DEPAR"1' ML:N' I OI' HEALTI•i AND HUMAN SERVICES TRANSMI'T' TAL AND NOTICE OF APPROVAL OF STATE PI.AN MATCRIAL I. TRANSMITTAL NUMBER: 09-41 FORM APPROVCD 2. STATE Louis'rana FOK: HEAL"1' H CARE FINANCINC AUMINIS'I' ItATION 3. PROGRAM IDENT[FICATION: TITLE X1X OF T3-lE SOCIAL SECUR[TY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMiNISTRAT[ON DEPARTMENT OF HFAf.TH AND HUMAN SECtVICES 4. PROPOSED EFFEC"1' IVE DATE 1uly 1, 2009 5. "I' YPE OF PI.AN MATERIAL (Check One): NEW STA"1' L PI.AN AMENDMF..NT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCICS 6 THRU 1 lF TH1S IS AN AMENDMENeparate Transmittalfor each amendment 6. FEDERAL STATUTE/REGULATION CITATION 1906 of thc Socil Security Act 7. FEDERAL BUDGET IMPACT: a. FFY 2009 $ 0.00 b. FFY 2010 $ 0.00 8. PAGE NUMBER OF THE PLAN SECTION OR A'T' TACHMEIT: Pre-print Page'70 Attachment 4.22- C, Page 1 9. PAGE NUMBER OF THE SUPERSEDED PLAN 3EC"I' lON OR ATTACHMENT (/fApplicable): Same (TN 44-03) Same (TN 91-29) 10. SUBJECT OF AMENDMENT: The purpose of this amendment is to revise the method of evaluating the cost effectiveness of the Louisiana Health Insurance Premium Payment Program (LaHIPP). I GOVERNpR'S REVi6W (Check One): GOVHRNOR'S OFFIC REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor does not review state plan material. NO REPLY iZECEIVED W[THIN 45 DAYS OF SUBMITTAC. l2: SIGNATURE F 13. TYPED NAME: Aln Levine 14. T[ TLE: Secretary l5. DATE SUBMITTED: September 11, 2009 17. DATG RECEIVED: FOR REGIONAL OFFICE USE ONLY 18. DATE APPRC PLAIV APPROVED ONE COPY AT"i' ACHED l9. GFFECTIVE DATE OF APPROVED MA'CERIAL: 20. STGN 21. TYPED NAME: 22. TITLE: . 5:c' Y' i iU C>(- 23. RF:MA[ iKS: 16. RETURN TO: State of Louisiarea Department of Health and Hospitals 628 N. 4 Street PO Box 91030 Baton Rouge, LA '70821-9030 IAL: h` i 0r'c- e-(. / i 1Li4I C.i t i c.u r i s l 12 T. FORM I- ICFA- 179 ( 07-92)

IZcvi,i n: II('I n-I' M-)I- K ( MI) nl ln'IIMI: NI O thrr I)) I I'a' I t )M li N ti Il 1 I'1.: 1N 11NUl:IZ 11 11. 1 XIX OI II II ti)(' I ti1 C'l Itlll' ;( i tit,itc I• rril r: I .(> l ltil;AN\ illli n I 9O( uf tl c:l nclitin < r IZcyuircmcnt gfalc Mcthod un (osl l? ffcclivcness ofl? n ploycr-13ascci Group 1- Icalth Bcnefit Plans Ihc tilatc iti usin thc ccrctary's mcth<d in all ascctti cxcct cgra hicall} wc arc usin statcwidc avcra6c instcad <f arish h arish avcracs. I N u f tiu,rr rcir I N f.. STATE ____el. l. l_. 1__ C.. DAfE REC'G.... C DAT APP1' C__... 1.._ nAT F._ ` 7."._..._ C? ....... w... HC;!= A 179 i . r Fpr val I) alr I; Ifcclivc I) atr II('I n IU: 7) R5 I;

70 Ilvisi n itaticn l I(' I !\- I' Nl-) 4- I 1 1. 131Z1', IZI' I'>) a tt! Irrrii r: I OIIII, Nn c< intinu l) N113) CA" .._...`_..:... L L.'.` t.... G1A(EIC:'.__ t; DATE APPV'f7,__,_ -.. Q,.._ r ___.`.- t__ MC;A ` 1"l9 C1 .-" r'1 tW....,. 1?( I IZ 133.151 (a) ( I Ih Mcdicaicl acncy has writtei cx crativc arrcmcnts fir thc cnfurcrmcnt Iri hls tu anl cllcctiun cl thircl ary bcncfits assincd t thc Sttc s a c< nditiuii uf clisihility iir mcciical assistancc with thc fil wing: ((' hcck as ar< riatc.) X Statc litic IV-I) agcncy. Ihc rccuircmcnls uf 4? CI R 433.152( h) arc mct. X Othcr appruriatc latc acncy( s): IV-n IV-I. Othcr arc> priatc acncy( s) ufanothcr statc: urls an1 law cil< rccmcnt flicials. I) 0?( a) ( 6U) Ithc /ct Ihc Medicaid aency assures lhat thc State has in cil ct thc laws rclatin; t> meclical chilcl sup irt undcr scctiun 19O8 <Ithc /ct. 1906 ulthc nct ( h) Ihc Medicaid a; ency specities lhc ;uidelincs uscd in leteriinin, tle cosl eftectiveness oian employcr-based group health plai by scicctii nc f thc tc> Iluwing: Ihc 5ccrctaiy's mcthud as roviciccl in thc Statc Mcclicaicl Manual. cctii 3) I 0. Ihc tatc Pr< vidcs mchc cls fir dctcrmining cust- Icctivci ctis / 1 I I nC'I IMI:N I??- C' I Nll fj nr ivil I). tr lf G tii ct'ti cJs I Nl, A- w . v I: f ic iv I) a( c e LR r7

