, 2007

Date Fifth Amendment Submitted: September 5, 2007 Date Fifth Amendment Approved: February 27, 2008 Effective Date of Fifth Amendment: January 1, 2008

Date Sixth Amendment Submitted: June 12, 2009 Date Sixth Amendment Approved: August 21, 2009 Effective Date of Sixth Amendment: June 12, 2009

Background

• On July 31, 1998, Louisiana submitted a proposal to implement a State Children's Health Insurance Program (SCHIP), which expanded Medicaid coverage to uninsured children at least 6 years of age but under 19 years of age in families with incomes at or below 133 percent of the Federal poverty level (FPL).

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Amendments

• Louisiana submitted its first State plan amendment (SPA) on June 30, 1999, to expand Medicaid coverage to children between birth and up to 19 years of age in families with incomes above 133 percent and at or below 150 percent of the FPL.

• Louisiana submitted its second State plan amendment on December 18, 2000, to further expand Medicaid eligibility to children from birth up to 19 years of age in families with incomes up to 200 percent FPL.

• Louisiana submitted its third State plan amendment on November 22, 2002, to update and amend the SCHIP State plan to indicate the State’s compliance with the final SCHIP regulations.

• Louisiana submitted its fourth State plan amendment on January 25, 2007, to create a separate child health program to extend health care coverage to unborn children, who are ineligible for Medicaid, with family income up to and including 200 percent of the FPL.

• Louisiana submitted its fifth State plan amendment on September 5, 2007 to cover uninsured children in families with gross income from 200 percent up to and including 250 percent of the FPL in the State’s separate SCHIP program.

• Louisiana submitted its sixth State plan amendment on June 12, 2009, to accept and utilize a $1 million 4-year grant from the Robert Wood Johnson Foundation, as a source of State share.

Children Covered Under the Program

• The State reported that a total of 147,863 children were ever enrolled in the Louisiana Children’s Health Insurance Program (LaCHIP) in Federal fiscal year (FFY) 2008.

Administration

• The program is administered by the State Department of Health and Hospitals.

Health Care Delivery System

• The State uses its current Medicaid delivery system (Fee for Service and Primary Care Case Management) to provide services to the expansion population and unborn children under the separate child health program. • For LaCHIP coverage in the separate child health program for children in families with gross income from 200 percent up to and including 250 percent of the FPL, Louisiana provides health insurance benefits through a plan managed by the Louisiana Department of Health &

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Hospitals (DHH) with health benefits provided on a fee-for-service basis through the Division of Administration’s Office of Group Benefits Preferred Provider Organization, from here on referred to as the State Employees Health Plan. Benefits and claims processing are administered by the State Employees Health Plan, and eligibility is determined by DHH staff.

Benefit Package

• The State offers its standard Medicaid package to persons eligible for LaCHIP Medicaid expansion. Unborn eligibles receive the pregnancy and pregnancy-related benefits offered under the SCHIP State plan. • The State offers Secretary approved coverage to those children from 200 percent of the FPL to 250 percent of the FPL in the Separate SCHIP program. The State Employees Health Plan uses pre-certification and limits on the number of days per plan year for many services.

Cost Sharing

• There is no cost sharing for the Medicaid expansion or unborn populations. • For children from 200 percent of the FPL to 250 percent of the FPL in the Separate SCHIP program, the following cost sharing is applicable: o Premiums: $50 per month per family o Deductibles: A $150 deductible for hospital emergency rooms (waived if admitted as inpatient) and a separate $200 deductible in place for mental health/substance abuse services o Coinsurance or copayments: Enrollees pay 10 percent of the contracted rate for most services, a 20 percent of the negotiated rate for hospice care and mental health/substance abuse services, and 30 percent of the negotiated rate for home health. For prescription drugs, enrollee pays 50 percent or a maximum of $50 per 30 day supply. After $1,200 per person per plan year, the co-payment is reduced to $15 for brand name drugs and $0 for generic drugs. Ambulance copayments are $50 for ground transport and $250 for licensed air ambulance services.

Outreach Activities

• The State launched an outreach program with the following key messages: 1) applying for LaCHIP is easy; 2) preventive health care is important; 3) health insurance is available to thousands of currently enrolled children under age 19 in Louisiana; 4) children in working families and two-parent households can be eligible for LaCHIP; and, 5) help with the enrollment process is readily available.

• The State utilizes a number of mechanisms to identify and enroll eligible children in the health care system. The measures include: --Employing posters, brochures, presentations, public service announcements, and television ads to target audiences of potentially eligible families and children.

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--Coordinating with the Office of Public Health, Maternal and Child Health, to conduct outreach in WIC Clinics, School Based Health Clinics and Children’s Special Health Services Clinics.

• The State continues to market the program to increase awareness of LaChip among specific audiences including adolescents, and their parents; low-income working parents; immigrants and limited English proficient individuals; grandparents and other kin care givers; current and former Families Independence-Temporary Assistance Program (FITAP) recipients; homeless or at risk of homelessness; children with special needs; Native Americans; migrant children; lower Mississippi delta region and other rural residents.

Financial Information

Total FFY ’09 CHIP Allotment – $207,402,800 FFY ’09 Enhanced Federal Matching Rate – 79.92 percent

Date Last Updated: CMS, CMSO, FCHPG, DSCHI, July 10, 2009

_____________________________________________________________________________

Table of Contents

State/Territory Name: Louisiana

State Plan Amendment (SPA) #: LA-14-0002

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16

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

Children and Adults Health Programs Group

APR 0 8 2014

Ruth Kennedy

Medicaid Director

Department of Health and Hospitals PO Box 91030

Baton Rouge, LA 70821-9030

Dear Ms. Kennedy:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number LA-14-0002, submitted on January 17, 2014, and related Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

In SPA number LA-14-0002, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups, using the approved MAGI conversion plan income thresholds. The state indicates on page CS7 that it will cover targeted low-income children, and indicates on page CS9 that it will cover children from conception to birth when the mother is not eligible for Medicaid. Page CS13 indicates that the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 and CS9 are attached and together supersede the current Geographic Area, Age and Income sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS13 is attached and should be incorporated within a separate subsection under section 4.3 of the state’s approved CHIP state plan. ;

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

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

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

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

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

Page 2 — Ms. Ruth Kennedy

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Mr. Bill Brooks, Associate Regional Administrator in our Dallas Regional Office. Mr. Brooks’ address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 1301 Young Street, Room 714

Dallas, TX 75202

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

Sincerely, Eliot Fishman Director Enclosures ce:

Bill Brooks, ARA, CMS Region VI

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility LA.0739.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Louisiana State Funds: $ Federal Funds: $ Submitted By: Roberta Diaz Last Revision Date: Feb 26, 2014 Submit Date: Jan 17, 2014 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. LA-14-0002 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102 (b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315, and 320, 42 CFR 457.10, Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:88 out of 2000 This SPA adopts MAGI income standards for the State's CHIP targeted low-income children. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

coms. CHIP Eligibility

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

CS15

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

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

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

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

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

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

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

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

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

An attachment is submitted.

PRA Disclosure Statement

APR 0 8 2014

SPA# LA-14-0002 Approval Date: Effective Date: January 1, 2014

Page I of 2

coms CHIP Eligibility

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

SPA# LA-14-0002 Approval Date: APR 0 8 2014

Effective Date: January 1, 2014

Page 2 of 2

coms CHIP Eligibility

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

CS7

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

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

The CHIP Agency operates this covered group in accordance with the following provisions: Age Must be under age 19. Income Standards Income standards are applied statewide.

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

Statewide Income Standards

Begin with lowest age range first.

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

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

oF [io 19 212 250 xX

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

Special Program for Children with Disabilities

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

PRA Disclosure Statement

APR 0 8 2014

SPA# LA-14-0002 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

coms CHIP Eligibility

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

V.20130709)

SPA# LA-14-0002 Approval Date: APR 0 8 2014 Effective Date: January 1, 2014

Page 2 of 2

“CMS CHIP Eligibility

NAN TOE MAONCART 8 NADA NETIC

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

cso 42 CFR 457.10 [| Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid. The CHIP Agency operates this covered group in accordance with the following provisions: Age Standard From conception through birth. Does the state have an additional age definition or other age-related conditions? |No Income Standards Income standards are applied statewide. [Yes Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a No county income standard? Statewide Income Standard The statewide income standard is: From zero up to {209 | % FPL [m) Exempted from requirement of providing or applying for a Social Security Number. [im] Exempted from requirement of verifying citizenship status.

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

APR 0 8 2014

SPA#LA 14-0002 Approval Date: Effective Date: January 1, 2014

Page | of 1

CCST ROR MATIC 4 AMRTHEANE SEICHE

CHIP Eligibility

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

813

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

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

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

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

The state elects the following option(s):

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

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

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

PRA Disclosure Statement

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

V.20130917

SPA# LA-14-0002 Approval Date: APR 0 8 2014 Effective Date: January 1, 2014

Page 1 of |

_____________________________________________________________________________

Table of Contents

State/Territory Name: Louisiana

State Plan Amendment (SPA) #: LA-14-0003

This file contains the following documents in the order listed:

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

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

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

Baltimore, Maryland 21244-1850 AER oak AIEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 14 2014

Ms. Ruth Kennedy

Medicaid Director

Department of Health and Hospitals P.O. Box 91030

Baton Rouge, LA 70821-9030

Dear Ms. Kennedy:

1am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number LA-14-0003, submitted on January 17, 2014, related Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

SPA number LA-14-0003 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion section (4.0) of the current CHIP state plan.

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

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

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

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Mr. Bill Brooks, Associate Regional Administrator (ARA) in our Dallas Regional Office. Mr. Brooks’ address is:

Centers for Medicare and Medicaid Services Office of the Regional Administrator

1301 Young Street, Suite 714

Dallas, TX 75202

Page 2 — Ms. Ruth Kennedy

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, Eliot Fishman Director Enclosures ce:

Mr. Bill Brooks, CMS Region VI, Dallas

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility LA.0740.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Louisiana State Funds: $ Federal Funds: $ Submitted By: Darlene Adams Last Revision Date: Mar 6, 2014 Submit Date: Jan 17, 2014 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. LA-14-0003 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:122 out of 2000 This SPA establishes the State's CHIP eligibility regulations for the Medicaid Expansion Program under the MAGI standards. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Cems. CHIP Eligibility

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

Y

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) fo [lo ‘||I6 142 212 x +. Ile 19 108 212 x

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

SPA# LA-14-0003 Approval Date: MAR 1 4 2014 Effective Date: January 1, 2014

Page 1 of 1

_____________________________________________________________________________

Table of Contents

State/Territory Name: Louisiana

State Plan Amendment (SPA) #: LA-14-0004

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES -

Centers for Medicare & Medicaid Services (CMs

7500 Security Boulevard, Mail Stop: S2-26-12 Cc M 4 CENTERS FOR MEDICARE & MEDICAID SERVICES:

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 1 1 2014

Ms. Ruth Kennedy

Medicaid Director

Department of Health and Hospitals P.O. Box 91030

Baton Rouge, LA 70821-9030

Dear Ms. Kennedy:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number LA-14-0004, related to Modified Adjusted Gross Income (MAGI) Eligibility, Establish 2101(f) Group, with an effective date of January 1, 2014.

SPA number LA-14-0004 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Louisiana’s approved CHIP state plan.

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

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

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

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Mr. Bill Brooks, Associate Regional Administrator (ARA) in our Dallas Regional Office. Mr. Brooks’ address is:

Page 2 — Ms. Ruth Kennedy

Mr. Bill Brooks

Centers for Medicare and Medicaid Services Office of the Regional Administrator

1301 Young St. Suite 714

Dallas, TX 75202

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, iot Fis! Director Enclosures cc:

Mr. Bill Brooks, ARA, CMS Region VI, Dallas

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility LA.0741.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Louisiana State Funds: $ Federal Funds: $ Submitted By: Roberta Diaz Last Revision Date: Jan 17, 2014 Submit Date: Jan 17, 2014 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. LA-14-0004 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:151 out of 2000 This SPA establishes the State's CHIP eligibility regulations for children ineligible for Medicaid as a result of the elimination of income disregards. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

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

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

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

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

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

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

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

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

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

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

% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family _ income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for

~ Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

MAR 1 1 2074

SPA# LA-14-0004 Approval Date: Effective Date:. January 1, 2014 Page 1 of 2

CHIP Eligibility

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

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

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

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

V.20130917

SPA#LA-14-0004 Approval Date: MAR 1 1 2044

Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: LA-15-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Louisiana consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

. Centers for Medicare & Medicaid Services

DEPARTMENT OF HEALTH & HUMAN SERVICES

—rrcorerecaasea a eee

ae

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

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

Children and Adults Health Programs Group

NOV 06 2015

Ms. J. Ruth Kennedy

State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4th Street

P. O. Box 91030

Baton Rouge, LA 70821-9030

Dear Ms. Kennedy:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), LA-15-0001, submitted on September 23, 2015, has been approved. The SPA has an effective date of November 1, 2015.

The SPA LA-15-0001 is approved to amend the provisions governing Federally Facilitated

Marketplace (FFM) eligibility determinations. Through this SPA, Louisiana will only accept

assessments of CHIP eligibility from the FFM rather than accept CHIP eligibility determinations

made by the FFM. A copy of the approved CS24 state plan page is attached to be incorporated into the current CHIP state plan.

Your title XXI project officer is Ms. Kathleen Connors de Laguna. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Connors de Laguna’s contact information is as follows:

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

7500 Security Boulevard

Mail Stop S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-2256

Fax: (410) 786-5882

E-mail: Kathleen.Connorsdelaguna@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Connors de Laguna and Mr. Bill Brooks, Associate Regional Administrator (ARA) in our Dallas Regional Office. Mr. Brooks’ address is:

Division of Medicaid and Children’s Health Operations

Page 2 — Ms. J. Ruth Kennedy

Centers for Medicare & Medicaid Services 1301 Young Street, Rm. 714 Dallas, TX 75202

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

Sincerely,

Anne Marie Costello Acting Director

Enclosure

ce: Bill Brooks, Associate Regional Administrator, Region VI, Dallas

Children's Health Insurance Program Eligibility

Control P ] . ” rer ; ee a Children's Health Insurance Program Eligibility: Summary Page

General Information State/Territory Louisiana File Management name: Transmittal Number: non ncn enero en Please enter the Transmittal Number (TN) in the format ST- Tribal Input 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. |LA-15-0001 |

Summary

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion | Establish 2101(f) Group “| Eligibility Processing Non-Financial Eligibility

Proposed Effective Date

(nm/de/yyyy)

Federal Statute/ Regulation Citation

[2402(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, Subpart C

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:232 out of 2000

[The State proposes to adopt provisions to become an assessment state and only accept eligibility assessments from the Federally Facilitated Marketplace (FFM) rather than accepting Medicaid eligibility determinations made by the FFM.

Signature of State Agency Official

Submitted By: Karen Barnes Last Revision Sep 23, 2015 Date:

Submit Date: Sep 23, 2015

CHIP Eligibility .. State Name: .... !L_o_u_is_i _an_ a _______________ ___, Transmittal Number: LA - 15 - 0001 0MB Control Number: 0938-1148 Expiration date: 10/31/2014 2102(b)(3) & 2107(e)(l )(O) of the SSA and 42 CFR 457, subpart C IZI The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment. Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard: ^ The single, streamlined application developed by the Secretary in accordance with section 1413(b)(l )(A) of the Affordable Care Act. ^ An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with section 1413(b)(l)(B) of the Affordable Care Act. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the D agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. IZI The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CFR 457.340(a), by telephone, via mail, in person and other commonly available electronic means. The agency accepts applications in the following other electronic means. ^ Other electronic means: Name of method Description Received by fax transmission Screen and Enroll Process The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial IZI application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low­ ./ income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs. Procedures include: SPA# LA-15-0001 Approval Date: -----November 6, 2015------Effective Date: November 1, 2015 Page 1 of3

CHIP Eligibility OO Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and OO Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and .. OO Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application. The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced premium tax credits in accordance with section 1943(b)(2) of the SSA. EJ Redetermination Processing IZl Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343: 00 Once every 12 months. OO 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 00 information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. Screening by Other Insurance Affordability Pro.grams The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals D screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state. The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering [gl insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP. Check all Insurance Affordability Programs that apply: D The Exchange [gl Medicaid D Other Insurance Affordability Program The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the D requirements of 457.348(b) and will provide this agreement to the Secretary upon request. SPA# LA-15-0001 Approval Date: --November 6, 2015--------Effective Date: November 1, 2015 Page 2 of3

CHIP Eligibility .. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 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 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. SPA# LA-15-0001 Approval Date: --November 6, 2015--------- V.20140415 ' Effective Date: November 1, 2015 Page 3 of3

_____________________________________________________________________________ Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: LA-16-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Louisiana consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

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

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

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

Children and Adults Health Programs Group

JUL 8 7 2016

Ms. Jen Steele, Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4th Street

P. O. Box 91030

Baton Rouge, LA 70821-9030

Dear Ms. Steele:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), LA-16-0002, submitted on April 21, 2016, has been approved. The SPA has an effective date of July 1, 2016.