DEPAR"1' MEN'1' OF HI:ALTH HUMAN SERVICIS Centers for Medicere c Medicaid Servirrs IO1 Yung Strcrt, Room 833 I_) alles, fras 75202 c s CENTERS torMEO/CARf B MEO/CA/ D SERV/CES Division of Medicaid Children's Health, Region VI Novcibcr 3, 2009 Ou Reference: SPA-L- 09-41 Mr. Jcrry Phillips, State Medicaid Director Dcpartmcnt of IIcalth and 1 Iospitals l3ienvill E3uildin 28 North 4`' Strcet Post Ofiice 13ox 91030 Baton Roue, Ln 70821-9030 Dear Mr. Phillips: We have ceviewed the proposed amendnent to you• Medicaid State Plan subtitted uilder Transmittal Number 09-41. This amendment reviscs the method used to cvaluatc the cost effectiveness of the Louisiana Health 1lsurance Premium payment pcogcam (LaHIPP) From a parish by parish average to a statcwide avei•age. ransmittal Number 09-41 is approved with an efiective date of July l, 2009 as requested. A copy of the 1- ICI A- 179, T' ransmittal No. 09-41 dated September 1 l, 2009 is enclosed along with the approved plai pa;es. 11' you have any questions, please coitact Cheryl Rupley at (214) 767-6278. Sincerely, Bill 13rooks Associate Regionall\ dministt ator I; nclosures

Marks, Marsha L. (CMS/SC) From: Sent: To: Cc: Subject: Attachments: See Attached. State: Louisiana Marks, Marsha L. (CMS/SC) Wednesday, November 04, 2009 2:20 PM CMS CMSO 508 SPA Rupley, Cheryl A. (CMS/SC); ' ALLYSON LAMY' FW: Approved SPA LA 09-41 SPA-LA- 09-41. doc; Approval Pkg for LA 09-41. pdf Brief Description: Plan Revised the method used to evaluate the cost effectiveness of the LA Health Insurance3 Premium payment program from a parish by parish average to a statewide average. Approval Date: 11/3/ 09 Effective Date: 7/1/ 09 R/ rsf flarks Dpt nf Neith Ham n ervices !1 nters fiar Medicare Pvledicair Srvices 1/ Da61as Ieyi na[ ffice li iisia of Melic ic & hilre` s Halth (1 ilas Texas 7520 i 4- 7- 628 ax 214-767- 0322 f/ marsha.marksa(. cros. hhs.qov

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street, Room 833 Dallas, Texas 75202 c s fENTERS forMEO/CARE& MfD/CA/ DSERY/CES Division of Medicaid & Children's Health, Region VI April 27, 2010 Our Reference: SPA-LA- 10-01 Mr. Don Gregory, State Medicaid Director Department of Health and Hospitals Bienville Building 628 North 4" Street Post Office Box 91030 Baton Rouge, LA 70821-9030 Dear Mr. Gregory: We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 10-01. This state plan ainendment implements the provisions of the Medicare Improvements for Patient and Providers Act of 2008 (MIPPA) to increase the resource limit for Qualified Medicaid Beneficiaries ( QMB), Specified Low-Income Medicare Beneficiaries (SLMB) and QIs to three times the Supplemental Security Income (SSI) resource limit, adjusted annually by the increase in Consumer Price Index. This state plan amendment also implements a disregard for QMBs, SLMBs, and QIs for certain assets in the eligibility determination process. In the future, when the State submits a State Plan Amendment (SPA) that may impact Indians or Indian health providers, CMS will look for evidence of the State's tribal corsultation process for that SPA. Pursuant to section 1902 (a) ( 73) of the Act added ty sectior 5006 (cj oi the Reeovery and Reinvestment Act of 2009, the State must submit evidence t CMS regarding the solicitation of advice prior to submission of the SPA. This consultation must include all federally recognized tribes, Indian Health Service and Urban Indian Organizations within l state. Transmittal Number 10-01 is approved with an effective date of January 1, 2010 as requested. A copy of the HCFA-179, Transmittal No. 10-01 dated January 26, 2010 is enclosed along with the approved plan pages. If you have any questions, please contact C1leryl Rupley at (214) 767-6 78. Sincerely, Bill Brooks Assaciate Regional Administrator Enclosures

DEPARTMENT OF HEALTFI AND HUMAN SERVICES HEAi,TH CARE FINANC(NG ADMINISTRATION TRANSMTTTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERYAL FORM APPEOVED 1. TRANSMITTAL NUMBER: lo-ol FOR: HEAI.TH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION January ],, 20i0 DEPARTMENT OF HEALTI-i AND HUMAN SERVICS 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENI' TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 TF THIS [S AN AMEND (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULAT[ ON CTTATION: 1902(r)( 2) of the Social Secnrity Act; and MIPPA 2008 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Supplement 8b to Attachment 2.6- A, Page 1 Stpplement 8b to Attachm'ent 2.6- A, Page 2 Attachment 2.2- A, Pages 9b, 9b1 rtr'.x. h a.- a P zza, 7. FEDERAL BUDGET IMPACT: a. FFY 2010 b. FFY 2011 2. STATE Louisiana 1 A47.79 1. 551. 34 10 SUBJECT OF AMENDMENT The purpose of this amendment is to revise the Medicare Savings Program in response to the Medicare Improvements ofPatients and Providers Act (NIIPPA) of2008 in order to incorporate provisions regarding thesubmittal of Iow income subsidy data and to disregard certain assets in the eligibiity determination qrocess. 11. GOVERNOR'S REVIEW (Check One}: GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIF[ED: COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor does not review sfate plan material. NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE IAL: 13. TYPED NAM'. A[an Leviae E4. TITLE: 16. RETURN TO: 9. PAGE NUMBER OF 7'HE SUPERSEDED PLAN SECTION OR ATTACNMENT (If. 4pplicable): Same (TN 07-15} Same (TN 06-13) Sanue ('I'N 93-09) State of Louisiana Department of Health and Hospitals 628 N. 4 Street PO Sox 91030 Baton Rouge, LA 7082.-9030 15. DATE SCJBMITTED: January 26, 2010 17. DATE OFFICE USE O[iLY A uA-I' U . Q /O l 8. DATE APPR n. PLAN APPROVED — OA1E COPY ATTACHD i9. EFFECTIVE DATE OF APPROVED MATERIAL: 20 OF f) U A 21, TYPED NAME: 23. REiVjARKS: ti. f- d k5 i, k- z-.l fr c ` o , / J . G -/ 22. TITLE' O 20/! FFIC AL: a- mrna 5 E-!/l G z.z. , ' n.w , FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTM AND HUMAN TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAIT MATERYAL FOR: HEAI,TH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTI-I AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRt1 10 TF THIS [S AN AMEIdDMENT e arate Transrnittal or each amendmett 6. FEDERAL STATUTFJREGULATION CTTATION: 7. FEDERAL BUDGET IMPACT: 1902(r)( 2) of tbe Social Secnrity Act; and a. FFY 2010 1 A47.79 1VIPPA 2008 b. FFY 2011 $ 1. 551. 34 b. YAVC P1UMlS1( Vl' lt t' LAN JC; i lUN UK A 1 1Al:HMt'. IV l: y. t' ACi NUMt3K Ul' 7H SUY,ILS DED PLAN SECTION OR ATTACHMENT (lf. 4pplicab/ e): Supplement 8b to Attschment 2.6- A, Page 1 Same (TN 07-15 Snpplement 8b ta Attachment 2.6- A, Page 2 Same (TN 06-13} Attachment 2.2- A, Pages 9b, 9b1 Same (TN 93-09) vE . - A pcu- zz4. 1r.c a..a c y 4 . G- A- e Z Z 5 TN o - lo ) 10 SUBJECT OF AMENDMENT The purpose of this amendment is to revse the Medicare Savings Program in response to the Medicare Improvemens ofPatients and ProvidersActPPA) of2008 in order toincoorate rovstons regardingthesubmittal ofIow income subsidy data aad to isregard certain assets in the eligibiLty etermination process. 11. GOVERNOR'S REVIEW (Check One}: GOVERNOR'S OFFICE REPORTED NO COMMENT OTHETt, AS SPECIFIED: COMMENT5 OF GOVERNOR'S OFEiCE ENCLOSED The Governor does not review state plan material. NO REPLY RECECVBD WITHIN 45 DAYS OF SUBMITTAL t2, SIGNATURE OF$ XTE A Y OFFICIAI.: 13. TYPED NAIvi A[an Leviae E 4. T[ TLE: 1 S. DATE SCJBMITTED: tGt-v c Q TL lef'L. '" , '- (/ 1 a'il c ' 4 - 21 - /D s,l-.{ January 1, 20i State of Louisiana Department of Aealth and Hospitals 628 N. 4"' Sbreet PO Box 91030 Baton Rouge, LA 70821.-9Q30 1, G!'' c rQ /iG/ i y1 L 3 -ZR - ab 1. 'TRANSMITTAL NUMBER: io-o1 FORM APPROVED OMB NO. 0938-019' 2. STATE Louisiana 3. PROCRAM 1DENTIFICATION: TITLE XIX OF TNE SOCtAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE 16. RETlJRN TO: 3 E-// l¢ G G -/ e N'Lu ,J'e FO1tM HCFA-179 (07-92)

Marks, Marsha L. (CMS/SC) From: Marks, Marsha L. (CMS/SC) Sent: Wednesday, April 28, 2010 7:32 AM To: CMS CMSO 508 SPA Cc: Rupley, Cheryl A. (CMS/SC); ' Allyson Lamy' Subject: Approval Pkg for LA 10-01 Attachments: LA1001APPROVAL.doc; Final Approval Pkg for l.A 10-01. pdf See Attached. Hard copies are being sent by regular mail. State: Louisiana Brief Description: This implements provision of Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) to increase the resource limit for Qualified Medicaid Beneficiaries (QMB), Specified Low Medicare Beneficiaries (SLMB) and Qts to three times the Supplemental Security Income (SSI) resource limit. It also implements a disregard for QMBs, SLMBs, and Qls for certain assets in the eligibility determination process. Approval Date: 27 April, 2010 Effective Date: 1 January, 2010 Nlarsa Nlark 1 Cept f N6 1 & Nunr rvics ! i Centers fior ledicr & Iedic id Servics / 1 Da6ls Rgiona€ Office 1r Divisir f tvleic i &. Chilcre' s -{ ea3 ! afls Texs 72 ft 214-767- 28 l Fx 214-767- 0322 ! 1 marsha.marks( acros. hhs.gov

Rupley, Cheryl A. CMS/SC} From: Allyson Lamy [ALLYSON.LAMY@LA. GOV] Sent: Monday, March 29, 2010 1:26 PM To: Rupiey, Cheryl A. (CMS/SC) Cc: Darlene Hughes; Diane Batts (DHH); Kyle Viator; Shirley Garland; Sandra Victor; Keydra Singleton Subject: RE: LA 10-01 Questions Attachments: 10-01 CMS Informal Questions Responses 3. 29. 10.docx; 10-01 Medicaid Savings Program revised submitted per CMS 3. 27. 10). docx; 10-01 Medicaid Savings Program (revised submitted per CMS 3. 27. 10). pdf We have revised the SPA pages as suggested by CMS. Please see att:ciiedrporist s ta thE infnrrral questions and the revised pages. Please substitute 2he attached pages for the pages pr:viously submitfied far this SPA (in both Word and pdf versions). Please let me know if there are any further questions. Thanks, Allyson From: Rupley, Cheryl A. (CMS/SC) [mailto:Cheryl. Rupley@cros.hhs. gov] Sent: Wednesday, March 03, 2010 12:07 PM To: Allyson Lamy; Keydra Singleton Cc: Seng, Suzette (CMS/SC) Subject: LA 10-01 Questions Importance: High Allyson, Keydra, Attached please find informal questions and page revisions needed for SPA 10-01. Please let me know if you have any questions. Thanks for your assistance. Cheryl Rupley Division of Medicaid and Children's Health 1301 Young St. Rm. 833 Dallas, TX 75202 Phone 214-767- 6278 FAX 214-767- 0322