The SPA LA-16-0002 is approved to amend the provisions governing the Federally Facilitated Marketplace (FFM) eligibility determinations. Through this SPA, Louisiana will accept CHIP eligibility determinations made by the FFM. A copy of the approved CS24 state plan page is attached to be incorporated into the current CHIP state plan.

Your title XXI project officer is Ms. Kathleen Connors de Laguna. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Connors de Laguna’s contact information is as follows:

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

7500 Security Boulevard

Mail Stop S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-2256

Fax: (410) 786-5882

E-mail: Kathleen.Connorsdelaguna@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Connors de Laguna and Mr. Bill Brooks, Associate Regional Administrator (ARA) in our Dallas Regional Office. Mr. Brooks’ address is:

Page 2 — Ms. Jen Steele

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

1301 Young Street, Rm. 714

Dallas, TX 75202

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

Sinegrely,

Anne Marie Costello Director

Enclosure

ce: Bill Brooks, Associate Regional Administrator, Region VI, Dallas

Children's Health Insurance

Program Eligibility

Control Panel ” on ro - ane ee Children's Health Insurance Program Eligibility:

Summary Page

General

Information

rE Ee State/Territory Louisiana

File Management name: Transmittal Number:

Tribal Input 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. [16-0002

Summary

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group “ Eligibility Processing Non-Financial Eligibility Proposed Effective Date

(nm/ da/ yyy)

Federal Statute/ Regulation Citation

[2102(b)(3) & 2107(e)(1)(0) of the SSA and 42 CFR 457, subpart C

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ | Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:209 out of 2000

The SPA proposes to amend the provisions governing Medicaid eligibility in order to return to a determination state and accept Medicaid eligibility determinations made by the Federally Facilitated Marketplace.

Signature of State Agency Official

Submitted By: Roberta Diaz

Last Revision Jun 20, 2016 Date: Submit Date: Apr 21, 2016

CONTINUE.

CHIP Eligibility State Name:j\L_o_u_is_ia_n_a _______________ ] Transmittal Number: LA - 16 - 0002 2I02(b)(3) & 2107(e)(l)(O) of the SSA and 42 CFR 457, subpart C 0MB Control Number: 0938-1148 Expiration date: 10/31/2014 [Z] The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment. Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard: IZ! The single, streamlined application developed by the Secretary in accordance with section 1413(b)(l)(A) of the Affordable Care Act. IZ! An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with section 1413(b)(l)(B) of the Affordable Care Act. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the D agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. [Z] The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CFR 457.340(a), by telephone, via mail, in person and other commonly available electronic means. The agency accepts applications in the following other electronic means. IZ! Other electronic means: Name of method Description !I Fax Received by fax transmission X Screen and Enroll Process The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low­ [{] income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs. Procedures include: SPA# LA-16-0002 Approval Date: ___July 7, 2016_______ _ Effective Date: July 1, 2016 Page 1 of3

CHIP Eligibility R Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and R Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and R Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application. The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced premium tax credits in accordance with section 1943(b)(2) of the SSA. EJ Redetermination Processing [Z] Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343: R Once every 12 months. R 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 R information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. Screening by Other Insurance Affordability Programs The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals D screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state. The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering [gl insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP. Check all Insurance Affordability Programs that apply: [gl The Exchange [gl Medicaid D Other Insurance Affordability Program The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the D requirements of 457.348(b) and will provide this agreement to the Secretary upon request. SPA# LA-16-0002 Approval Date: _July 7, 2016_________ _ Effective Date: July 1, 2016 Page 2 of 3

CHIP Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 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 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. SPA# LA-16-0002 Approval Date: _____July 7, 2016_____ _ V.20140415 Effective Date: July 1, 2016 Page 3 of3

_____________________________________________________________________________ Table of Contents State/Territory Name: Louisiana State Plan Amendments (SPA) #: LA-18-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7 500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group Jen Steele Medicaid Director Department of Health and Hospitals 628 North 4th Street Baton Rouge, LA 70802 Dear Ms. Steele: CENltKS FOR MIUICAKE & MIUICAID +EKVICES CENTER FOR MEDICAID & CHIP SERVICES NOV O 8 2018 I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) LA-18-0008, submitted on June 27, 2018 with additional information submitted.on October 29, 2018, has been approved. LA-18-0008 implements mental health parity requirements found in section 2103(c)(7) of the Social Security Act (the Act) and regulations at 42 CFR 457.496 to ensure that treatment limitations and financial requirements applied to mental health and substance use disorder benefits are no more restrictive than those applied to medical/surgical benefits. This SP A has an effective date of October 2, 2017. Section 2103( c )(7)(B) of the Act, as implemented through regulations at 42 CFR 457.496(b ), provides that if CHIP coverage includes the Early, Periodic Screening, Diagnostic and Treatment (EPSDT) benefit as defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the state plan will be deemed to satisfy parity requirements. Louisiana has provided the necessary assurances and supporting documentation that EPSDT is covered under Louisiana's CHIP program and provided in accordance with sections 1905(r) and 1902(a)(43) of the Act. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately. Your title XXI project officer is Jasmine Aplin. She is available to answer questions concerning these amendments. Ms. Aplin's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: ( 410) 786-8102 E-mail: jasmine.aplin@cms.hhs.gov

Page 2 - Ms. Jen Steele Official communications regarding program matters should be sent simultaneously to Ms. Jasmine Aplin and to Mr. Bill Brooks, Associate Regional Administrator (ARA) in our Dallas Regional Office. Mr. Brooks' address is: Centers for Medicare & Medicaid Services 1301 Young St. Suite 714 Dallas, TX 75202 If you have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at ( 410) 786-0721. We look forward to continuing to work with you and your staff. Director cc: Mr. Bill Brooks, ARA, CMS Region VI, Dallas /signed Anne Marie Costello/

2

TN:

Approval Date:

Effective Date:

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

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

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

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

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3.

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

1.1-DS

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

1.2.

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

1.3.

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

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased

3

TN:

Approval Date:

Effective Date:

eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

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

Original Plan LaCHIP Phase I Medicaid Expansion SCHIP for children 6-18 between 101- 133 Percent of the FPL Effective Date: November 1, 1998 Implementation Date: November 1, 1998

Amendment 1 LaCHIP Phase II Medicaid Expansion SCHIP for Children 0-18 Between 134-150 Percent of the FPL Effective Date: October 1, 1999

Amendment 2 LaCHIP Phase III Medicaid Expansion SCHIP for Children 0-18 Between 151-200 Percent of the FPL Effective Date: June 6, 2001

Amendment 3 Removal of Waiting Period in Medicaid Expansion SCHIP Approval date: February 24, 2003

Amendment 4 LaCHIP Phase IV Creation of Separate SCHIP – Unborn Child Option Effective date: April 1, 2007

Amendment 5 LaCHIP Phase V Separate SCHIP for Children 0-18 between 201-250 Percent of the Federal Poverty Level Effective date: April 1, 2008 Implementation date: May 1, 2008

Amendment 6 Addition of Robert Wood Johnson Foundation Maximizing Enrollment for Children Grant Funds $999,926.00 for grant period: February 15, 2009 through February 14, 2003

Effective date: February 15, 2009 Implementation date: February 15, 2009

4

TN:

Approval Date:

Effective Date:

Amendment 7 Addition of Prospective Payment Methodology for Federally Qualified Health Centers and Rural Health Centers LaCHIP Phase V Effective date: July 1, 2010 Implementation date: July 1, 2010

Amendment 8 Addition of Dental Benefit for LaCHIP Phase V Effective date: February 1, 2012 Implementation date: February 1, 2012

Amendment 9 Withdrawn

Amendment 10 Withdrawn

Amendment 11 Reduction of Dental Reimbursement Fees for EPSDT Dental Services for Phase V Effective date: July 1, 2012 Implementation date: July 1, 2012

Amendment 12 LaCHIP Phase V Benefits Administration Changes Effective date: January 1, 2013 Implementation date: January 1, 2013

Amendment 13 LA SPA TN 13-01 CH Reimbursement Rate Reduction for LaCHIP Affordable Plan Dental Services Effective date: August 1, 2013

Amendment 14 LA SPA TN 18-0008 Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Compliance Effective date: October 2, 2017

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

On June 15, 2018, a tribal notification with a summary of the State’s intent to comply with the Mental Health Parity and Addiction Equity Act, was sent to the five federally recognized tribes. The seven-day comment period for the tribal notification ended on June 22, 2018.

5

TN:

Approval Date:

Effective Date:

Section 6. Coverage Requirements for Children’s Health Insurance

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

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

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

6.1.1.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

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

Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:

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 the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service,

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as well as any exclusions or limitations. Attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431.

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state-based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state- based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

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6.1.4.1.

Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

6.1.4.2.

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

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population.

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in §457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage.

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverage applicable only in New York, Pennsylvania or Florida. (under 42 CFR 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than coverage under one of the benchmark plans specified in 457.420, through the use of a benefit-by-benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6.

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

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other. (Describe)

The state will use the Medicaid network of providers but offer the limited benefit package outlined in the separate program and offer the same benefits package except for LaCHIP Phase IV children. LaCHIP Phase IV for unborn child coverage mirrors the benefit package

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offered through Title XIX program in Louisiana.

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42 CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

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

For the unborn child, the State covers pregnancy related services and services that if not treated could complicate the pregnancy, i.e., the State covers the same services that it covers for the SOBRA pregnant women category in the Medicaid State Plan. Exception: Sterilization procedures are not covered for the SCHIP unborn child group. The services checked below are generally covered for Medicaid categorically needy eligibles and are potentially covered for the SCHIP unborn child group, depending on the need of the recipient. Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc. 6.2.1.

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

6.2.1.1 Unborn - Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc. 6.2.2.

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

6.2.2.1 Unborn - Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc. 6.2.3.

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

6.2.4.

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

6.2.5.

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

6.2.6.

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

6.2.7.

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

Limited to unborn children covered in LaCHIP Phase IV. 6.2.8.

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

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

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

State/Territory:

LOUISIANA

(Name of State/Territory)

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

June 26, 2018 Jen Steele, Medicaid Director, Louisiana Department of Health

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

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

Name: Jen Steele

Position/Title: Medicaid Director

Bureau of Health Services Financing

Name: Rhett Decoteau

Position/Title: Medicaid Deputy Director

Bureau of Health Services Financing

*Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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6.2.9.

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

6.2.10.

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

6.2.10.1 Unborn - Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc. 6.2.11.

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

6.2.11.1 Unborn - Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc. 6.2.12.

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

6.2.13.

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

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

6.2.14.

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

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.15.

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

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

6.2.17.

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

LaCHIP Phases IV and LaCHIP Phase V has the same benefit as outlined in the Medicaid State Plan. Please reference Appendix A: EPSDT Dental Program Fee Schedule for full list of services. 6.2.18. Vision screenings and services (Section 2110(a)(24))

6.2.19. Hearing screenings and services (Section 2110(a)(24)) 6.2.20.

Inpatient substance abuse treatment services and residential substance abuse

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treatment services (Section 2110(a)(18))

6.2.18.1 Unborn - Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc. 6.2.21.

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

6.2.19.1 Unborn - Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc. 6.2.22.

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

6.2.23.

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

6.2.24.

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

6.2.25.

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

Guidance: See guidance for Section 6.1.4.1 for guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check the box below. 6.2.26. EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.27.

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

These services are limited to unborn children covered through LaCHIP Phase IV, who would obtain those services through the Medicaid State Plan. 6.2.28.

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

6.2.29.

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

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.30. Enabling services (such as transportation, translation, and outreach services)

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(Section 2110(a)(27))

6.2.31.

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

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

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

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

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

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT2 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

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

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

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

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered

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benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or

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member handbooks describing the state’s provision of EPSDT.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r)) All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r)) All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5)) Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

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Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5)) EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5)) The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43)) All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

6.2.3.1.1 MHPAEA The State assures that:

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The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub- classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered

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under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: ) No Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

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6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5- MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

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6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or

The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes

No Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non- quantitative treatment limitations.

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative

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treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E))

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The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one- half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5))

6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers?

Yes No Guidance: The State can answer no if the State or MCE only provides out of

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network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information

6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other

Guidance: If other is selected, please specify the entity.

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State Managed Care entities Both Other Guidance: If other is selected, please specify the entity.

Formatted: Space After: 0 pt, Line spacing: single Formatted: Space After: 0 pt, Line spacing: single

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Section 8. Cost-Sharing and Payment

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

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42 CFR 457.505) Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09-006, issued May 11, 2009)

8.1.1.

Yes 8.1.2.

No, skip to question 8.8. Unborn children covered in LaCHIP Phase IV

8.1.1-PW

Yes 8.1.2-PW

No, skip to question 8.8.

Guidance: It is important to note that for families below 150 percent of poverty, the same limitations on cost sharing that are under the Medicaid program apply. (These cost- sharing limitations have been set forth in Section 1916 of the Social Security Act, as implemented by regulations at 42 CFR 447.50 - 447.59). For families with incomes of 150 percent of poverty and above, cost sharing for all children in the family cannot exceed 5 percent of a family's income per year. Include a statement that no cost sharing will be charged for pregnancy-related services. (CHIPRA #2, SHO # 09-006, issued May 11, 2009) (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b) and (c), 457.515(a) and (c))

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

8.2.1.

Premiums:

$50 per month per family where family income is from 201 up to and

including, 250 percent of the federal poverty level (FPL) 8.2.2.

Deductibles:

8.2.3.

Coinsurance or copayments:

8.2.4.

Other:

8.2-DS

Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) For children enrolled in the dental-only supplemental coverage, describe the amount of cost- sharing, specifying any sliding scale based on income. Also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c),

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457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, 6.2- DS, and 9.10 when electing this option.

8.2.1-DS Premiums:

8.2.2-DS Deductibles:

8.2.3-DS Coinsurance or copayments:

8.2.4-DS Other:

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

The cost sharing information is explained to potential enrollees through the application, which includes a chart of income eligibility and premium payment amounts. This information is also prominently displayed on the LaCHIP website. If changes are necessary to the cost sharing requirements, all current enrollees are notified by letter of the changes and the effective dates. Public hearings are held to allow the public to comment on any proposed changes to cost sharing.

Guidance: The State should be able to demonstrate upon request its rationale and justification regarding these assurances. This section also addresses limitations on payments for certain expenditures and requirements for maintenance of effort.

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

8.4.1.

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

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

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

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health

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plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: Pharmacy co-payments) No Guidance: For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits?

Yes No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E))

Guidance: Please include the state’s methodology and results of the parity analysis as an attachment to the State child health plan.