CMS Informal questions for TN 10-01 The Statutory reference for this SPA should be that of the MSP eligibility groups and not ofthe MIPPA law. Please revise box 6 of the 179. The following statutes correspond with the MSP groups: 1902(a)( 10)( E), 1905(p) and 1860D-14( a)( 3)( D). Resnonse: Please make a pen and ink change to Box 6 of the Form 179 to change the citation reference from MIPPA 2008 to 1902(a)( 10)( E), 1905(p) and 1860D- 14(a)( 3)( D) of the Act. 2. The State has not included the Qualified Individuals group in Attachment 2.2- A, page 9(b), ( bl). Please revise. We have attached a draft pre-print the State may use as a reference. Resaonse: We have revised the state plan page. Please substitute the attached revised page for the page previously submitted for this SPA. 3. The State has amended the Qualified Working Disabled group, number 26 on page 9b of Attachment 2.2- A, to reflect the resource limit of 3 times the maximum standard under SSI, indexed annually by the increase in the consumer price index. Please revise, the QDWI group was not included in the MIPPA legislation. The resource limit should remain at twice the SSI standard. Response: We have revised the state plan page. Ptease substitute the attached revised page for the page previously submitted for this SPA. 4. The State also needs to amend number 8 on page 22 in Attachment 2.6- A to reflect the increase in the resource standard due to MIPPA. Also, Qualified Individuals (QIs) should be added to the language under number 8. Please submit a revised page. Response: We have revised the state plan page. Please make a pen and ink change to Box 8 and 9 on the Form 179 to add Attachment 2.6- A, Page 22 which supersedes TN 01-16, and Attachment 2.6- A, Page 22a, which is a new page. 5. Please add the citations for the following groups: QMB, SLMB and needs to add the citations for the QIs. This needs to be done for th., Attachment 2.2- A pages and the Attachment 2.6- A pages that were submitted. Please refer to the attached draft pre-print for the correct citations. (Please refer to the pre-print attached.) Response: We have revised the state plan page. Please substitute the attached revised page for the page previously submitted for this SPA. 6. Does the State intend to cover QDWIs under this disregard even if MIPPA did not extend to that group? Response: The State does not wish to apply the resource disregards to QDWI since this group was not included in MIPPA, so it was remoed as a group to which new resource disregards apply.

Revision: State: LOUISIANA Citation(s) Condition or Requirement 7. Resource Standard - Medically Needy a. I 902(a)( ! 0)( C)( i) of the Act c. Resource standards are based on fami(y size. Attachment 2.6- A Page 22 A sing(e standard is employed in determining resource resource eligibility for all groups. In 1902(fl States, the resource standards are more restrictive than in 7.b. above for-- Aged Blind Disabled 1902(a)( 10)( E), 1905(p)( 1)( D), 1905(p)( 2)( B) and 1860D-14( a)( 3)( D) of the Act Supplement 2 to ATTACHMENT 2.6- A specifies the resource standards for all covered medically needy groups. (f the agency chooses more restrictive levels under 7.c., Supplement 2 to ATTACHMENT 2.6- A so indicate. 8. Resource Standard - Qualified Medicare Beneficiaries, Specified Low-[ ncome Medicare Beneficiaries and Qualified Individuals For Qualified Medicare Beneficiaries covered under section I 902(a)( 10)( E)( i) of the ,,ct, Specified Low-lncome Medicare Beneficiaries covered under section 1902(a)( 10)( E)( iii) of the Act, and Qualified [ ndividuals coered under 1902(a)( 10)( E)( iv) of the Act, the resource standard is three times the SSI resource limit, adjusted annually by the increase in the Consumer Price Index (CPI). aL3E. SDE: - U ` TN # / G — GI Effective Date — G Supersedes 1'N # 1— / G ST:+I° EldLs% G/ _ DAfE R:'L --- uO _... DATE Ai" J_.._ ATE EFF_ l HC:'A 179 ,._._ l d / _- Approval Date '¢'- — fb

Revision: rrr LA December 2001 ATTACHMENT 2.6- A Page 22 State: LOUISIANA Citation Condition or Requirement 7. Resource Standard - Medically Need_v a. Resource standards are based on family size. 1902 (a) ( 10} (C) (i) b. A single standard is employed in determining of the Act resource eligibility for Aged, Blind, and Disabled. c. In 1902 (fl States, the resource standards are more restrictive than in 7.b. above for -- Aged Blind Disabled i 1905 (p) ( 1) ( D) and ( p) ( 2) ( B) of the Act Supplement 2 to ATTACHMENT 2 6-A specifies the resource standards for all covered medically needy groups. If the agency chooses more restrictive levels under 7.c., Supplement 2 so indicates. Resource Standard - Qualied Medicare Beneficiaries and Specified Low-Income Medicare Beneficiaries For qualified Medicare beneficiaries covered under section 1902 (a) ( 10) (E) (i) of the Act and specified low- income Medicare beneficiaries covered under section 1902 (a) ( 10) (E) ( iii) of the Act, the resource standard is twice the SSI standard. 1905 (s) of the Act STATF _...' S 1 Cl l (. t_,_._ _...--- DATE ?F°' C,' ._. Z --. ul_..._ 1;_._ 7z.: L=. l. DATE .4.,: ---- DATE EF= _.._._ 1.=..? v.. HCFA178 ___.n= TN No. Ul- ( o Approval Date Supersedes TN No. q3-2 0 Resource Standard - Qualified Disabled and Working Individuals For qualified disabled and working individuals covered under section 1902 (a) ( 10) (E) (ii) of the Act, the resource standard for an individual or a couple (in the case of an individual with a spouse) is twice the SSI resource standard. C 2- 2 - bZ Effective Date l I- 2 i- u