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8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i))

Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

_____________________________________________________________________________ Table of Contents State/Territory Name: Louisiana State Plan Amendments (SPA) #: LA-19-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Template

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, MailStop 52-01-16 Baltimore, MD 21244-1850 Children en¡l Adults Healfh Proprnms Grorrn crvts ctNTtRs foR MÉDtcAnt & MrorcltD snvrcEs CENTEN FOR MEDICA¡D & CHIP SEßVICES Jen Steele Medicaid Director Department of Health and Hospitals 628 North 4th Street Baton Rouge, LA 70802 APR t 4 e019 Dear Ms. Steele: Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) LA- l9-0010, submitted on January 22,2019 with additional information submitted on April l, 2019, has been approved. This SPA has an effective date of February l, 2019. SPA LA-19-0010 allows Louisiana to obtain federal funding to expand coverage to otherwise eligible lawfully residing, non-citizen targeted low income children under section 214 of the Children's Health Insurance Program Reauthorization Act of 2009. On March 22,2019, the state received approval for the same type of amendment under Medicaid SPA LA-19-0009. A copy of the approved CS I I state plan page is attached to be incorporated into the state's approved CHIP state plan. This page supersedes the previous CSl8 that was approved on April tt,2014. Your title XXI project officer is Ms. Jasmine Aplin. She is available to answer questions conceming this amendment and other CHlP-related issues. Her contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (41 0) 786-8 I 02 E-mail : Jasmine.Aplin@cms.hhs. gov Official communications regarding program matters should be sent simultaneously to Ms. Aplin and Mr. Bill Brooks, Director, Division of Medicaid Field Operations South. Mr. Brooks' address is: Centers for Medicare & Medicaid Services 1301 Young St. Suite 714 Dallas, TX75202

Page 2-Ms. Jen Steele If you have quàstions additional questionso please contact Amy Lutzky, Director, Division of State Coverage Programs (410) 786-0721. Sincerel¡ Director cc: Mr. Bill Brooks, Director, Dívision of Medicaid Field Operations South I /signed Anne Marie Costello/

ffi* CHIP Eligibility State Name: Louisiana Transmittal Numbff: LA - l9 - 0010 OMB Control Number': 0938-l 148 Effeclivo Date: February 1, 2019 Page 1of 3 lections 2105(c)(9) and 2107(e)(1)(J) ofthe SSA and 42 CFR 457.320(b)(6), (c) and (d) Jitizenship Thc CHIP Agency ptovides CHIP eligibility to otherwise eligible citizens and nationals ofthe United States and calta¡n non-citizens, @ including the time period duling which they are provided with rcasonable oppoftunity to submit verification oftheil citizenship, national sfatus or satisfactory immigration status. I The CHIP Agency ptovides eligibility under the Plan to otherwise eligible individuals: Who are citizens or na[ionals ofthe United States; or Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Oppotunity Reconciliatio¡ Act (PRWORA) (8 U.S.C. $ 1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. ô l6l2(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. 91613); or Who have declared themselves to be citizens or nationals ofthe United States, or an individual having satisfactory immigration status, during a teasonable oppodunity period pending verification oftheir citizenship, nationality, or satisfactory immiglation status consistent with requirem ents of I903 (x), I 137(d), and 1902(ee) of the Act, an d 42 CFP. 435.406, 407,956 wtd 457 .380 . The rcasonable oppoÍunity period begins on and extends 90 days fiom the date the notice ofreasonable oppoltunity is rcccived by the individual. The agency plovides for an extension ofthe [easonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any neccssaly documcntation, or the agenay needs more time to complete the verification process, The agency begins to fumish benefits to othevise eligible individuals during the reasonable oppotunity period on a earlier than the date the notice is received by the individual. The dat€ benefits are furnished is: OThe dat€ ofappliçation containing the declaration ofcitizenship or immigratìon status. C The datc the Ìcasonable oppoúunìty nofice ¡s sent, C Other date, as described: The CHIP Agency elects the option to provide CHI P coverage to othclwise eligible children up to age I 9, lawfully residing in the United States, as provided in Section 2107(exl)(J) ofthe SSÀ (Seation 214 ofCHIPRA 2009, P.L. 111-3). Otherwise eligible childlen means children meeting the eligibility lequirements oftargeted low-income children with the exception of non-citizen status. No Yes sPA# LA-19-0010 Approval APR 0 4 20ts

CHIP Eligibility Efiect¡ve Date: February 1, 2019 Page 2 of3 E The CFIIP Agency plovides assurance that lawfully residing children ale also cover€d under the state's Medicaid program. The CHIP Agency elects the option to provide CHIP covelage to othelwise eligible pregnant women, lawfully residing in the Unit€d States, as provid€d in Soction 214 of CHIPRA 2009, P.L. 1l l-3. The state may not select this option unless the state also elects to covel lawfully lesiding children. A state may not select this option unl€ss the state also covcrs Targeted Low- lncome Pregnant Women. E An individual is considered to be lawfully residing in the United States if he or sh€ is lawfully present and meets state residency rcqu irements. E An individual is considered to be laÏvfully present in the United States ifhe or.she is: l. A qualified non-cìtizen as defined ir 8 U.S.C. I óa I (b) and (c); 2. A non-citizen in a valid nonimmiglant status, as defined in 8 U. S.C. I I 0l (a)( 15) or othenvise undeÍ the immigration laws (as defined in 8 U.S.C. I 101(aX17)); 3. A non-citizen who has been pa|o led into the United States i n accordance with I U.S.C.l 182(d)(5) for less than I year, except for an individual paroled for prosecution, fol defelred inspection or pending removal proceedings; 4, A non-citizen who belongs to one ofthe following classes: (i) Granted tempolary resident status in accordance with 8 U.S.C.I 160 or 1255a, respectively; (ii) Granted Tempotary Protocted Status (TPS) in accordance with I tJ.S.C. $1254a. and individuals with pending applications for TPS who have been granted employment authorization; (iii) Granted employment authorization under 8 CFR 274a.12(c); (iv) Family Unity beneficiaries in accordance with section 301 ofPub. L. 101-649, as amended; (v) Under Defeffed Enforced Departurc (DED) in accordance with a decision made by the President; (vi) Gl anted Deferred Action status; (vii) Granted an administrative stay ofremoval under 8 CFR 241; (viii) Beneficiary ofapproved visa petition who has a pending application for adjustment of status; 5. Is an individual with a pending application fol asylum under I U.S.C. I 158, or for withholding ofremoval under 8 U,S.C.l23l,or under the Convention Against Tolture, who: (i) Has been granted employment authorization; or (ii) Is under the age of l4 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal undel the Convention Against Tolture; 7. Is a child who has a pending application foÍ Special Immigrant Juvenile status as desçribed in 8 U. S.C.I 101 (aX27XJ); 8. Is lawfully present in Ameriçan Samoa under the immigration laws ofAmerican Samoa; or 9. Is avictim ofsevele trafficking in persons, in accordance with fhe Victims ofTrafficking and Violence Protecfion Act of 2000, Pub. L. 106-386, as amended (22 U.S.C, 7105(b)). No sPA# LA-19-00'10 ooo.ouu,o",u APR 0 4 2019

CHIP Eligibility 10, ExceÞÍion: An individual with deferued action under the Department ofHomeland Security's deferred action for the childhood arivals plocess, as described in the Secretary ofHomeland Secutity's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any ofthe above categories in paragraphs (l) through (9) ofthis definition. PRA Disclosure Statement According to the Papen¡,ork ReduÇtion Act of 1995, no persons are required to respond to a collection ofinformation unless it displays a valid OMB control number. The valid OMB control number for this infoÌmation collection is0938-1148. The time requircd to complete this information collection is estimated to average 50 hours per response, including th€ time to review instructions, search existing data rasources, gathel the data needed, and complete and review the information colleat¡on. Ifyou have comments concetning the acçuracy of the time estimate(s) ol suggestions for improving this fo[m, please write to: CMS, 7500 Security Boulevatd, Attn: PRA Repoús Cleal¿nce Officer', Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. v 20160722 Effective Dater February 1,2019 Page 3 o1'3 sPA# LA-19-0010 Approval APR 0 4 Zorg

_____________________________________________________________________________ Table of Contents State/Territory Name: Louisiana State Plan Amendments (SPA) #: LA-19-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, MailStop 52-01-16 Baltimore, MD 21244-1850 crvts CTNTERS K'X MÉDICATE & MTDICAID STNVICES CENTEN FOR A{EDICAID & CHIP SERVICES Children and Adults Health Proqrams Grouo Jen Steele Medicaid Director Department of Health and Hospitals 628 North 4th Street Baton Rouge, LA70802 FEB 2 B U0t9 Dear Ms. Steele: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), LA-19-0013, has been approved. LA-19-0013 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L for use of a managed care delivery system. This SPA has an effective date of July 1,2018. Sections 2l0l(a),2103(Ð(3), 2107(b), and2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Louisiana has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan as of the effective clate of the SPA, except that the state came into compliance with beneficiary protections for service costs described in section 3.8.2 of the state plan (42 CFR a57.1201(p)) on January 7,2079. This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on July 1 , 201 8 must comply with the CHIP managed care regulations and be submitted for CMS review. Your title XXI project officer is Ms. Jasmine Aplin. She is available to answer questions conceming this amendment and other CHlP-related issues. Her contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (41 0) 786-8102 E-mail : Jasmine.Aplin(alcms.hhs. gov

Page 2- Ms. Jen Steele Official communications regarding program matters should be sent simultaneously to Ms. Aplin and Mr. Bill Brooks, Associate Regional Administrator (AI{A) in our Dallas Regional Office. Mr. Bill Brooks' address is: Centers for Medicare & Medicaid Services Division of Medicaid Field Operations South 1301 Young St. Suite 714 Dallas,TX75202 We look forward to continuing to work with you and your staff. Director Cc: Mr. Bill Brooks, ARA, CMS Region VI, Dallas /signed Anne Marie Costello/

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM (Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b))) State/Territory: LOUISIANA (Name of State/Territory) As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b)) /s/ Jen Steele

February 15, 2019 Jen Steele, Medicaid Director, Louisiana Department of Health submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Jen Steele Position/Title: Medicaid Director Bureau of Health Services Financing Name: Jarrod Coniglio Position/Title: Medicaid Deputy Director Bureau of Health Services Financing *Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements 1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70): Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI. 1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2)) 1.1-DS The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2. Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3. Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42 CFR 457.130) Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is

3 defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications). 1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date. Original Plan LaCHIP Phase I Medicaid Expansion SCHIP for children 6-18 between 101- 133 Percent of the FPL Effective Date: November 1, 1998 Implementation Date: November 1, 1998 Amendment 1 LaCHIP Phase II Medicaid Expansion SCHIP for Children 0-18 Between 134-150 Percent of the FPL Effective Date: October 1, 1999 Amendment 2 LaCHIP Phase III Medicaid Expansion SCHIP for Children 0-18 Between 151-200 Percent of the FPL Effective Date: June 6, 2001 Amendment 3 Removal of Waiting Period in Medicaid Expansion SCHIP Approval date: February 24, 2003 Amendment 4 LaCHIP Phase IV Creation of Separate SCHIP – Unborn Child Option Effective date: April 1, 2007 Amendment 5 LaCHIP Phase V Separate SCHIP for Children 0-18 between 201-250 Percent of the Federal Poverty Level Effective date: April 1, 2008 Implementation date: May 1, 2008 Amendment 6 Addition of Robert Wood Johnson Foundation Maximizing Enrollment for Children

4 Grant Funds $999,926.00 for grant period: February 15, 2009 through February 14, 2003 Effective date: February 15, 2009 Implementation date: February 15, 2009

Amendment 7 Addition of Prospective Payment Methodology for Federally Qualified Health Centers and Rural Health Centers LaCHIP Phase V Effective date: July 1, 2010 Implementation date: July 1, 2010

Amendment 8 Addition of Dental Benefit for LaCHIP Phase V Effective date: February 1, 2012 Implementation date: February 1, 2012

Amendment 9 Withdrawn

Amendment 10 Withdrawn

Amendment 11 Reduction of Dental Reimbursement Fees for EPSDT Dental Services for Phase V Effective date: July 1, 2012 Implementation date: July 1, 2012

Amendment 12 LaCHIP Phase V Benefits Administration Changes Effective date: January 1, 2013 Implementation date: January 1, 2013

Amendment 13 LA SPA TN 13-01 CH Reimbursement Rate Reduction for LaCHIP Affordable Plan Dental Services Effective date: August 1, 2013

Amendment 14 LA SPA TN 18-0008 Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Compliance Effective date: October 2, 2017

Amendment 15 CHIP Managed Care

5 Effective date: July 1, 2018

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

On November 20, 2018, a tribal notification with a summary of the State’s intent to comply with the Centers for Medicare and Medicaid Services’ 2016 Final Rule, was sent to the five federally recognized tribes. The seven-day comment period for the tribal notification ended on November 27, 2018.

6 Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for- service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the

7 State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of:  The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a))  The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. CHIP populations that are members of the Chisholm Class receive behavioral health services through a managed care delivery system; however, Chisholm Class members may opt out of managed care for physical health services.

8 The State would then provide those physical health services through fee-for-service. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Describe population served: All, with the exception of those in a Prepaid Inpatient Health Plan (PIHP) Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served: Children at risk of out of home placement who are in the Coordinated System of Care (CSoC).

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

9 If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)):  All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity).  The information requirements in 42 CFR 457.1207 (see Section 3.5 below for

10 more details).  The provision against provider discrimination in 42 CFR 457.1208.  The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees).  The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226.  The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards).  An enrollee's right to a State review under subpart K of 42 CFR 457.  Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285.  Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3))

11 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information.

12 If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State:  Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and  Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity:  Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1));  Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and  Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c))

13 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008)

14 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1))

15 The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times:  During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later;  At least once every 12 months thereafter;  If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and  When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use:  Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and  Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207,

16 cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that:  The format is readily accessible;  The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible;  The information is provided in an electronic form which can be electronically retained and printed;  The information is consistent with the content and language requirements in 42 CFR 438.10; and  The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to:  Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area;  Making oral interpretation available in all languages and written translation available in each prevalent non-English language;  Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area;  Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and  Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and

17 includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities:  Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance;  The basic features of managed care;  Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program;  The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity;  Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service;  The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i);  Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan;  The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68;  The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and  To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that:  The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make

18 a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and  The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items:  Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services;  The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled;  Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider;  The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care;  Any restrictions on the enrollee's freedom of choice among network providers;  The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of-network providers;  Cost sharing, if any is imposed under the State plan;  Enrollee rights and responsibilities, including the elements specified in

19 42 CFR §438.100;  The process of selecting and changing the enrollee's primary care provider;  Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee;  How to access auxiliary aids and services, including additional information in alternative formats or languages;  The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and  Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(i), including:  Which medications are covered (both generic and name brand); and  What tier each medication is on.

20 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross- referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206)

21 3.6.3

The State assures that it:  Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10;  Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross- referencing 42 CFR 438.68(e)) 

Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers:  A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities;o  Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and  Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by:  Requiring the contract to adequately and timely cover out-of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the

22 network;  Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services;  Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees;  Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary;  Establishing mechanisms to ensure compliance by network providers;  Monitoring network providers regularly to determine compliance;  Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207) 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area:  Offers an appropriate range of preventative, primary care and specialty services; and  Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including:  Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and  Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts)

23 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that:  The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures;  The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and  Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)) 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including:  Ensure that each enrollee has an ongoing source of care appropriate to his or her needs;  Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee;  Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services;  Coordinate the services the MCO, PIHP, or PAHP furnishes to the

24 enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers;  Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees;  Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs;  Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and  Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)) Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs:  Is in accordance with applicable State quality assurance and utilization review standards;  Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3))

25 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross- referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that:

26 The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3). 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242)

27 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following:  The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a))  Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(b))  Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b))

28 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is:  At the enrollee's option and not required before or used as a deterrent to proceeding to the State review;  Independent of both the State and MCO, PIHP, or PAHP;  Offered without any cost to the enrollee; and  Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains:  The adverse benefit determination.  The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used

29 in setting coverage limits.  The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review.  The procedures for exercising the rights specified above under this assurance.  The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease:  An appeal of a denial that is based on lack of medical necessity.  A grievance regarding denial of expedited resolution of an appeal.  A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals.

30 The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross- referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following:  Make reasonable efforts to give the enrollee prompt oral notice of the delay.  Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision.  Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)) 3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the

31 MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)) 3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items:  The results of the resolution process and the date it was completed; and  For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review:  The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review;  The review is independent of both the State and MCO, PIHP, or PAHP; and  The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes:  The right to file grievances and appeals;  The requirements and timeframes for filing a grievance or appeal;  The availability of assistance in the filing process;

32  The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and  The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414) 3.9.26 The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27 The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)) 3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including: Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards; Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate,

33 information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following:  A compliance program that include all of the elements described in 42 CFR 438.608(a)(1);  Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State;  Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility;  Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP;  Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis;  In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers;  Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program

34 integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and  Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f))

35 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

36 3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15 The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides:  The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services;  Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and  The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)). 3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4).

37 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250. 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items:  The State-defined network adequacy and availability of services

38 standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236;  A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP;  Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract;  A description of the State's transition of care policy required under 42 CFR 438.62(b)(3);  The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language;  For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438;  A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity;  The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs);  Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities;  Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and  The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the

39 MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS:  A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and  A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will:  Make the strategy available for public comment; and  If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects

40 Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least:  Standard performance measures specified by the State;  Any measures and programs required by CMS (42 CFR 438.330(a)(2);  Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d);  Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c);  Mechanisms to detect both underutilization and overutilization of services; and  Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1))

Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements:  Measurement of performance using objective quality indicators;  Implementation of interventions to achieve improvement in the access to and quality of care;  Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and  Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42

41 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The assessment and program must include:  Standard performance measures specified by the State;  Mechanisms to detect both underutilization and overutilization of services; and  Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and

42 performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include:  The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and  The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3. 3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)) 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)) Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a

43 methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review). 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or

44 PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include:  Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and  A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must

45 include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met:  The EQRO has sufficient information to use in performing the review;  The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360;  For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and  The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)) 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items:  A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2));  For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated

46 performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data;  An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries;  Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries;  Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and  An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)) 3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii))

47 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10 The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d))

Key for Newly Incorporated Templates The newly incorporated templates are indicated with the following letters after the numerical section throughout the template.

 PC- Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)  PW- Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)  TC- Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)  DC- Dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)  DS- Supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)  PA- Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)  EL- Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)  LR- Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

48

CMS Regional Offices CMS Regional Offices States Associate Regional Administrator Regional Office Address Region 1- Boston Connecticut Massachuset ts Maine New Hampshire Rhode Island Vermont Richard R. McGreal richard.mcgreal@cms.hhs.gov John F. Kennedy Federal Bldg. Room 2275 Boston, MA 02203-0003 Region 2- New York New York Virgin Islands New Jersey Puerto Rico Michael Melendez michael.melendez@cms.hhs.gov 26 Federal Plaza Room 3811 New York, NY 10278-0063 Region 3- Philadelphia Delaware District of Columbia Maryland Pennsylvania Virginia West Virginia Ted Gallagher ted.gallagher@cms.hhs.gov The Public Ledger Building 150 South Independence Mall West Suite 216 Philadelphia, PA 19106 Region 4- Atlanta Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee Jackie Glaze jackie.glaze@cms.hhs.gov

Atlanta Federal Center 4th Floor 61 Forsyth Street, S.W. Suite 4T20 Atlanta, GA 30303-8909 Region 5- Chicago Illinois Indiana Michigan Minnesota Ohio Wisconsin Verlon Johnson verlon.johnson@cms.hhs.gov 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 Region 6- Dallas Arkansas Louisiana New Mexico Oklahoma Texas Bill Brooks bill.brooks@cms.hhs.gov 1301 Young Street, 8th Floor Dallas, TX 75202 Region 7- Kansas City Iowa Kansas Missouri Nebraska

James G. Scott james.scott1@cms.hhs.gov Richard Bulling Federal Bldg. 601 East 12 Street, Room 235 Kansas City, MO 64106-2808 Region 8- Denver Colorado Montana North Dakota South Dakota Utah Wyoming Richard Allen richard.allen@cms.hhs.gov Federal Office Building, Room 522 1961 Stout Street Denver, CO 80294-3538 Region 9- San Francisco

Arizona California Hawaii Nevada American Samoa Guam Northern Mariana Islands Gloria Nagle gloria.nagle@cms.hhs.gov 90 Seventh Street Suite 5-300 San Francisco Federal Building San Francisco, CA 94103 Region 10- Seattle Idaho Washington Alaska Oregon Carol Peverly carol.peverly@cms.hhs.gov 2001 Sixth Avenue MS RX-43 Seattle, WA 98121

49 GLOSSARY Adapted directly from Sec. 2110. DEFINITIONS. CHILD HEALTH ASSISTANCE- For purposes of this title, the term ‘child health assistance’ means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in Section 2105(a)(2)(A), payment for part or all of the cost of providing any of the following), as specified under the State plan: 1. Inpatient hospital services. 2. Outpatient hospital services. 3. Physician services. 4. Surgical services. 5. Clinic services (including health center services) and other ambulatory health care services. 6. Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person. 7. Over-the-counter medications. 8. Laboratory and radiological services. 9. Prenatal care and prepregnancy family planning services and supplies. 10. Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services. 11. Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services. 12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). 13. Disposable medical supplies. 14. Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home). 15. Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting. 16. Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. 17. Dental services. 18. Inpatient substance abuse treatment services and residential substance abuse treatment services. 19. Outpatient substance abuse treatment services. 20. Case management services. 21. Care coordination services. 22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. 23. Hospice care. 24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or

50 rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is-- a. prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law, b. performed under the general supervision or at the direction of a physician, or c. furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license. 25. Premiums for private health care insurance coverage. 26. Medical transportation. 27. Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals. 28. Any other health care services or items specified by the Secretary and not excluded under this section.

TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title-- 1. IN GENERAL- Subject to paragraph (2), the term ‘targeted low-income child’ means a child-- a. who has been determined eligible by the State for child health assistance under the State plan; b. (i) who is a low-income child, or (ii) is a child whose family income (as determined under the State child health plan) exceeds the Medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the Medicaid applicable income level; and c. who is not found to be eligible for medical assistance under title XIX or covered under a group health plan or under health insurance coverage (as such terms are defined in Section 2791 of the Public Health Service Act). 2. CHILDREN EXCLUDED- Such term does not include-- a. a child who is a resident of a public institution or a patient in an institution for mental diseases; or b. a child who is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State. 3. SPECIAL RULE- A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program's operation. 4. MEDICAID APPLICABLE INCOME LEVEL- The term ‘Medicaid applicable income level’ means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under title XIX (including under a waiver authorized by the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical assistance under Section 1902(l)(2) for the age of such child. 5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‘targeted low-income pregnant woman’ means an individual— (A) during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; (B) whose family income exceeds

51 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this title for a targeted low-income child; and (C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of Section 2110(b) in the same manner as a child applying for child health assistance would have to satisfy such requirements. ADDITIONAL DEFINITIONS- For purposes of this title: 1. CHILD- The term ‘child’ means an individual under 19 years of age. 2. CREDITABLE HEALTH COVERAGE- The term ‘creditable health coverage’ has the meaning given the term ‘creditable coverage’ under Section 2701(c) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to a targeted low-income child under this title or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service waiver). 3. GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The terms ‘group health plan’, ‘group health insurance coverage’, and ‘health insurance coverage’ have the meanings given such terms in Section 2191 of the Public Health Service Act. 4. LOW-INCOME CHILD - The term ‘low-income child’ means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved. 5. POVERTY LINE DEFINED- The term ‘poverty line’ has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. 6. PREEXISTING CONDITION EXCLUSION- The term ‘preexisting condition exclusion’ has the meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(b)(1)(A)). 7. STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires, the terms ‘State child health plan’ and ‘plan’ mean a State child health plan approved under Section 2106. 8. UNINSURED CHILD- The term ‘uninsured child’ means a child that does not have creditable health coverage.

_____________________________________________________________________________ Table of Contents State/Territory Name: Louisiana State Plan Amendments (SPA) #: LA-19-0022 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

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

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

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

Children and Adults Health Programs Group

Jen Steele

Medicaid Director

Department of Health and Hospitals AUG 15 2019 628 North 4th Street

Baton Rouge, LA 70802

Dear Ms. Steele:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), LA-19-0022, has been approved. This SPA has an effective date of July 10, 2019.

Through SPA LA-19-022, the state may provide temporary adjustments to enrollment and redetermination policies, prior authorization requirements, and cost-sharing requirements for children in families living or working in a Federal Emergency Management Agency (FEMA) or Governor declared disaster area. Specifically, the state may take the following actions:

e Waive monthly premiums; Waive prior authorization requirements;

e Provide enrollees eligibility beyond the certification period, allowing families additional time to submit a renewal or verification;

e Waive certain verification requirements at application and renewal. The state may allow self-attestation to complete the eligibility determination, consistent with the regulations.

This SPA, as it applies to Hurricane Barry, has an effective date of July 10, 2019 and a duration through August 31, 2019. The state may use its flexibilities for children in impacted families in Jefferson, Lafourche, Plaquemines, St. Mary, and Terrebonne parishes. If the state needs to extend these flexibilities beyond August 31, 2019, they will inform CMS of the new end date.

In the event of a future natural disaster, this SPA provides Louisiana with the authority to implement the aforementioned temporary policy adjustments by notifying CMS. The notification to CMS must contain the effective date and duration of the disaster provisions, and a list of the relevant FEMA or Governor declared disaster areas. While the state must provide notice to CMS, this option provides an administratively streamlined pathway for the state to effectively respond to any future natural disasters as they are evolving.

Your title XXI project officer is Ms. Jasmine Aplin. She is available to answer questions concerning this amendment and other CHIP-related issues. Her contact information is as follows:

Page 2-Ms. Jen Steele

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8102

E-mail: Jasmine.Aplin@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Aplin and Mr. Bill Brooks, Director, Division of Medicaid Field Operations South. Mr. Brooks’ address is:

Centers for Medicare & Medicaid Services Division of Medicaid Field Operations South 1301 Young St. Suite 714 Dallas, TX 75202 We look forward to continuing to work with you and your staff. Sincerely,

/signed Anne Marie Costello/

AXtine MarieCosteéllo Director

Ce: Mr. Bill Brooks, Director, Division of Medicaid Field Operations South

LOUISIANA TITLE XXI STATE PLAN Revised 07/10/2019 1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

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

State/Territory:

LOUISIANA

(Name of State/Territory)

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

/s/ Jen Steele

July 10, 2019 Jen Steele, Medicaid Director, Louisiana Department of Health

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

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

Name: Jen Steele

Position/Title: Medicaid Director

Bureau of Health Services Financing

Name: Jennifer Katzman

Position/Title: Medicaid Deputy Director

Bureau of Health Services Financing

*Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

LOUISIANA TITLE XXI STATE PLAN Revised 07/10/2019 6 Amendment 24 LA SPA TN 19-0022 CHIP Disaster Eligibility and Enrollment Effective date: July 10, 2019 Provisions for implementing temporary adjustments to eligibility and enrollment policies for application and redetermination, cost sharing, enrollment fees and prior authorization requirements for children in families living in Federal Emergency Management Agency (FEMA) or governor-declared disaster areas at the time of the disaster event. In the event of a disaster, the State will notify the Centers for Medicare & Medicaid Services (CMS) of the intent to provide these temporary adjustments, the effective dates of such adjustments, and the parishes/areas impacted by the disaster.

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. On July 16, 2019, a tribal notification with a summary of the State’s intent to seek approval from CMS to implement temporary adjustments to eligibility and enrollment policies for application and redetermination, cost-sharing, enrollment fees and prior authorization requirements for children in families living in Federal Emergency Management Agency (FEMA) or governor-declared disaster areas at the time of the disaster event, was sent to the five federally recognized tribes. The seven-day comment period for the tribal notification ended July 23, 2019.

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

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

Phase I: 1) On July 31, 1998, Louisiana submitted a proposal to implement a State Children’s Health Insurance Program, which expanded Medicaid coverage to uninsured children who were at least six years of age but under 19 years of age in families with incomes at or below 133 percent of the federal poverty level (FPL).

The expansion was to serve an estimated additional 28,350 children. Louisiana implemented this expansion on November 1, 1998.

LOUISIANA TITLE XXI STATE PLAN Revised 07/10/2019 58 documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

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

4.2.1.

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

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

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

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350) The methods of establishing eligibility and continuing enrollment will be the same as under Title XIX except for citizenship. In the event of a FEMA or governor-declared disaster, the State will notify CMS of the intent to provide temporary adjustments to its eligibility and enrollment policies, the effective dates of such adjustments, and the parishes/areas impacted by the disaster.

In the event of a FEMA or governor-declared disaster and at the State’s discretion, enrollees may be granted eligibility and receive services beyond their certification period.

In the event of a FEMA or governor-declared disaster and at the State’s discretion, enrollees may be provided additional time to submit a renewal or verification.

In the event of a FEMA or governor-declared disaster and at the State’s discretion, eligibility verification requirements may be waived at application and renewal. The State may allow self-attestation to complete the eligibility determination, in accordance with 42 CFR 457.380.

In the event of a FEMA or governor-declared disaster and at the State’s discretion, the State may waive or delay collection of enrollment fees in accordance with Sections 8.2.1 and 8.2.3.

Such measures will be recorded in the case notes of the eligibility record.

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

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

LOUISIANA TITLE XXI STATE PLAN

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79

6.1.4.7.

Other. (Describe)

The state will use the Medicaid network of providers but offer the limited benefit package outlined in the separate program and offer the same benefits package except for LaCHIP Phase IV children. LaCHIP Phase IV for unborn child coverage mirrors the benefit package offered through Title XIX program in Louisiana.

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42 CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

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

For the unborn child, the State covers pregnancy related services and services that if not treated could complicate the pregnancy, i.e., the State covers the same services that it covers for the SOBRA pregnant women category in the Medicaid State Plan. Exception: Sterilization procedures are not covered for the SCHIP unborn child group. The services checked below are generally covered for Medicaid categorically needy eligibles and are potentially covered for the SCHIP unborn child group, depending on the need of the recipient. Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc.

The State may waive the prior authorization requirements for services for children in families living in FEMA or governor-declared disaster areas at the time of the disaster event.

6.2.1.

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

6.2.1.1 Unborn - Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc. 6.2.2.

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

6.2.2.1 Unborn - Louisiana Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior

LOUISIANA TITLE XXI STATE PLAN

Revised 07/10/2019

98 available for children with asthma and diabetes.

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

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) The methods used to assure access to well-baby care, well-child care, well- adolescent care and childhood and adolescent immunizations, as appropriate, are the same as under Title XIX for unborn children in LaCHIP Phase IV.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b)) The methods used to assure access to covered services, including emergency services as defined in 42 CFR are the same as under Title XIX for unborn children in LaCHIP Phase IV.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) The methods used to assure access to appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of- network providers when the network is not adequate for the enrollee’s medical condition are the same as under Title XIX for unborn children covered in LaCHIP Phase IV.

Children between 200-300 percent FPL with chronic, complex or serious medical conditions will also be eligible for the optional Family Opportunity Act program being implemented concurrently with LaCHIP Phase V. This program will have the same methods to assure access as Medicaid, as it is a Title XIX program.

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

The State may waive the prior authorization requirements for services for

LOUISIANA TITLE XXI STATE PLAN

Revised 07/10/2019

99 children in families living in FEMA or governor-declared disaster areas at the time of the disaster event.

Section 8. Cost-Sharing and Payment

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

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42 CFR 457.505) Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09- 006, issued May 11, 2009)

8.1.1.

Yes In the event of a FEMA or governor-declared disaster and at the State’s discretion, the State may waive cost sharing for families living in FEMA or governor-declared disaster areas at the time of a disaster event. 8.1.2.

No, skip to question 8.8. Unborn children covered in LaCHIP Phase IV

8.1.1-PW

Yes 8.1.2-PW

No, skip to question 8.8.

Guidance: It is important to note that for families below 150 percent of poverty, the same limitations on cost sharing that are under the Medicaid program apply. (These cost-sharing limitations have been set forth in Section 1916 of the Social Security Act, as implemented by regulations at 42 CFR 447.50 - 447.59). For families with incomes of 150 percent of poverty and above, cost sharing for all children in the family cannot exceed 5 percent of a family's income per year. Include a statement that no cost sharing will be charged for pregnancy-related services. (CHIPRA #2, SHO # 09-006, issued May 11, 2009) (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b) and (c), 457.515(a) and (c))

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

8.2.1.

Premiums: $50 per month per family where family income is from 201 up to and including, 250 percent of the federal poverty level (FPL)

In the event of a FEMA or governor-declared disaster and at the State’s discretion, the State may waive or delay collection of premiums at initial application or renewal for families living in FEMA or governor-declared

LOUISIANA TITLE XXI STATE PLAN

Revised 07/10/2019

100 disaster areas at the time of a disaster event. If the State elects to delay collection of premiums, eligible individuals will be enrolled prior to payment of the premium.

8.2.2.

Deductibles:

8.2.3.

Coinsurance or copayments:

8.2.4.

Other:

8.2-DS

Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) For children enrolled in the dental-only supplemental coverage, describe the amount of cost-sharing, specifying any sliding scale based on income. Also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2- DS, 6.2-DS, and 9.10 when electing this option.

8.2.1-DS Premiums:

8.2.2-DS Deductibles:

8.2.3-DS Coinsurance or copayments:

8.2.4-DS Other:

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

The cost sharing information is explained to potential enrollees through the application, which includes a chart of income eligibility and premium payment amounts. This information is also prominently displayed on the LaCHIP website. If changes are necessary to the cost sharing requirements, all current enrollees are notified by letter of the changes and the effective dates. Public hearings are held to allow the public to comment on any proposed changes to cost sharing.