Revision: HCFA-PM- 9l - 4 (BPD) Revised: November 1989 SUPPLEMENT 8b TO ATTACHMENT 2.6- A Page 1 OMB No: 0938 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: LOUISIANA MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902(r)( 2) OF THE ACT* Section 1902 ( fl State Non-Section 1902 ( fl State 1) The Bureau of Health Services Financing eliminates the consideration ofresources in determining Medicaid eligibility for the Low Income Families with Children and child related Medically Needy Programs. 2) An annuity meeting the criteria contained in Supplement 9 to Attachment 2.6- A, Page l d, Item D, is not considered a resource in determining eligibility for individuals under 42 CFR 435.236. 3) The following will apply in the determination of Medicaid eligibility for the Medically Needy Program [1902(a)( 10)(c)], TB infected individuals [1902(a)( 10)( A)( ii)( XII)], the special income level group (individuals in a medical institution for at least 30 consecutive days [1902(a)( 10)( A)( ii)( V)]) and individuals receiving home and community based waiver services for at least 30 consecutive days with gross income that does not exceed 300 percent of the SSI income standard [1902(a)(] 0)( A)( ii)( VI)], and Disability Medicaid [Optional Group of Aged and Disabled under the FPL covered under 1902(a)( 10)( A)( ii)( X)]: a. The maximum burial fund exclusion will be increased to $10,000. 4) b. The cash surrender value of life insurance and burial policies with a combined face value up to $10,000 will be disregarded. For Working Individuals — TWWIIA Basic Coverage Group- L,egal spouse's share of community property and spouse's separate assets will be disregarded. All life insurance policies will be disregarded. Medical Savings accounts will be disregarded. All retirement accounts will be disregarded, including private retirement accounts, such as IRA's and other individual accounts, and employer sponsored retirement accounts such as 401 K plans, Keogh and employer pension plans. TN # / d Effective Date "/ Supersedes TN # D'Z l r. Approval Date 71" `027' sT.T ____. -° u.i ila,a__ oAi Ei":'_ a / 6 _.._ DATEAF,`r° r;_ 4 a-7.-. d -- ATE EFF,_. :...:.. HC; =A 179 _ _____ 0 r .,--.,.._... r'

Revision: HCFA-PM- 91-4 ( BPD) Revised: November 1989 SUPPLEMENT 8b TO ATTACHMENT 2.6- A Page 2 OMB No: 0938 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: LOUISIANA 5) MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902(r)( 2) OF THE ACT* The agency will comply with the mandatory provisions under Section 1917 of the Social Security Act as amended by the Deficit Reduction Act of 2005. 6). In determining eligibility for Qualified Medicare Beneficiary (1902(a)( 10)( E)( i) Qualified and Disabled Working Individuals [1902(a)( 10)( E)( ii), Specified Low Income Beneficiary [1902(a)( 10)( E)( iii)], and Qualified Individuals [1902(a)( 10)( E)( iv), the following treatment of resources shall apply: a. The maximum burial fund exclusion is $10,000; b. All life insurance will be disregarded regardless of cash surrender value; and c. All vehicles will be disregarded regardless of value. t , il _ ST.TE ...C.L.. C,U.,.-- E DAi"E RECC ' . o /6 DATE APP\ [ - 2 7-/ 6 ATEEFF "- HC "A 179 _,...-..... TN # b - D / Effective Date ` Approval Date - - Supersedes TN # OG 3

Revision: HCFA-PM- 93-2 ( MB) MARCH 1993 b. Agency* Citation(s) A 1902(a)( 10)( E)( i), 1905(p) and 1860D-14( a)( 3)( D) of tne Act 1902(a)( 10)( E)( ii), 1905(p)( 3)( A)( i), and 1905(s) of the Act State: LOUISIANA c. Attachment 2.2- A Page 9 b OMB NO: 0938- Mandatorv Coverage - CategoricallNeedy and Other Required Special Groups continued) 25. Qualified Medicare beneficiaries-- a. 26. TT L.. Y-°----- fAI EI' Z C,o' fJ._._,.. d... o,._ fATE A6+". ::. '_ ATE k_.._..._. ' - HG,A ,..... d..... Groups Covered Who are entitled to hospital insurance benefits under Medicare Part A, (but not pursuant to an enrollment under section 1818A of the Act); Whose income does not exceed 100 percent of the Federal poverty level; and Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the Consumer Price Index (CPI). Medical assistance for this group is limited to Medicare cost-sharing as defined in item 3.2 of this plan.) Qualified disabled and working individuals-- a. Who are entitled to hospital insurance benefits under Medicare Part A under section 1818A of the Act; b. Whose income does not exceed 200 percent of the Federal poverty level; and c. Whose resources do not exceed twice the maximum standard under SSI d. Who are not otherwise eligible for medical assistance under Title XIX of the Act. Medical assistance for this group is limited to Medicare Part A premiums under section 1818A of the Act.). sp: r- 3 -09 . TN # fd ' Effective Date 1' ' Approval Date ' ' 7 0 Supersedes TN # j , 3 - O 9'

Revision: HCFA-PM- 93-2 ( MB) MARCH 1993 State: LOUISIANA Agency* Citation(s) Groups Covered Attachment 2.2- A Page 9 b 1 OMB NO: 0938- A. Mandatorv Coverage — Cateoricallv Needv and Other Required Special Grouus continued 27. Specified low-income Medicare beneficiaries-- a. Who are entitled to hospital insurance benefits under Medicare Part A, (but not pursuant to an enroliment under section 1818A of the Act); b. Whose income for calendar years 1993 and 1994 exceeds the income level in 25.b., but is less than 100 percent of the Federal poverly level, and whose income for calendar years beginning in 1995 is less than 120 percent of the Federal poverty level; and c. Whose resources do not exceed- three times the maximum standard under SSI, indexed annually by the increase in the consumer price index. Medical assistance for this group is limited to Medicare Part B premiums under section 1839 of the Act.) 0- ( Effective Date `" `- I Supersedes TN # 3 ` OI ST,TE _._.ui Cln,__ DAl"E '1..... m ,..,.` -- DATE A°" r' : '` : / 0 _,.._ ATE F., / - I - /6 HC>•A 179 _ .,..---- ti.,._._ a,._.. w.. y...._ b.. Approval Date ' ` 27 r f6

Revision: Attachment 2.6- A Page 22a State: LOUISIANA Citation(s) Condition or Requirement 1902(a)( 10)( E)( ii), 1905(s) 9. Resource Standard - Qualified Disabled and Working and 1860D-14( a)( 3)( D) Individuals of the Act For qualified disabled and working individuals covered under section 1902(a)( 10)( E)( ii) of the Act, the resource standard for an individual or a couple (in the case of an individual with a spouse) is twice the SSI resource standard. 1902(u) of the Act 10. For COBRA continuation beneficiaries, the resource standard is: Twice the SSI resource standard for an individual. More restrictive standard as applied under section 1902( fl of the Act as described in Supplement 8 to Attachment 2.6- A. atr f Ll i5 JLQ,/C ,___ nA Er'.._ G _ DATEA'`:' 4: d._../ b nATE EF_.._! - r - f HC:`= A 179 _. l D D/ ___ z-,._,.. Y,,..._ ,... M._ t... , s.. a9 d Effective Date - - d Approval Date '` t - 0 Supersedes TN # 3i,, jy, _ J' p

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street, Room 833 Dallas, Texas 75202

Division of Medicaid & Children’s Health, Region VI

June 26, 2012

Our Reference: SPA LA 12-09

Mr. Don Gregory, State Medicaid Director Department of Health and Hospitals Bienville Building 628 North 4th Street Post Office Box 91030 Baton Rouge, LA 70821-9030

Attn: Keydra Singleton

Dear Mr. Gregory:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 12-09. This state plan amendment allows the State to comply with the federal requirements of Section 1202 of the Affordable Care Act. Louisiana does not cover freestanding birth center services.

In the future, when the State submits a State Plan Amendment (SPA) that may impact Indians or Indian health providers, CMS will look for evidence of the State’s tribal consultation process for the SPA. Pursuant to section 1902(a) (73) of the Act added by section 5006(e) of the Recovery and Reinvestment Act of 2009, the State must evidence to CMS regarding the solicitation of advice prior to submission of the SPA. This consultation must include all federally recognized tribes, Indian Health Service and Urban Indian Organizations within the state.

Transmittal Number 12-09 is approved with an effective date of April 1, 2012 as requested. A copy of the HCFA-179, Transmittal No. 12-09 dated June 8, 2012 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks

Associate Regional Administrator

Enclosures

Attachment 3.1-A Page 13 OM B Approved 0938-1024 Attachment 3.1A: Freestanding Birth Center Services 28. (i) licensed or Otherwise State-Approved Freestanding Birth Centers Provided: 0 No limitations 0 With limitations I2_<;]None licensed or approved Please describe any limitations: 28. (ii) Licensed or Otherwise State-Recognized covered professionals providing services in the Freestanding Birth Center Provided: 0 No limitations 0 with limitations (please describe below) 12_<;] Not Applicable (there are no licensed or State approved Freestanding Birth Centers) Please describe any limitations: ~---···,.._,.. ....................... .--... -?.-..~· r STATE L 0 (} j $ 1 'a.t16l_. _,4 l DATE REC'I:l 6 - 7-/ Ol CATe A~PV'I!l h -c:ztt>-'il--l A DATE EFF t,/-/-/01.. -I '''t::" 17n ;oz .... ea ~ • • ·~~-. ·. "' 7 ...................... _.. • , -4 .... ----.. _...:::=.--.._.. __ .. Please check all that apply: 0 (a) Practitioners furnishing mandatory services described in another benefit category and otherwise covered under the State plan (i.e., physicians and certified nurse midwives). 0 (b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth center within the scope of practice under State law whose services are otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professional midwives (CPMs), and any other type of licensed midwife). * 0 (c) Other health care professionals licensed or otherwise recognized by the State to provide these birth attendant services (e.g., doulas, lactation consultant, etc.).* *For (b) and (c) above, please list and identify below each type of professional who will be providing birth center services: TN# __ / ::Z._-_0_~ .:___ Approval Date '~ -DJ-fo- 1 OL Effective Date '1-I -/01_ Supersedes TN# #orJe -fi/6-J~ SUPERSEDES: NONE - NEW PAGE -

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTU CARE EINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

!. TRANSMITTAL NUMBER:

12-09 Louisiana 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

2. STATE

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE ‘April 1, 2012

“5. TYPE OF PLAN MATERIAL (Check One): (] NEW STATE PLAN

[] AMENDMENT TO BE CONSIDERED AS NEW PLAN

— AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 440.165 & 440.60 ( Section 1202 of the ACA)

7. FEDERAL BUDGET IMPACT:

a. FFY _ 2012. $0.00 b. FFY _ 2013 $0.00

“8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 3.1-A, Page 13

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): None (New Page)

10. SUBJECT OF AMENDMENT: section 1202 of the Affordable Care Act, “Freestanding Birtl

The purpose of this amendment is to comply with the federal requirements of

1 Center Service.”

11. GOVERNOR'S REVIEW (Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

KX] OTHER, AS SPECIFIED: The Governor does not review state plan material.

CL] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

“Td. TITLE: Seeretary 15. DATE SUBMITTED: June 8, 2012

16. RETURN TO:

Don Gregory, Medicaid Director Department of Health and Hospitals 628 N. 4" Street

PO Box 91030

Baton Rouge, LA 70821-9030

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

7 June, 2012

8. DATE APPROVED: F 26 June, 2012

PLAN APPROVED - ONE COPY ATTACHED

19. FFFECTIVE DATE OF APPROVED MATERIAL: 1 April, 2012

“21. TYPED NAME: —_ Bill Brooks

22. TITLE: /Associate ministrator Division of Medicaid & Children's Health

“23. REMARKS:

FORM HCFA-179 (07-92)