Guidance: The State should be able to demonstrate upon request its rationale and justification regarding these assurances. This section also addresses limitations on payments for certain expenditures and requirements for maintenance of effort.

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

LOUISIANA TITLE XXI STATE PLAN

Revised 07/10/2019

103 than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

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

Because there will no longer be co-pays, the maximum amount that a family would pay for coverage is $600 per year for premiums. This will never exceed the five percent cost sharing required for 200 percent FPL.

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

All Louisiana Medicaid and SCHIP applications request ethnicity information on each applicant. No cost sharing is imposed on those children who are verified to be a member of a federally recognized tribe. The applicant’s statement on the application form is sufficient to exempt the child from any cost-sharing obligations.

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

Applicants will not be enrolled in LaCHIP Phase V until they pay for the first month’s premium. They will not receive access to benefits and will subsequently be notified that their eligibility is ending due to failure to pay. Premiums are due by the tenth of each month. If payment is not received by the tenth of the month a notice is generated notifying the responsible party that coverage will be terminated if payment is not received by the twenty-first of the month. Non- payment of premium results in disenrollment effective 60 days after the due date.

In the event of a FEMA or governor-declared disaster and at the State’s discretion, the State may waive or delay collection of premiums in accordance with Sections 8.1.1 and 8.2.1.

8.7.1 Please provide an assurance that the following disenrollment protections are

_____________________________________________________________________________ Table of Contents State/Territory Name: Louisiana State Plan Amendments (SPA) #: LA-20-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850 Children and Adults Health Programs Group December 17, 2020 Tara LeBlanc Interim Medicaid Executive Director State of Louisiana, Department of Health Bureau of Health Services Financing 628 North 4th Street Baton Rouge, LA 70821-0629 Dear Ms. LeBlanc: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number LA-20-0008, has been approved. Through this SPA, Louisiana has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. This SPA has an effective date of October 24, 2019. Section 5022 of the SUPPORT Act added Section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, Section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Louisiana demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner. Your Project Officer is Ms. Sandra Phelps. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Phelps’ contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-1968 E-mail: Sandra.Phelps@cms.hhs.gov

Page 2 — Ms. LeBlanc

If you have additional questions, please contact Meg Barry, Acting Division Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and

your staff.

Sincerely, /signed Amy Lutzky/

Amy Lutzky Deputy Director

Bienville Building ▪ 628 N. Fourth St. ▪ P.O. Box 629 ▪ Baton Rouge, Louisiana 70821-0629 Phone: (225) 342-9500 ▪ Fax: (225) 342-5568 ▪ www.ldh.la.gov An Equal Opportunity Employer

VIA ELECTRONIC MAIL ONLY

December 17, 2020

Meg Barry, Acting Director Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

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

Dear Ms. Barry:

RE: LA SPA TN 20-0008 Section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act

Please refer to our proposed amendment to the Children’s Health Insurance Program (CHIP) State Plan submitted under transmittal number (TN) 20-0008 with the proposed effective date October 24, 2019. The purpose of this SPA is to adopt provisions in Section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act that amends section 2103(c)(5) of the Social Security Act (the Act), to make behavioral health services that are culturally and linguistically appropriate and different from the Mental Health Parity and Addiction Equity Act (P.L. 110-343) (MHPAEA) a required benefit in the Children’s Health Insurance Program (CHIP). We are providing the following in response to your request for additional information (RAI) dated August 6, 2020.

Outstanding Questions SPA #: LA-20-0008

Section 6.2-BH: Covered Services 1. Based on the responses that the state provided to questions 1 and 2 in the submission from October 15, the state provides all services to children under 21 if medically necessary. Therefore, we recommend that the state check off the John Bel Edwards GOVERNOR Dr. Courtney N. Phillips SECRETARY S tate of Louisiana

L o uisiana Department of Health

B u r eau of Health Services Financing

LA SPA TN 20-0008 December 17, 2020 Page 2

service boxes for the following benefits in section 6.2-BH of the state plan to indicate that children will receive the services if needed:  6.3.2.4-BH Peer support for substance use disorder (SUD)  6.3.2.7-BH Intensive in-home services  6.3.2.8-BH Intensive outpatient for mental health  6.3.2.9-BH Psychosocial rehabilitation for SUD  6.3.3-BH Day treatment  6.3.3.1-BH Partial hospitalization  6.3.5.1-BH Crisis intervention and stabilization for SUD  6.3.6-BH Continuing care services  6.3.7-BH Care coordination  6.3.7.2-BH Care transition services  6.3.8-BH Case management

LDH Response: The boxes have been checked. Please see attached revised State Plan pages.

2. We suggest that the state revise the language in section 6.2-BH of the state plan for services that are indicated as covered only through the coordinated system of care. We reviewed the information on the state’s website about the Coordinated System of Care, and think it would be helpful to include some of that language in the descriptions of these services in the state plan. If applicable, please use the following language in the description of services for peer support, respite care, and intensive wraparound in section 6.2-BH: “Children in need of (peer support/ respite care/ intensive wraparound) services will be evaluated to determine whether the child is eligible for the state’s Coordinated System of Care. The Coordinated System of Care ensures there is a coordinated network of services and supports for children and youth with behavioral health challenges and their families. Children eligible for services through the Coordinated System of Care include those in or at risk of out of home placement with significant behavioral health challenges.”

LDH Response: The language has been added as follows: Children in need of peer support, respite care, and intensive wraparound services will be evaluated to determine whether the child is eligible for services through the State’s Coordinated System of Care. The Coordinated System of Care ensures there is a coordinated network of services and supports for children and youth with behavioral health challenges and their families. Children eligible for services through the Coordinated System of Care include those in, or at risk of, out-of-home placement. Please see attached revised State Plan pages, Section 6.2-BH.

LA SPA TN 20-0008 December 17, 2020 Page 3

Section 6.3.1.2 and 6.4.2 BH: Strategies to Facilitate the Use of Validated Screening and Assessment Tools 3. Louisiana indicates that it will convey that screenings should be conducted in accordance with the Bright Futures initiative of the American Academy of Pediatrics through an informational bulletin on the state’s website. However, we are requesting that the state please describe how it will facilitate the use of validated screening tools rather than screenings. We have attached examples from other states in this area in case helpful.

LDH Response: The screening tools are required through the State’s managed care contracts. The MCOs are tasked with educating providers on the screening tool requirements as well as care coordination and service referrals if member needs cannot fully be met by the attending provider. The State has added language to the attached revised State Plan pages, Section 6.3.1.2-BH.

4. Please update Section 6.4.2 of your CHIP state plan with the additional information the state provided in response to CMS’ questions on the frequency of updates provided relative to assessment tools.

LDH Response: The language has been added. Please see attached revised State Plan pages, Section 6.4.2-BH.

Please consider this a formal request to begin the 90-day clock. We trust this additional information will result in the approval of the pending SPA. We look forward to negotiating with CMS to ensure approval.

As always, we appreciate the assistance of CMS in resolving these issues. If further information is required, you may contact Karen H. Barnes at Karen.Barnes@la.gov or by phone (225) 342-3881.

Sincerely,

Tara A. LeBlanc Interim Medicaid Executive Director

TAL:KHB:MVJ

Attachment

c: Kelly Zimmerman Karen H. Barnes

Tobias Griffin

12 Amendment 26 LA SPA TN 20-0008 Section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act To adopt provisions in Section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act that amends section 2103(c)(5) of the Social Security Act (the Act), to make behavioral health services that are culturally and linguistically appropriate and different from the Mental Health Parity and Addiction Equity Act (P.L. 110-343) (MHPAEA) a required benefit in the Children’s Health Insurance Program (CHIP). Proposed effective date: October 24, 2019 Proposed implementation date: October 24, 2019

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

On June 12, 2020 a tribal notification with a summary of the State’s intent to seek approval from CMS to adopt provisions in Section 5022 of the SUPPORT Act that amends Section 2103(c)(5) of the Social Security Act (the Act), to make behavioral health services a required benefit in the Children’s Health Insurance Program (CHIP). The comment period for the tribal notification ended June 19, 2020. TN No: Approval Date Effective Date

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description.  Population  Number of uninsured  Race demographics  Age Demographics  Info per region/Geographic information

71 6.2.16.

Vision screenings and services (Section 2110(a)(24))

6.2.17.

Hearing screenings and services (Section 2110(a)(24))

6.2.18.

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

6.2.19.

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

6.2.20.

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

6.2.21.

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

Guidance: See guidance for section 6.1.4.1 for a guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check this box.

6.2.22.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

6.2.22.1 The state assures that any limitations applied to the amount, duration, and scope of benefits described in Sections 6.2 and 6.3- BH of the CHIP state plan can be exceeded as medically necessary.

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.23.

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

These services are limited to unborn children covered through LaCHIP Phase IV, who would obtain those services through the Medicaid State Plan. 6.2.24.

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

6.2.25.

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

Guidance: Enabling services, such as transportation, translation, and outreach services, may

72 be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.26.

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

6.2.27.

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

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn children.

Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related coverage, please describe the recommendations being followed for those services.

Children in need of peer support, respite care, and intensive wraparound services will be evaluated to determine whether the child is eligible for services through the State’s Coordinated System of Care. The Coordinated System of Care ensures there is a coordinated network of services and supports for children and youth with behavioral health challenges and their families. Children eligible for services through the Coordinated System of Care include those in, or at risk of, out-of-home placement.

6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any covered CHIP populations:

State-developed schedule American Academy of Pediatrics/ Bright Futures Other Nationally recognized periodicity schedule (please specify: ) Other (please describe: )

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders. If there are differences in benefits based on the population or type of condition being treated, please specify those differences.

If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit.

73 Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1-BH.

All EPSDT medically necessary services are provided through referral to a behavioral health clinician by the primary care provider, even when such health care is not otherwise covered under State Plan. These services may require prior authorization.

6.3.1- BH Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age-appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools.

The screening tools are required through the State’s managed care contracts. The MCOs are tasked with educating providers on the screening tool requirements as well as care coordination and service referrals if member needs cannot fully be met by the attending provider.

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

6.3.2.1- BH Psychosocial treatment Provided for: Mental Health Substance Use Disorder

6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

74 Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the Act, MAT benefits are required for the treatment of opioid use disorders. However, if the state provides MAT for other SUD conditions, please include a description of those benefits below at section 6.3.2.3- BH.

6.3.2.3- BH Medication Assisted Treatment Provided for: Substance Use Disorder

6.3.2.3.1- BH Opioid Use Disorder

6.3.2.3.2- BH Alcohol Use Disorder

6.3.2.3.3- BH Other

6.3.2.4- BH Peer Support Provided for: Mental Health Substance Use Disorder

Coordinated System of Care (CSoC) only.

6.3.2.5- BH Caregiver Support Provided for: Mental Health Substance Use Disorder

6.3.2.6- BH Respite Care Provided for: Mental Health Substance Use Disorder

CSoC only.

6.3.2.7- BH Intensive in-home services Provided for: Mental Health Substance Use Disorder

6.3.2.8- BH Intensive outpatient Provided for: Mental Health Substance Use Disorder

75 6.3.2.9- BH Psychosocial rehabilitation Provided for: Mental Health Substance Use Disorder

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit, please indicate that in the benefit description. If there are differences between these benefits, such as the staffing or intensity of the setting, please specify those in the description of the benefit’s amount, duration, and scope.

6.3.3- BH Day Treatment Provided for: Mental Health Substance Use Disorder

6.3.3.1- BH Partial Hospitalization Provided for: Mental Health Substance Use Disorder

6.3.4- BH

Inpatient services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18)) Provided for: Mental Health Substance Use Disorder

Guidance: If applicable, please clarify any differences within the residential treatment benefit (e.g. intensity of services, provider types, or settings in which the residential treatment services are provided).

6.3.4.1- BH Residential Treatment Provided for: Mental Health Substance Use Disorder

6.3.4.2- BH Detoxification Provided for: Substance Use Disorder

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or short term residential or other facility based services in order to avoid inpatient hospitalization.

76 6.3.5- BH Emergency services Provided for: Mental Health Substance Use Disorder

6.3.5.1- BH Crisis Intervention and Stabilization Provided for: Mental Health Substance Use Disorder

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

6.3.7- BH Care Coordination Provided for: Mental Health Substance Use Disorder

6.3.7.1- BH Intensive wraparound Provided for: Mental Health Substance Use Disorder

CSoC only.

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder

6.4- BH Assessment Tools

6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

77 ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use Disorders

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders

State-specific criteria (e.g. state law or policies) (please describe) Mental Health Substance Use Disorders

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Managed care entities may use medical management criteria endorsed by a national or state health care provider or association, such as MCG or Interqual, to support clinical decision-making and service authorization for certain levels of care, such as inpatient and other services, in accordance with the State’s medical necessity criteria.

Other (please describe) Mental Health Substance Use Disorders

No specific criteria or tools are required Mental Health Substance Use Disorders

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools to determine possible treatments or plans of care, providing education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

78 6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

The use of the LOCUS/CALOCUS is mandated in the provider manual. The CANS is mandated through the waiver. The assessment tools are required through the State’s managed care contracts and the Behavioral Health Provider Manual. The tools are updated by the State as frequently as they are updated by the developer of the tools. The CSoC contractor and the MCOs push the updates out to their providers. The CSoC services are available to all CHIP populations who meet the level of care.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex or serious conditions.

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

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

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

Louisiana Medicaid EPSDT Periodicity Schedule

INFANCY EARLY CHILDHOOD MIDDLE CHILDHOOD: ADOLESCENCE

Newborn] 3-5] By |AGE Prenatal (2) day} 1Mo |2MO| 4Mo |6MO|9 MO} 12 MO] 15 MO | 18 MO|24 MO] 30 MO |3 YR]}4 YR]5 YRJ6 YR]7 YR| 8 YR| 9 YR| 10 YRJ 11 YR |12 YR] 13 YR ]14 YR] 15 YR] 16 YR| 17 YR] 18 YR

19 YR | 20 YR}

initial/Interval e . ele . . ele . . . . . eleletelelelele . . . elele . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

[Length/Height and Weight

[Head Circumference

[Weight for Length

[body Mass Index

Pa . . . . . . . . . .

[Blood Pressure

ISENSORY SCREENING

Ie] p>]

Vision Screening

ole] p+] oP] | |

pe pt Pee] poe] Pe) | >

>] bee] foe]

De] Dee] tl De pe

.

.

.

. Ht

. eal

.

De |

.

be

be

.

be

be

Hearing Screening

| DEVELOPMENTAL/BEHAVIORAL HEALTH

[Developmental Screening

[Autism Screening - |e

[Developmental Surveillance ~fel-lele-

[Psychosocial/Behavioral Assessment °e fel «|e le flele]e ° ° |e ° Telefelelele]e]|e

[Tobacco, Alcohol and Drug Use Assessment

>| ePtfele

» eptiele eptlele ePtlele ePtlele oe Ptlele

[Depression Screening

oPtlele oPtlele

[Maternal Depression Screening . . . .

[PHYSICAL EXAMINATION ° ° ° ° ° ° ° ° ° ° ° . elfetetete| ele ° ° . ° ° .

|PROCEDURES

Newborn Blood

Newborn Bilirubin

(Critical Congenital Heart Defect

immunization [4]

+ »| | > De] ate a ot >» | pa >|

[anemia x

[Lead Risk Assessment [5] ele

[Blood Lead Screening [6]

[>t] PH] at |ae] « [>t]

be De Ptlelelele

[Tuberculosis

tt] o |e pt] at PH ]>e] o Joe] & pel]. pe]

[yslipidemia

>t pat pe at) >e} oe]

[Sexually Transmitted Infections

at >t |e pe pt] ae] aH oe] be [>t | ee

ae foel + be

HIV

a >t) oe] e be

> > a

x [x

>| a a

ORAL HEALTH ° e

Fluoride Varnish [7]

oH >¢] >| oa] a a

wk Te Te pe fe fe De Te

[Fluoride Supplementation zk[x T*

eptle

JANTICIPATORY GUIDANCE [8] e . el . . ele ° . . . .

. . . . . . . . . . . . . . .