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 12-57 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young St., Room 833 Dallas, TX 75202 ,:fiif>"','/ CMS CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID AND CIDLDREN'S HEALTII, REGION VI December 21, 2012 Our Reference: SPA LA 12-57 Ms. Ruth Kennedy, State Medicaid Director Department ofHealth and Hospitals Bienville Building 628 North 4th Street Post Office Box 91030 Baton Rouge, LA 70821-9030 Attn: Keydra Singleton Dear Ms. Kennedy: We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 12-57. This state plan amendment allows the State to implement immediate auto-assignment of pregnant women whose Medicaid eligibility is limited to prenata~ delivery, and post-partum services to the Bayou Health program. Transmittal Number 12-57 is approved with an effective date of August 1, 2012 as requested. A copy of the HCFA-179, Transmittal No. 12-57 dated September 25, 2012 is enclosed along with the approved plan pages. If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381. Brooks Associate Regional Administrator Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMIIT ALAND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION I. TRANSMITTAL NUMBER: FORM APPROVED OMB NO 0938-0193 2. STATE ll-57 Louisiana 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINJSTRA TOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1, lOll 5. TYPE OF PLAN MATERIAL (Check One): 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT 'Se orate Transmittal or each amendment 6. FEDERAL STATUTfJREGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Social Security Act, Section 1931 (a)(4) a. FFY .1ru1.. so 42 CFR 448.50 b. FFY 2013 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-F, Page 8 Same (TN 11-ll) Attachment 3.1-F, Page Sa Same (TN 11-11) 10. SUBJECT OF AMENDMENT: The purpose of this SPA is to implement immediate auto-assignment of pregnant women whose Medicaid eligibility is limited to prenatal, delivery and post-partum services. I I. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STA Bruce D. G 14. TITLE: Secreta 15. DATE SUBMITTED: September 21, lOll 181 OTHER, AS SPECIFIED: Tbe Governor does not review state plan material. 16. RETURN TO: J. Ruth Kennedy, Medicaid Director State of Louisiana Department of Health and Hospitals 628 N. 41b Street PO Box 91030 Baton Rouge, LA 70821-9030 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: I8. DATE APPROVED: 25 September, 2012 December 21 2012 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGN 1 August, 2012 21. TYPED NAME: Bill Brooks 23. REMARKS: FORM HCFA-179 (07-92) ssoc1ate reg1ona Adm1n1strator Division of Medicaid & Children's Health

State: Louisiana Citation 42 CFR 438.50 1932(a)(4) 42 CFR 438.50 1932(a)(4) 42 CFR 438.50 Condition or Requirement ATTACHMENT 3.1-F Page 8 OMB No.:0938- G. List all other eligible groups who will be permitted to enroll on a voluntary basis N/A H. Enrollment process. I. Definitions i. An existing provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous year. This may be established through state records of previous managed care enrollment or fee-for-service experience, or through contact with the recipient. ii. A provider is considered to have "traditionally served" Medicaid recipients if it has experience in serving the Medicaid population. 2. State process for enrollment by default. Describe how the state's default enrollment process will preserve: i. the existing provider-recipient relationship (as defined in H.l.i). As part of the financial Medicaid and LaCHIP application process, applicants may be given the option to indicate their preferred choice of CCN and PCP. If the choice of CCN and PCP is not indicated on the new enrollee file transmitted by DHH to the Enrollment Broker, the Enrollment Broker shall contact the enrollee to request their choice of CCN and PCP. The Enrollment Broker shall encourage the continuation of any existing satisfactory provider/patient relationship with their current PCP who is in a CCN. Enrollment Broker staff will be available by telephone to assist program enrollees. Program enrollees will be offered multilingual enrollment materials or materials in alternative formats, large print, and/or Braille when needed. The enrollment broker shall assist the Medicaid enrollee with the selection of a CCN that meets the enrollee's needs by explaining in a non-biased manner the criteria that may be considered when selecting a CCN. If no CCN choice is made, the enrollment broker will utilize available information about relationships with existing PCPs in the assignment process. Medicaid potential enrollees who are eligible for CCN, excluding those whose Medicaid eligibility is predicated upon determination of pregnancy, will have thirty (30) calendar days from the postmark · date that an enrollment form is sent to them by the Enrollment Broker to select a CCN. Pregnant recipients with Medicaid eligibility limited to prenatal, delivery, and post-partum services will immediately be automatically assigned to a CCN by the enrollment broker. All members of a family unit will be encouraged to select tbe same CCN.

State: Louisiana Citation Condition or Requirement ATTACHMENT 3. I-F Page 8a OMB No.:0938- With the implementation of the CCNs in a geographic service area, enrollees will be given the chance to choose a CCN. Enrollees have 90 days from the initial date of enrollment into a CCN in which they may change the CCN for any reason. If the enrollee does not request a disenrollment from the CCN within 90 days, the enrollee will be locked-in to the CCN for up to 12 months, or until their next annual open enrollment period unless they are disenrolled for cause. ii. the relationship with providers that have traditionally served Medicaid recipients (as defined in H.2.ii). All CCNs will contract with providers who have traditionally served Medicaid recipients and will be available for choice and default assignment. Preexisting relationships are a factor in the auto- assignment algorithm. DATE APPV'E> DATE EFF

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 13-49 MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

LA Redacted SPAs Page 2

Medicaid State Plan Eligibility: Summary Page (CMS 179) Statefferritory name: Louisiana 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. I LA-1 3-0049 Jl Proposed Effective Date l._o_I_IO_I_I_20_1_4 ____ _....] (mml dd/yyyy! Federal Statute/Regulation Citation 142 CFR 435.110, 1902(a)( IO)(A) (i)( l), 193 1(b) and (d), 42 CFR435.116, 42 CFR 435.118-119, 42 CFR 435.150 Federal Budget Impact Federal Fiscal Year Amount First Year 12014 I $180.45 Jl Second Year I20I 5 J Subject of Amendment This SPA amends the provisions covering the mandatory eligibility groups in order to adopt the MAGI Income Standards methdology. Governor's Office Review 0 Governor's office reported no comment 0 Comments of Governor's office received Describe: 0 No reply received within 45 days of submittal 0 Other, as specified Describe: Governor's office review is not required. Signature of State Agency Official Submitted By: Roberta Diaz Last Revision Date: Feb 28, 2014 Submit Date: Dec27, 2013 Date Received: Date Approved: 27 December, 2 013 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13 - 49 MM1 Printed Name and Title: Bill Brooks, Associate Regional Administrator Division of Medicaid & Children's Health

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0049

STATE:

Louisiana

Pages or sections of pages being superseded by S14, S25, S28, S30, S51, S52, S53, S54, S55, and S57, and related pages or sections of pages being deleted as obsolete

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

Page 1 Page 3 Page 3a Page 4 Page 4a Page 12 Page 13 Page 13a Page 14 Page 14a Page 23 Page 23b Page 23c Page 23d Page 23e Page 23i

Page 5, A.10 Page 9c, B.1 for caretaker relatives & pregnant women Page 20, B.14 Page 23d, B.21 and B.23 Page 25, C.4