© = to be performed x = risk assessment to be performed with appropriate action to follow, if positive <— ¢ ——»=range during which a service may be provided

[1] Baseline lab and developmental screening must be done at the initial medical screening on all children under age six. [2] The newborn screening examination at birth must occur prior to hospital discharge. [3] The physical examinations/assessment must be unclothed or undraped and include all body systems. [4] The state health department immunization schedule must be done at every medical screening.

[5] Anticipatory guidance and verbal risk assessment for lead must be done at every medical screening. [6] The frequency of screening using the blood lead tests depends on the result of the verbal risk

assessment. Blood Lead Screening at ages 12 and 24 or 36 and 72 if not pr ly screened, is required by Louisiana State regulations. Details are in the “Public Health Surveillance M " section of the Pr al Services I. [7] See USPSTF recommendations (http://www.uspreventi icestaskforce.ot /uspsdnch.htm). Once teeth are present, fluoride varnish may be applied to all children every 6 months in the primary care or dental office. Indications for fluoride use are noted in “Fluoride Use in Caries Prevention in the Primary Care Setting” (http://pediatrics.aappublications.org/content/134/3/626).

[8] Youth, ages 12 through 20, must receive more intensive health education which addresses psychological issues, substance usage, and reproductive health issues at each screening visit. Refer to the specific guidance by age as listed in the Bright Futures Guidelines (Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL American Academy of Pediatrics, 2017)

12 Amendment 26 LA SPA TN 20-0008 Section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act To adopt provisions in Section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act that amends section 2103(c)(5) of the Social Security Act (the Act), to make behavioral health services that are culturally and linguistically appropriate and different from the Mental Health Parity and Addiction Equity Act (P.L. 110-343) (MHPAEA) a required benefit in the Children’s Health Insurance Program (CHIP). Proposed effective date: October 24, 2019 Proposed implementation date: October 24, 2019

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

On June 12, 2020 a tribal notification with a summary of the State’s intent to seek approval from CMS to adopt provisions in Section 5022 of the SUPPORT Act that amends Section 2103(c)(5) of the Social Security Act (the Act), to make behavioral health services a required benefit in the Children’s Health Insurance Program (CHIP). The comment period for the tribal notification ended June 19, 2020. On July 16, 2019, a tribal notification with a summary of the State’s intent to seek approval from CMS to implement temporary adjustments to eligibility and enrollment policies for application and redetermination, cost sharing, and prior authorization requirements for children in families living in Federal Emergency Management Agency (FEMA) or governor declared disaster areas at the time of the disaster event, was sent to the five federally recognized tribes. The seven day comment period for the tribal notification ended July 23, 2019.

In the event of a state or federally declared disaster or public health emergency, the State may modify the tribal consultation process by shortening the number of days before submission of the SPA and/or conducting consultation after submission of the SPA. The duration of the provisions may not exceed the duration of the state or federal disaster period. TN No: Approval Date Effective Date

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

72 school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.23.

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

These services are limited to unborn children covered through LaCHIP Phase IV, who would obtain those services through the Medicaid State Plan. 6.2.24.

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

6.2.25.

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

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.26.

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

6.2.27.

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

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn children.

Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related coverage, please describe the recommendations being followed for those services.

Children in need of peer support, respite care, and intensive wraparound services will be evaluated to determine whether the child is eligible for services through the State’s Coordinated System of Care. The Coordinated System of Care ensures there is a coordinated network of services and supports for children and youth with behavioral health challenges and their families. Children eligible for services through the Coordinated System of Care include those in, or at risk of, out-of-home placement.

6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any

73 covered CHIP populations:

State-developed schedule American Academy of Pediatrics/ Bright Futures Other Nationally recognized periodicity schedule (please specify: ) Other (please describe: )

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders. If there are differences in benefits based on the population or type of condition being treated, please specify those differences.

If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit.

Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1-BH.

All EPSDT medically necessary services are provided through referral to a behavioral health clinician by the primary care provider, even when such health care is not otherwise covered under State Plan. These services may require prior authorization.

6.3.1- BH

Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age-appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools.

74 The screening tools are required through the State’s managed care contracts. The MCOs are tasked with educating providers on the screening tool requirements as well as care coordination and service referrals if member needs cannot fully be met by the attending provider.

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

6.3.2.1- BH Psychosocial treatment Provided for: Mental Health Substance Use Disorder

6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the Act, MAT benefits are required for the treatment of opioid use disorders. However, if the state provides MAT for other SUD conditions, please include a description of those benefits below at section 6.3.2.3- BH.

6.3.2.3- BH Medication Assisted Treatment Provided for: Substance Use Disorder

6.3.2.3.1- BH Opioid Use Disorder

6.3.2.3.2- BH Alcohol Use Disorder

6.3.2.3.3- BH Other

6.3.2.4- BH Peer Support Provided for: Mental Health Substance Use Disorder[JK1]

Coordinated System of Care (CSoC) only:

6.3.2.5- BH [] Caregiver Support Provided for: [[] Mental Health [_] Substance Use Disorder

6.3.2.6- BH Xi Respite CarepK2] Provided for: [<j[-} Mental Health [[] Substance Use Disorder

—CSoC only.

6.3.2.7- BH Dd} Intensive in-home services Provided for: <j} Mental Health [<|] Substance Use Disorder

6.3.2.8- BH JE} Intensive outpatient Provided for: [<jE} Mental Health [x]E] Substance Use Disorder

6.3.2.9- BH IH} Psychosocial rehabilitation Provided for: }<E} Mental Health [<j] Substance Use Disorder

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit,

please indicate that in the benefit description. If there are differences between these benefits, such as the staffing or intensity of the setting, please specify those in the description of the

benefit’s amount, duration, and scope.

6.3.3- BH DE} Day Treatment Provided for: [</} Mental Health [<j] Substance Use Disorder

6.3.3.1- BH [Xj Partial Hospitalization Provided for: [<j-} Mental Health [<j] Substance Use Disorder

75

76 6.3.4- BH Inpatient services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18)) Provided for: Mental Health Substance Use Disorder

Guidance: If applicable, please clarify any differences within the residential treatment benefit (e.g. intensity of services, provider types, or settings in which the residential treatment services are provided).

6.3.4.1- BH Residential Treatment Provided for: Mental Health Substance Use Disorder

6.3.4.2- BH Detoxification Provided for: Substance Use Disorder

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or short term residential or other facility based services in order to avoid inpatient hospitalization.

6.3.5- BH Emergency services Provided for: Mental Health Substance Use Disorder

6.3.5.1- BH Crisis Intervention and Stabilization Provided for: Mental Health Substance Use Disorder

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

6.3.7- BH Care Coordination Provided for: Mental Health Substance Use Disorder

77 6.3.7.1- BH Intensive wraparound Provided for: Mental Health Substance Use Disorder

CSoC only.

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder

6.4- BH Assessment Tools

6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use Disorders

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders

State-specific criteria (e.g. state law or policies) (please describe) Mental Health Substance Use Disorders

78

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Managed care entities may use medical management criteria endorsed by a national or state health care provider or association, such as MCG or Interqual, to support clinical decision-making and service authorization for certain levels of care, such as inpatient and other services, in accordance with the State’s medical necessity criteria.

Other (please describe) Mental Health Substance Use Disorders

No specific criteria or tools are required Mental Health Substance Use Disorders

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools to determine possible treatments or plans of care, providing education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions. The use of the LOCUS/CALOCUS is mandated in the provider manual. The CANS is mandated through the waiver. The assessment tools are required through the State’s managed care contracts and the Behavioral Health Provider Manual. The tools are updated by the State as frequently as they are updated by the developer of the tools. The CSoC contractor and the MCOs push the updates out to their providers. The CSoC services are available to all CHIP populations who meet the level of care.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex or serious conditions.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Louisiana LA-21-0017

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 < Ry] Ss Baltimore, MD 21244-1850

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

Children and Adults Health ms Groi

September 8, 2021

Michael Boutte

Interim Medicaid Executive Director State of Louisiana, Department of Health Bureau of Health Services Financing 628 North 4th Street

Baton Rouge, LA 70821-0629

Dear Mr. Boutte:

Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) number LA-21-0017, submitted on June 30, 2021, has been approved. This SPA has a retroactive effective date of April 1, 2021.

Through this SPA, Louisiana adds three exceptions to the 90-day waiting period for CHIP coverage including involuntary termination of health benefits due to a long-term disability or other medical condition, exhausting coverage under the COBRA continuation provision, and reaching the COBRA life maximum. A copy of the approved CS20 page is attached to be incorporated into the state's approved CHIP state plan. This page supersedes the previous CS20 that was approved on April 11, 2014.

Your title XXI project officer is Ms. Sandra Phelps. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Phelps’ contact information is as follows:

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

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

Telephone: (410) 786-1968

E-mail: Sandra.Phelps@cms.hhs.gov

If you have additional questions, please contact Ms. Meg Barry, Director, Division of State Coverage Programs at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely, /Signed by Amy Lutzky/

Amy Lutzky Deputy Director

Page 1 of 3 CHIP Eligibility Transmittal Number: LA State Name: Louisiana OMB Control Number: 0938‐1148 - 21 - 0017 Separate Child Health Insurance Program Non-Financial Eligibility - Substitution of Coverage CS20 Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3), 457.350(i), and 457.805 Substitution of Coverage The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include: ✔ Substitution of coverage prevention strategy: ■ Add Name of policy Description Remove Add Coordination of Benefits (COB) Match In addition to using employer-based coverage information provided on applications, Louisiana conducts a cross match with group health insurance providers through our third-party liability contractor to determine current and recent health insurance status. This match assists in verifying that the applicant is uninsured and has met the required period of uninsurance. This match also provides an independent source of data for the number of individuals who applied for CHIP and had private insurance within the previous 90 days prior to application. Remove A waiting period during which an individual is ineligible due to having dropped group health coverage. Yes How long is the waiting period? One month Two months 90 days Other The state allows exemptions from the waiting period for the following reasons: ■ The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income. ■ The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B–2(c)(3)(v). ■ The cost of family coverage that includes the child exceeded 9.5 percent of the household income. ■ The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan. ■ A change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA). ■

Page 2 of 3 CHIP Eligibility The child has special health care needs. ■ The child lost coverage due to the death or divorce of a parent. ■ Does the state allow other exemptions in addition to those listed above? Yes Add Describe Remove Add Involuntary termination of health benefits due to a long-term disability or other medical condition. Remove Add The child has exhausted coverage under the COBRA continuation provision (i.e., COBRA expired). Remove Add The COBRA lifetime maximum has been reached. Remove Describe the processes the state employs to facilitate enrollment of CHIP-eligible children who have satisfied the waiting period. ■ The children who apply while in the waiting period will be processed up to the point of having their eligibility approval entered into the eligibility system. It will be in a pending status until released at the end of the waiting period. This will be documented in the case record and an alert entered as to the waiting period status. Pending list reports are monitored frequently by eligibility staff and their supervisors and used as a mechanism to track applications through the eligibility process (i.e. pending verification/information request, etc.), to ensure timely processing and for workload balancing. Describe the processes the state employs to coordinate coverage of children subject to a waiting period with other insurance affordability programs, including safeguards to prevent gaps in coverage for children transitioning from another insurance affordability program to CHIP after satisfying the waiting period. ■ Applications (either sent directly to the State, or referred from other insurance affordability programs to the CHIP agency) determined eligible for CHIP except for satisfying the waiting period, will be placed in a pending status. For children who meet an exception to the waiting period or for whom a waiting period does not apply, the state will notify the other insurance affordability program (such as the FFM for QHP coverage) through an electronic account transfer of the date in which the individual is enrolled into the separate CHIP program. For children subject to a waiting period, the applicant status will change from a pending to active status upon completion of the waiting period, and the state will notify the other insurance affordability program of the start and end date through an electronic account transfer. The state provides assurance that: It does not require a new application or the submission of information already provided by the family immediately preceding the waiting period for the purpose of enrolling CHIP-eligible children who have satisfied a waiting period. ✔ For children subject to the waiting period, it will promptly transfer each individual’s electronic account to the applicable insurance affordability program and notify such program of the date on which the waiting period ends for each individual. ✔ If the state covers pregnant women, the waiting period does not apply to pregnant women. If the state elects to offer dental only supplemental coverage, the following assurances apply: The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA. The waiting period does not apply to children eligible for dental only supplemental coverage.

Page 3 of 3 CHIP Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20181119

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Louisiana LA-21-0026

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

November 9, 2021

Patrick Gillies Medicaid Executive Director State of Louisiana Department of Health Bureau of Health Services Financing 628 North 4th Street, Room 769 Baton Rouge, LA 70802

Dear Mr. Gillies:

Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) LA- 21-0026, submitted on September 30, 2021, has been approved. This amendment allows Louisiana to claim federal matching funds to implement a new health services initiative (HSI) to support the Louisiana Poison Center. The effective date for this amendment is July 1, 2021.

SPA LA-21-0026 provides funding through the HSI option at section 2105(a)(l)(D)(ii) of the Social Security Act (the Act) and 42 CFR §457.10 to use available title XXI administrative funding for expenditures for HSIs under the plan to improve the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR §457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding.

The state will ensure that remaining title XXI funding, within the state’s 10 percent limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program. The state will report annually to CMS the expenditures funded by the HSI for each federal fiscal year.

Your title XXI project officer is Ms. Sandra Phelps. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Phelps’ contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-1968 E-mail: Sandra.Phelps@cms.hhs.gov

If you have additional questions, please contact Ms. Emily King, Deputy Director, Division of State Coverage Programs at (443) 478-6811.

Page 2 — Mr. Patrick Gillies We look forward to continuing to work with you and your staff.

Sincerely,

/Signed by Amy Lutzky/

Amy Lutzky Deputy Director

LOUISIANA TITLE XXI STATE PLAN Revised September 22, 2021

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

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

State/Territory:

LOUISIANA

(Name of State/Territory)

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

/s/ Patrick Gillies

Patrick Gillies, Medicaid Executive Director, Louisiana Department of Health

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

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

Name: Patrick Gillies

Position/Title: Medicaid Executive Director Bureau of Health Services Financing

Name: Kelly Zimmerman

Position/Title: Interim Medicaid Deputy Director

Bureau of Health Services Financing

Disclosure Statement This information is being collected to pursuant to 42 U.S.C. 1397aa, which requires states to submit a State Child Health Plan in order to receive federal funding. This mandatory information collection will be used to demonstrate compliance with all requirements of title XXI of the Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of information requirements under this control number is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4- 26-05, Baltimore, Maryland 21244-1850.

LOUISIANA TITLE XXI STATE PLAN Revised September 22, 2021

2 Amendment 28 LA SPA TN 21-0026 CHIP – Poison Treatment Advice and Prevention The purpose of this SPA is to utilize the health services initiative option as allowed at 42 CFR 457.10, to support the Louisiana Poison Center at Louisiana State University Health Shreveport, in providing daily, 24-hour emergency telephone treatment advice, referral assistance, and information to manage exposure to poisonous and hazardous substances. Effective date: July 1, 2021

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. On July 30, 2020, a tribal notification with a summary of the State’s intent to seek approval from CMS to utilize the health services initiative option as allowed at 42 CFR 457.10, to support the Louisiana Poison Center at Louisiana State University Health Shreveport, in providing daily, 24-hour emergency telephone treatment advice, referral assistance and information to manage exposure to poisonous and hazardous substances. The comment period for the tribal notification ended August 29, 2020.

LOUISIANA TITLE XXI STATE PLAN Revised September 22, 2021

3 2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

Poison Treatment Advice and Prevention

As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, LDH will use CHIP funding for a health services initiative, within the 10 percent federal administrative expenditures cap allowed for states, in accordance with 2105(c)(2)(A) of the Social Security Act. Through the Louisiana State University Health Sciences Center-Shreveport (LSUHSC-S), the funds will support Louisiana Poison Center (LPC) activities impacting children 18 years of age or younger.

The State assures that funding under this HSI will not supplant or match CHIP federal funds with other federal funds, nor will it allow other federal funds to supplant or match CHIP federal funds. The non-federal share of the CHIP funding for the LPC HSI will be provided by LSUHSC-S in the form of certified public expenditures, in accordance with procedures specified by LDH. Projected costs of this program are $1,830,384.

The LPC serves every Louisiana community, including demographics that are typically underserved, such as uninsured, low income, indigent, and those living in rural areas. It directs attention and resources to “at-risk” children and adolescents, low -income populations, minority, migrant and immigrant communities.

The LPC operates a call center to provide: 1. Emergency telephone treatment advice; 2. Referral assistance; and 3. Information to manage exposure to poisonous and hazardous substances.

A hotline is available to the general public and health care providers needing assistance 24 hours per day, 365 days per year, at no charge to the caller. Calls are answered by Certified Specialists in Poison Information (CSPI). Clinical oversight is provided by experienced Medical Doctors boarded in Emergency Medicine and Medical Toxicology. Translation is available in over 240 languages via Language Line service and via relay service for the deaf and hearing impaired.

The LPC handles approximately 35,000 calls to the hotline per year, gathering information, triaging the patient and providing medical management recommendations to the treating physician. Approximately one-third of all calls received by the LPC are initiated from hospital emergency departments and

LOUISIANA TITLE XXI STATE PLAN Revised September 22, 2021

4 intensive care units across the state. The remainder of the calls are primarily from home settings, with a small percentage from other non-healthcare sites.

In 2018, 70 percent of all calls to the LPC involved children under 19 years of age. Children under age six represented 58 percent of all calls to LPC. An estimated one-third of all calls relate to children age 0-18 with annual household incomes of $66,816 or less (250 percent of the FPL for a family of 4). The Kids Count Data Center (2020) website data for 2018, states there are a total of 632,000 children aged 0-18 below 250 percent federal poverty level (FPL) that qualify for either CHIP or Medicaid.

The LPC provides public education programs on poisoning response and prevention. It works closely with schools, healthcare organizations, parenting groups, and childcare providers throughout the state to promote awareness in the identification and treatment of poisoning and hazardous exposures. LPC educates heath care providers in management of poisonings and drug overdoses. It offers continuing education courses to help physicians, nurses, first responders and other healthcare providers manage pediatric patients exposed to poisonous materials.

The LPC distributes educational materials throughout the state, free of charge to the public. Materials are available in multiple languages beyond English, as indicated by state demographics, and are disseminated in hard copy and electronic formats, including websites and social media. The LPC will maintain, on its website, links to assist the public in applying for health coverage through Medicaid and CHIP.

LOUISIANA TITLE XXI STATE PLAN

5 9.10. Provide a 1-year projected budget. A suggested financial form for the budget is below. The budget must describe: (Section 2107(d)) (42CFR 457.140)

• Planned use of funds, including: • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected expenditures for the separate child health plan, including but not limited to expenditures for targeted low-income children, the optional coverage of the unborn, lawfully residing eligibles, dental services, etc. • All cost sharing, benefit, payment, eligibility need to be reflected in the budget.

• Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Include a separate budget line to indicate the cost of providing coverage to pregnant women. • States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. • Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. • Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. • Provide a 1-year projected budget for all targeted low-income children covered under the state plan using the attached form. Additionally, provide the following: - Total 1-year cost of adding prenatal coverage - Estimate of unborn children covered in year 1 - CHIP Budget

STATE: Louisiana FFY Budget Federal Fiscal Year 2022 State’s enhanced FMAP rate 81.95%

Benefit Costs

Insurance payments 0 Managed care $472,729,528 per member/per month rate 0 Fee for Service 0 Total Benefit Costs $472,729,528

LOUISIANA TITLE XXI STATE PLAN

6 STATE: Louisiana FFY Budget (Offsetting beneficiary cost sharing payments) $129,002 Net Benefit Costs $472,600,526 Cost of Proposed SPA Changes – Benefit $1,830,384

Administration Costs

Personnel $3,975,329 General administration $8,121,432 Contractors/Brokers $8,500,555 Claims Processing $2,257,552 Outreach/marketing costs 0 Health Services Initiatives $1,830,384 Other 0 Total Administration Costs $24,685,252 10% Administrative Cap $52,511,170

Cost of Proposed SPA Changes $1,830,384

Federal Share $407,525,695 State Share $89,760,083 Total Costs of Approved CHIP Plan $497,285,778

NOTE: Include the costs associated with the current SPA. • Amounts above are projections from the May CMS 21B submission with the poison control amount added to total plus an additional 4.34 percent FMAP. • All amounts above are based on total expenditures. Federal share is 81.95 percent of total. • Amounts are projections for federal fiscal year, not state fiscal year. The Source of State Share Funds: State General Fund

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Louisiana LA-22-0001

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

April 7, 2022

Patrick Gillies Medicaid Executive Director State of Louisiana Department of Health Bureau of Health Services Financing 628 North 4th Street, Room 769 Baton Rouge, LA 70802

Dear Mr. Gillies:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number LA-22-0001, submitted on March 31, 2022, has been approved. Through this SPA, Louisiana has demonstrated compliance with the American Rescue Plan Act of 2021 (ARP). This SPA has an effective date of March 11, 2021 and extends through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period, as described in section 1135(g)(1)(B) of the Social Security Act (the Act).

Section 9821 of the ARP amended sections 2103(c)(11)(B) and 2103(e)(2) of the Act to mandate coverage of COVID-19 testing, treatment, and vaccines and their administration without cost- sharing or amount, duration, or scope limitations. Sections 2103(c)(11)(B) and 2103(e)(2) of the Act also require states to cover, without cost sharing, the treatment of conditions that may seriously complicate COVID-19 treatment, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19. The state provided the necessary assurances to demonstrate compliance with the ARP in accordance with the requirements of sections 2103(c)(11)(B) and 2103(e)(2) of the Act.

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. 457.65 that the state submit SPAs that are related to the COVID-19 public health emergency by the end of the state fiscal year in which they take effect. CMS is allowing states that submit SPAs after the last day of the state fiscal year to have an effective date in the prior state fiscal year, but no earlier than the effective date of the public health emergency. Louisiana requested a waiver to obtain an earlier effective date of March 11, 2021.

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 2107(e)(1)(f) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. Louisiana requested a waiver to modify the tribal consultation timeline by completing tribal consultation after the effective date of the SPA.

Page 2 – Mr. Patrick Gillies

This letter approves Louisiana’s request for a March 11, 2021 effective date and provides the state with the authority to modify the tribal consultation timeline.

Your Project Officer is Ms. Sandra Phelps. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-1968

E-mail: Sandra.Phelps@cms.hhs.gov

If you have additional questions, please contact Ms. Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

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

cc: Courtney Miller, Director, Medicaid and CHIP Operations Group

Jackie Glaze, Deputy Director, Medicaid and CHIP Operations Group /Signed by Amy Lutzky/

LOUISIANA TITLE XXI STATE PLAN Revised April 7, 2022

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

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

State/Territory:

LOUISIANA

(Name of State/Territory)

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

/s/ Patrick Gillies

Patrick Gillies, Medicaid Executive Director, Louisiana Department of Health

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

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

Name: Patrick Gillies

Position/Title: Medicaid Executive Director Bureau of Health Services Financing

Name:

Position/Title: Medicaid Deputy Director

Bureau of Health Services Financing

Disclosure Statement This information is being collected to pursuant to 42 U.S.C. 1397aa, which requires states to submit a State Child Health Plan in order to receive federal funding. This mandatory information collection will be used to demonstrate compliance with all requirements of title XXI of the Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of information requirements under this control number is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4- 26-05, Baltimore, Maryland 21244-1850.

LOUISIANA TITLE XXI STATE PLAN Revised April 7, 2022

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

This template outlines the information that must be included in the state plans and the State plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes:  Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance.  Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including:  Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)  Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)  Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)  Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)  Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)  Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)  Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)  Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5.  Removed crowd-out language that had been added by the August 17 letter that later was repealed.  Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016) States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is

LOUISIANA TITLE XXI STATE PLAN Revised April 7, 2022

3 disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90-day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section

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4 2102(c)(1)); (42 CFR 457.90)

6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary-approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for States’ use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for

LOUISIANA TITLE XXI STATE PLAN Revised April 7, 2022

5 states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below:  Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid.  Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections:  1 (General Description)  2 (General Background) They will also be required to complete the appropriate program sections, including:  4 (Eligibility Standards and Methodology)  5 (Outreach)  9 (Strategic Objectives and Performance Goals and Plan Administration including the budget)  10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State plan amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections:  3 (Methods of Delivery and Utilization Controls)  4 (Eligibility Standards and Methodology)  6 (Coverage Requirements for Children’s Health Insurance)  7 (Quality and Appropriateness of Care)  8 (Cost Sharing and Payment)  11 (Program Integrity)  12 (Applicant and Enrollee Protections)

 Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for

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6 children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Where the state’s assurance is requested in this document for compliance with a particular requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in compliance no later than the applicable compliance date.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address:

Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

LOUISIANA TITLE XXI STATE PLAN Revised April 7, 2022

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

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

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

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

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

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

1.2.

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

1.3.

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

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to

LOUISIANA TITLE XXI STATE PLAN Revised April 7, 2022

8 provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

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

Original Plan LaCHIP Phase I Medicaid Expansion SCHIP for children 6-18 between 101- 133 Percent of the Federal Poverty Level Effective Date: November 1, 1998 Implementation Date: November 1, 1998

Amendment 1 LaCHIP Phase II Medicaid Expansion SCHIP for Children 0-18 Between 134-150 Percent of the Federal Poverty Level Effective Date: October 1, 1999

Amendment 2 LaCHIP Phase III Medicaid Expansion SCHIP for Children 0-18 Between 151-200 Percent of the Federal Poverty Level Effective Date: June 6, 2001

Amendment 3 Removal of Waiting Period in Medicaid Expansion SCHIP Approval date: February 24, 2003

Amendment 4 LaCHIP Phase IV Creation of Separate SCHIP – Unborn Child Option Effective date: April 1, 2007

Amendment 5 LaCHIP Phase V Separate SCHIP for Children 0-18 between 201-250 Percent of the Federal Poverty Level Effective date: April 1, 2008 Implementation date: May 1, 2008

Amendment 6 Addition of Robert Wood Johnson Foundation Maximizing Enrollment for Children Grant Funds $999,926.00 for grant period: February 15, 2009 through February 14, 2003 Effective date: February 15, 2009 Implementation date: February 15, 2009

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9 Amendment 7 Addition of Prospective Payment Methodology for Federally Qualified Health Centers and Rural Health Centers LaCHIP Phase V Effective date: July 1, 2010 Implementation date: July 1, 2010

Amendment 8 Addition of Dental Benefit for LaCHIP Phase V Effective date: February 1, 2012 Implementation date: February 1, 2012

Amendment 9 Withdrawn

Amendment 10 Withdrawn

Amendment 11 Reduction of Dental Reimbursement Fees for EPSDT Dental Services for Phase V Effective date: July 1, 2012 Implementation date: July 1, 2012

Amendment 12 LaCHIP Phase V Benefits Administration Changes Effective date: January 1, 2013 Implementation date: January 1, 2013

Amendment 13 LA SPA TN 13-01 CH Reimbursement Rate Reduction for LaCHIP Affordable Plan Dental Services Effective date: August 1, 2013

Amendment 14 LA SPA TN 14-0002 Modified Adjusted Gross Income (MAGI) eligibility and methods to cover targeted low-income children from conception to birth to non- Medicaid eligible mothers. Effective date: January 1, 2014 Implementation date: January 1, 2014

Amendment 15 LA SPA TN 14-0003 MAGI Eligibility for Children Covered Under Title XXI Funded Medicaid Program Effective date: January 1, 2014 Implementation date: January 1, 2014

Amendment 16 LA SPA TN 14-0004 Establishment of 2101(f) Groups to cover children who lose Medicaid eligibility as a result of discontinuation of disregards. Effective date: January 1, 2014 Implementation date: January 1, 2014

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10 Amendment 17 LA SPA TN 14-0005 MAGI-based eligibility processing to utilize the model single streamline paper and online application. Effective date: October 1, 2013 Implementation date: October 1, 2013

Amendment 18 LA SPA TN 14-0006 MAGI non-financial eligibility policy on residency, citizenship, social security numbers, substitution of coverage, non-payment of premiums, and continuous eligibility. Effective date: January 1, 2014 Implementation date: January 1, 2014

Amendment 19 LA SPA TN 15-0001 MAGI Eligibility and Methods – Determination State to Assessment State Effective date: November 1, 2015

Amendment 20 LA SPA TN 16-0001 MAGI Eligibility Processing – Assessment State to Determination State Effective date: April 20, 2016

Amendment 21 LA SPA TN 18-0008 Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Compliance Effective date: October 2, 2017

Amendment 22 LA SPA TN 19-0013 CHIP Managed Care Effective date: July 1, 2018

Amendment 23 LA SPA TN 19-0010 Children’s Health Insurance Program Reauthorization Act (CHIPRA) Lawfully Resident Children Effective date: February 1, 2019

Amendment 24 LA SPA TN 19-0022 CHIP Disaster Eligibility and Enrollment Effective date: July 10, 2019 Provisions for implementing temporary adjustments to eligibility and enrollment policies for application and redetermination, cost sharing, and prior authorization requirements for children in families living in Federal Emergency Management Agency (FEMA) or governor-declared disaster areas at the time of the disaster event. In the event of a disaster, the State will notify the Centers for Medicare & Medicaid Services (CMS) of the intent to provide these temporary adjustments, the effective dates of such adjustments, and the parishes/areas impacted by the disaster.

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11

Amendment 25 LA SPA TN 20-0005 CHIP Disaster Eligibility and Enrollment Effective date: March 1, 2020 Implementation date: March 1, 2020 To implement provisions for temporary adjustments to eligibility and enrollment policies for tribal consultation, eligibility standards and methodology, and premiums lock-out period for children in families living in state or federally declared disaster or public health emergency areas at the time of the event. In the event of a disaster/public health emergency, the State will notify the Centers for Medicare & Medicaid Services (CMS) of the intent to provide these temporary adjustments, the effective dates of such adjustments, and the parishes/areas impacted by the disaster. The duration of the provisions may not exceed the duration of the state or federal disaster period.

Amendment 26 LA SPA TN 20-0008 Section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act To adopt provisions in Section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act that amends section 2103(c)(5) of the Social Security Act (the Act), to make behavioral health services that are culturally and linguistically appropriate and different from the Mental Health Parity and Addiction Equity Act (P.L. 110-343) (MHPAEA) a required benefit in the Children’s Health Insurance Program (CHIP). Proposed effective date: October 24, 2019 Proposed implementation date: October 24, 2019

Amendment 27 LA SPA TN 21-0017 CHIP – Substitution of Coverage To amend the provisions governing substitution under group health plans, to revise waiting periods for CHIP beneficiaries from 12 months to a maximum of 90 days and to establish mandatory waiting period exemptions described at 42 CFR §457.805(b)(3). Effective date: April 1, 2021

Amendment 28 LA SPA TN 21-0026 CHIP – Poison Treatment Advice and Prevention The purpose of this SPA is to utilize the health services initiative option as allowed at 42 CFR 457.10, to support the Louisiana Poison Center at Louisiana State University Health Shreveport, in providing daily, 24-hour emergency telephone treatment advice, referral assistance, and information to manage exposure to poisonous and hazardous substances. Effective date: July 1, 2021

Amendment 29 LA SPA TN 22-0010 CHIP – Medicaid and CHIP Twelve Months Postpartum Option The purpose of these SPAs is to adopt the State Plan option to provide 12 months of continuous postpartum coverage to CHIP beneficiaries, regardless of any changes in circumstances. Effective date: April 1, 2022

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12 Amendment 30 LA SPA TN 22-0001 CHIP - American Rescue Plan (ARP) Act Coverage The purpose of this SPA is to demonstrate compliance with the American Rescue Plan Act provisions that require states to cover treatment (including treatment of a condition that may seriously complicate COVID-19 treatment), testing, and vaccinations for COVID-19 without cost sharing in CHIP. Effective date: March 11, 2021

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

On January 27, 2022, notification of the State’s intent to seek approval from CMS to demonstrate compliance with the American Rescue Plan Act provisions that require states to cover treatment (including treatment of a condition that may seriously complicate COVID-19 treatment), testing, and vaccinations for COVID-19 without cost sharing in CHIP, was submitted to the tribes. The comment period ended February 26, 2022. No comments were received.

TN 22-0001 Approval Date: April 7, 2022 Effective Date: March 11, 2021

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13 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) 2.1. Describe the extent to which, and manner in which, children in the state, including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

Phase I: 1) On July 31, 1998, Louisiana submitted a proposal to implement a State Children’s Health Insurance Program, which expanded Medicaid coverage to uninsured children who were at least six years of age but under 19 years of age in families with incomes at or below 133 percent of the federal poverty level (FPL).

The expansion was to serve an estimated additional 28,350 children. Louisiana implemented this expansion on November 1, 1998.

Phase II: 2) On June 30, 1999, Louisiana submitted a state plan amendment to expand Medicaid coverage to children between birth and up to 19 years of age in families with incomes above 133 percent and at or below 150 percent FPL. The expansion was to serve an estimated additional 10,725 children. Louisiana implemented this Phase II LaCHIP Medicaid expansion on October 1, 1999.

Phase III: 3) On December 18, 2000, Louisiana submitted a state plan amendment to further expand Medicaid eligibility to children from birth up to 19 years of age in families with incomes up to 200 percent FPL. A total enrollment of 22,575 was projected. Phase III implementation began January 1, 2001.

Children Below 200 Percent FPL - See attached Exhibit 2.1.

Creditable Coverage At initial implementation of SCHIP in 1998, privately provided creditable coverage was minimal, with only one private foundation, Blue Cross/Blue Shield’s Caring Program for Children, providing limited health services coverage to children in the state who were uninsured. This does not meet the definition of creditable coverage. Prior to implementation of Phase I of LaCHIP, participation was limited to children below 133 percent FPL and less than 1,000 children were covered. Upon implementation of LaCHIP Phase I, the Caring Program for Children then increased its threshold to 150 percent FPL and 187 children were covered with a limit of 200 enrollees. Upon implementation of LaCHIP Phase II, the Caring Program for Children was discontinued. The only creditable public coverage

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14 available is Medicaid. The State’s public hospital system continues to function as a “safety net” system and operates pediatric outpatient clinics throughout the state.

As a direct result of SCHIP implementation in 1998, Louisiana experienced a significant increase in the percentage as well as number of children with creditable health coverage under its public health insurance programs. Administrative data shows that the number of children with public coverage has increased from 315,571 in October 1998 to 620,926 in August of 2007. This takes into consideration the decrease in publicly covered children in New Orleans by 61,188 as a result of Hurricane Katrina.

A state level, 10,000 household survey -- referred to as the Louisiana Health Insurance Survey (LHIS)—was conducted in the Summers of 2003, 2005, and 2007 [results pending for 2007] to determine health coverage status. We believe this survey provides the most accurate available information for Louisiana based on the survey size as well as adjustments for the state specific Medicaid undercount which was calculated through surveying a subset of individuals enrolled. The survey results provide information on health coverage of children by income level, race and ethnicity and geographic location and can be accessed on the “Reports” page of our website at www.lachip.org.

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

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance): Louisiana currently outstations Medicaid eligibility workers at the State’s eleven public disproportionate share hospitals. In addition, Louisiana has more than 400 certified Medicaid Application Centers throughout the state that offer opportunities for assistance in applying for Medicaid for children at locations other than the “welfare office.” These include Community Action Agencies, Head Start, school-based health centers, churches and other faith-based organizations and health care providers, etc. (A complete current listing of Medicaid application centers is available for review.)

Eligibility for cash assistance (Temporary Assistance for Needy Families known in Louisiana as Family Income Temporary Assistance Program-FITAP) is determined by the Department of Social Services (DSS), Office of Family Security. The Louisiana Department of Health (LDH) has a memorandum of understanding with DSS to determine initial and ongoing Medicaid eligibility using July 16, 1996 eligibility criteria for applicants determined eligible

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15 for cash assistance. Applicants rejected because of income and resources are referred on-line to LDH for exploration of Medicaid eligibility. Individuals who lose eligibility for cash assistance receive an additional month of Medicaid eligibility while they are referred to BHSF to determine continuing eligibility for Medicaid only. Possible eligibility in all Medicaid Programs is evaluated before Medicaid is terminated.

The Maternal and Child Health Section of the Office of Public Health also provides referrals to Medicaid via its Women, Infants and Children (WIC) and prenatal clinics as well as a toll-free hotline through which they try to link callers with available resources for medical and social services.

LaCHIP outreach activities have included: 1) Back to School Campaigns at locations statewide each August; 2) Distributing LaCHIP flyers to all public school children and many parochial school children; 3) Providing “Application Assistor” training for school-based health centers; 4) Continuing interagency agreement with Department of Education that encompasses LaCHIP outreach and education about the benefits and processes; 5) Contracting for “Walkers and Talkers Enrollment Initiative” in four parishes; 6) Participating in fiscal intermediary provider training workshops to inform providers; 7) Hiring Spanish-language in-house translator to translate materials and attend outreach opportunities; 8) Awarded six-month grant to conduct outreach to Hispanic community in metropolitan New Orleans; 9) Providing programs and materials for meetings with Annual 100 Black Men Conferences, Louisiana Chapter National Conference of Black Mayors, Inc., Native American tribal gatherings, and faith-based organizations; and 10) Providing information packets to headquarters of American, United, U.S. Airways, and Delta airlines following the September 11 tragedies.

Louisiana continues to be aggressive in identifying and enrolling all uncovered low-income children who are eligible to participate in Medicaid and SCHIP. In 2004, Governor Blanco identified enrolling all eligible children in LaCHIP and Medicaid as one of her immediately health policy goals and by August 2005, the number of low-income children with public coverage had increased by more than 50,000. In conjunction with expansion to moderate-income households, the

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16 administration and Legislature appropriated money to enroll an additional 24,000 children in Medicaid or LaCHIP in SFY 08, including unprecedented funding for outreach.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership: Louisiana’s Department of Health is not directly involved in a public-private partnership concerning health insurance for children but made referrals to the private “Caring Program for Children” as appropriate until program was discontinued. A denied Medicaid application was necessary to qualify for the program. Louisiana currently has a task force on the working uninsured that is examining potential options for future public-private partnerships to increase access to health coverage.

2007 legislation to expand health coverage [Act 407] included a provision that the Department work to develop a premium assistance program. With our Medicaid expansion SCHIP program we use Section 1906 authority to provide premium reimbursement for families who have employer sponsored insurance available when cost effectiveness can be established. The scale of our HIPP program has been greatly expanded with staff of 13 (7 added for SFY 08), an increase from just one staff person prior to 2004.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

Poison Treatment Advice and Prevention As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, LDH will use CHIP funding for a health services initiative, within the 10 percent federal administrative expenditures cap allowed for states, in accordance with 2105(c)(2)(A) of the Social Security Act. Through the Louisiana State University Health Sciences Center-Shreveport (LSUHSC-S), the funds will support Louisiana Poison Center (LPC) activities impacting children 18 years of age or younger.

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17 The State assures that funding under this HSI will not supplant or match CHIP federal funds with other federal funds, nor will it allow other federal funds to supplant or match CHIP federal funds. The non-federal share of the CHIP funding for the LPC HSI will be provided by LSUHSC-S in the form of certified public expenditures, in accordance with procedures specified by LDH. Projected costs of this program are $1,220,256.

The LPC serves every Louisiana community, including demographics that are typically underserved, such as uninsured, low income, indigent, and those living in rural areas. It directs attention and resources to “at-risk” children and adolescents, low -income populations, minority, migrant and immigrant communities.

The LPC operates a call center to provide: 1. Emergency telephone treatment advice; 2. Referral assistance; and 3. Information to manage exposure to poisonous and hazardous substances.

A hotline is available to the general public and health care providers needing assistance 24 hours per day, 365 days per year, at no charge to the caller. Calls are answered by Certified Specialists in Poison Information (CSPI). Clinical oversight is provided by experienced Medical Doctors boarded in Emergency Medicine and Medical Toxicology. Translation is available in over 240 languages via Language Line service and via relay service for the deaf and hearing impaired.

The LPC handles approximately 35,000 calls to the hotline per year, gathering information, triaging the patient and providing medical management recommendations to the treating physician. Approximately one-third of all calls received by the LPC are initiated from hospital emergency departments and intensive care units across the state. The remainder of the calls are primarily from home settings, with a small percentage from other non-healthcare sites.

In 2018, 70 percent of all calls to the LPC involved children under 19 years of age. Children under age six represented 58 percent of all calls to LPC. An estimated one-third of all calls relate to children age 0-18 with annual household incomes of $66,816 or less (250 percent of the FPL for a family of 4). The Kids Count Data Center (2020) website data for 2018, states there are a total of 632,000 children aged 0-18 below 250 percent federal poverty level (FPL) that qualify for either CHIP or Medicaid.

The LPC provides public education programs on poisoning response and prevention. It works closely with schools, healthcare organizations, parenting groups, and childcare providers throughout the state to promote awareness in the identification and treatment of poisoning and hazardous exposures. LPC educates heath care providers in management of

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18 poisonings and drug overdoses. It offers continuing education courses to help physicians, nurses, first responders and other healthcare providers manage pediatric patients exposed to poisonous materials.

The LPC distributes educational materials throughout the state, free of charge to the public. Materials are available in multiple languages beyond English, as indicated by state demographics, and are disseminated in hard copy and electronic formats, including websites and social media. The LPC will maintain, on its website, links to assist the public in applying for health coverage through Medicaid and CHIP.

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

1. Coordination with Medicaid The same one-page application form is used to apply for Medicaid and LaCHIP. Applicants are first evaluated for eligibility for Title XIX programs, then for Title XXI, but the process is transparent to applicants.

2. Coordination with Private Insurance Given that the first two phases of Title XXI were expansions of Medicaid coverage up to 133 percent and 150 percent FPL respectively, problems with crowd out were not significant. In addition, provisions which required a three-month gap in insurance coverage previously incorporated into the Title XXI Medicaid expansion policy in 1998 were deleted in 2001 at the request of CMS to bring the state into compliance with current federal regulations at 42 CFR 435.914.

3. Coordination with Title V Office of Public Health (OPH) administers the State’s Title V Block Grant which includes outreach programs to pregnant women and children, and they have shared their expertise and successful methods in conducting outreach. OPH operates WIC clinics in 108 different locations throughout the state and oversees 32 school- based health centers. Each of these locations has been designated as a LaCHIP Application Assistance Site and formal training has been conducted for over 350 employees to enable them to assist applicants in completing the application form and in gathering necessary verifications. We will continue our collaboration with OPH in jointly developing outreach strategies involving WIC clinics, school- based health clinics, and Children’s Special Health Services clinics. Title V clinics are enrolled as Medicaid providers and bill for

LOUISIANA TITLE XXI STATE PLAN

19 services provided to the Title XIX and Title XXI children while Title V funds are reserved for patients with no health coverage.

The Office of Public Health, Section of Maternal and Child Health, received a grant of nearly $1 million in 1999 from the Robert Wood Johnson Foundation (RWJF) for Louisiana’s Covering Kids Initiative which assists in outreach to uninsured children. We closely coordinated with OPH to ensure that the Covering Kids initiative complemented and filled in the gaps in LaCHIP outreach initiatives. The OPH initiative included two pilots, the first targeting service industry employers in the Greater New Orleans area and a second through St. Francis Cabrini Hospital in Central Louisiana. Additional components included a statewide public relations campaign and development of outreach materials for limited English proficient populations, former TANF recipients and other specific target populations.

4. Coordination with Other Medical Programs The State’s charity hospital system has Medicaid eligibility outreach workers in all facilities who assist potential eligibles in applying for Medicaid or LaCHIP, as appropriate. Other public treatment programs such as mental health services also make these applications available. Many Medicaid providers and community agencies also make LaCHIP applications available.

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

20 Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2.

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

21 Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of:  The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a))  The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service.

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

22 Examples of carved out services may include transportation and dental, among others. CHIP populations that are members of the Chisholm Class receive behavioral health services through a managed care delivery system; however, Chisholm Class members may opt out of managed care for physical health services. The State would then provide those physical health services through fee-for-service. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Describe population served: All, with the exception of those in a Prepaid Inpatient Health Plan (PIHP) Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served: Children at risk of out of home placement who are in the Coordinated System of Care (CSoC).

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

23 Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe) 3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non-emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

24 NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)):  All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity).  The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details).  The provision against provider discrimination in 42 CFR 457.1208.  The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees).  The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226.  The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards).  An enrollee's right to a State review under subpart K of 42 CFR 457.  Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285.  Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

25 the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1))

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26 No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay remittances but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State:  Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and  Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity:  Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1));  Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and  Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

27 referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider- beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2))

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28 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

29 intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross- referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times:  During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later;  At least once every 12 months thereafter;  If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and  When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

30 notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)- (i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use:  Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and  Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that:  The format is readily accessible;  The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible;  The information is provided in an electronic form which can be electronically retained and printed;  The information is consistent with the content and language requirements in 42 CFR 438.10; and  The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to:  Establishing a methodology that identifies the prevalent non- English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area;  Making oral interpretation available in all languages and written

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

31 translation available in each prevalent non-English language;  Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non-English languages in its particular service area;  Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and  Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross- referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross- referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities:  Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance;  The basic features of managed care;  Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program;  The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity;  Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service;  The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i);  Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan;

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32  The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross- referencing 42 CFR 438.68;  The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and  To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that:  The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and  The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items:  Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO,

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

33 PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services;  The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled;  Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider;  The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care;  Any restrictions on the enrollee's freedom of choice among network providers;  The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of- network providers;  Cost sharing, if any is imposed under the State plan;  Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100;  The process of selecting and changing the enrollee's primary care provider;  Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee;  How to access auxiliary aids and services, including additional information in alternative formats or languages;  The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and  Information on how to report suspected fraud or abuse.

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

34 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(i), including:  Which medications are covered (both generic and name brand); and  What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross-referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102.

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

35 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross- referencing to 42 CFR 438.206) 3.6.3

The State assures that it:  Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10;  Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross-referencing 42 CFR 438.68(e)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206)

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

36 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers:  A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities;  Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and  Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross- referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by:  Requiring the contract to adequately and timely cover out- of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network;  Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services;  Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For- Service, if the provider serves only Medicaid or CHIP enrollees;  Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary;  Establishing mechanisms to ensure compliance by network providers;  Monitoring network providers regularly to determine compliance;

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

37  Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross- referencing to 42 CFR 438.207) 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area:  Offers an appropriate range of preventative, primary care and specialty services; and  Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross- referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including:  Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and  Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that:  The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures;  The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and  Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

38 referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)) 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross- referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including:  Ensure that each enrollee has an ongoing source of care appropriate to his or her needs;  Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee;  Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services;  Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers;  Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees;  Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs;  Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

39  Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)) Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs:  Is in accordance with applicable State quality assurance and utilization review standards;  Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

40 PAHP to follow those policies. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross-referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

41 specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3). 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

42 requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following:  The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a))  Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(b))  Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c))

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

43 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is:  At the enrollee's option and not required before or used as a deterrent to proceeding to the State review;  Independent of both the State and MCO, PIHP, or PAHP;  Offered without any cost to the enrollee; and  Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross- referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains:  The adverse benefit determination.  The reasons for the adverse benefit determination, including the

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

44 right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits.  The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review.  The procedures for exercising the rights specified above under this assurance.  The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision- making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease:  An appeal of a denial that is based on lack of medical necessity.  A grievance regarding denial of expedited resolution of an appeal.  A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination.

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

45 Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(c)(1))

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46 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following:  Make reasonable efforts to give the enrollee prompt oral notice of the delay.  Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision.  Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)) 3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(c)(3)) 3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items:  The results of the resolution process and the date it was completed; and  For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii))

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47 3.9.23

The State assures that if it offers an external medical review:  The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review;  The review is independent of both the State and MCO, PIHP, or PAHP; and  The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes:  The right to file grievances and appeals;  The requirements and timeframes for filing a grievance or appeal;  The availability of assistance in the filing process;  The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and  The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross- referencing to 42 CFR 438.414) 3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a))

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

48 3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following:  A compliance program that include all of the elements described in 42 CFR 438.608(a)(1);  Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State;

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

49  Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility;  Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP;  Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis;  In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers;  Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and  Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b))

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

50 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)) 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs,

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51 PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides:  The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services;  Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and  The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)).

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52  3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to

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53 terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250. 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items:  The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence- based clinical practice guidelines the State requires in accordance with 42 CFR 438.236;  A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019

54 for beneficiaries enrolled in an MCO, PIHP, or PAHP;  Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract;  A description of the State's transition of care policy required under 42 CFR 438.62(b)(3);  The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language;  For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438;  A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity;  The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs);  Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities;  Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and  The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2))

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55 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS:  A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and  A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will:  Make the strategy available for public comment; and  If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least:  Standard performance measures specified by the

LOUISIANA TITLE XXI STATE PLAN Revised February 28, 2019