Supplement 1 to Attachment 2.2-A

Page 1

Attachment 2.6-A

Page 3b Page 11a Page 19 Page 19a Page 19b Page 21

Page 1, A.2.a(i) and (iii) Page 6 related to AFDC recipients, pregnant women, infants, and children Page 7, 1.a(1) and (2) Page 12, C.1.e(2) Page 18, C.5.e Page 21a, C.6.e Page 25, C.11.a(3)

Supplement 1 to Attachment 2.6-A Pages 1, 1(a), 1(b), 2, and- 3

Supplement 2 to Attachment 2.6-A

Pages 1-5

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49

2

Supplement 8a to Attachment 2.6-A

Page 1, #1 related to pregnant women Supplement 8b to Attachment 2.6-A

Page 1,#3 related to TB individuals Page 2, #7 related to children and pregnant women Supplement 14 to Attachment 2.6-A Page 1

Supplement 16 to Attachment 2.6-A Page 1-2

State: Louisiana Date Received: 23 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 MM1

Medicaid Eligibility OMB ontrol Number 0938-1 148 OMO Expiration date· 10/3111014 . - AFDC Income Standards IS14 Enter the AFDC tandards below. All states must enter: MAGI-equivalent AFD ' Payment Standard in Effect As of May I. 19!18 and AFD Payment Standard in Eflcct A of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard In Effect As of May 1. 1988 Income Standard Entry· Dollar Amount · Automatic Increase Option lJa The standard is as lollows: r tatcwidc standard (e Standard varies by region I Standard varies by li\'ing arrangement r tandard varies in orne other\ ay Enter the standard by region I Remove Region I Name of region Description !urban Area.~ I East Baton Rouge, Jefferson, Orleans. and , t. Bernard Parishes llouschold size Standard ( ) + I 128 X + 2 213 X + 3 285 X State: Louisiana Date Received: 27 December, 2013 + 4 348 X Date Approved: 6 March, 2014 + 5 410 X Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 + 6 469 X + 7 524 X I + 8 582 X 1- TN: 13 - 49 Approval Date : 3 - 6 - 14 Effectiv e Date : 1 - 1 - 14 1 o f 10 St ate: Louis i ana Pag e Number : 814

~--s Medicaid Eligibility + 9 638 X + 10 692 X + II 751 X + 12 809 X + 13 868 X + 14 928 X + 15 989 X + 16 1.053 X + 17 1.107 X + 18 1,174 X Name of region I Rural Areas Household size Standard ($) + I 121 X + 2 197 X + 3 267 X + 4 .329 X + s .389 X + 6 445 X + 7 502 X + s 560 X + 9 614 X TN: 13 - 49 Approval Da t e : 3 - 6 - 14 State : Louisiana Page Number: 814 I -- Additional incremental amount I Ci Yes r No Increment amount 191 I : I I Remove Region I Description All Parishes not listed as Urban I I l State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 i J --- -- Effect i ve Da t e: 1 - 1 - 14 2 of 10 -

Medicaid Eligibility ~ - - - + 10 669 X Additional incremental amount (i' Yes ('No + II 726 X $185 I Increment amount + 12 784 X + 13 846 X State: Louisiana + 14 907 X Date Received: 27 December, 2013 + 15 967 X Date Approved: 6 March, 2014 + X Date Effective: 1 January, 2014 16 1.028 Transmittal Number: LA 13-49 ' + 17 1.087 X + 18 1.147 X I -- I Add Region I The dollar amounts increa. c automatically each year (' Yes (i' No AFDC Payment Standard in Effect AJ of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option Sl3a The standard is as follows: (' Statewide standard (i' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way Enter the standard by region - ----- I I Remove Region Name of region Description I urban Areas jiEast Baton Rouge. Jefferson. Orleans. and ·1. I Bernard Parishes - - TN: 13 - 49 Approval Date: 3-6 - 14 State: Louisiana Page Number: 814 Effective Date: 1-1-14 3 of 10

Medicaid Eligibility I Hou chold si7e Standard ( ) + I 72 X + 2 138 X + J 190 X !i + 4 234 X + 5 277 X + 6 316 X + 7 352 X I I + s 391 X I + 9 427 X ! + 10 462 X I + II 50 1 X + 12 540 X + 13 580 X + 14 620 X + 15 662 X + 16 707 X + 17 741 X + 18 789 X Name of region I Rural Areas I I llousehold size I Standard($) I I TN: 13-49 Approval Date: 3-6-14 State: Louisiana Page Number: 814 Additional incremental amount (i Yes r No Increment amount sin I State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 i ! I I ! I - I Remo\ e Region I Description I All t>arishes not listed as rban Effective Date: 1-1-14 4 of 10

Medicaid Eligibility + I 66 X Additional incremental amount (i' Yes (' No + 2 123 X lnl:rement amount $ 166 I I I + J 174 X + 4 217 X i + s 2"9 X + 6 296 X I + 7 334 X State: Louisiana + s 373 X Date Received: 27 December, 2013 + 9 408 X Date Approved: 6 March, 2014 + 10 444 X Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 + II 482 X I + 12 521 X + 13 564 X + 14 606 X I + 15 647 X + 16 689 X + 17 729 X + 18 771 X - I Add Region I The dollar amounts increase automatically each year (' Yes (i' No MAGI-equivalent AFDC Payment Standard in Ell'ect As of July 16,1996 Income Standard Entry - Dollar Amount - Automatic Increase Option Sl3a - TN : 13 - 49 Appr oval Date : 3-6-14 Effectiv e Date: 1-1-14 Stat e : Lou i s iana Page Number : 814 5 of 10

Medicaid Eligibility The standard is as follows: (' Statewide standard (i' Standard varies by region (' Standard varies by living arrangement (' tandard varies in some other way Enter the standard by region Name of region !urban Areas Household size Standard ( ) + 1 128 X + 2 213 X + 3 285 X + 4 348 X + s 410 X + 6 469 X + 7 524 X + s 582 X + 9 638 X + 10 692 X + II 751 X + 12 809 X + 13 868 X + 14 928 X + 15 989 X TN: 13 - 49 Approval Date : 3 - 6 - 14 State : Louisiana Pag e Number : 814 I I Remove Region I Description East Baton Rouge. Jcllcrson. Orleans. and St. Bernard Parishes ! I I State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Effective Date : 1 - 1 - 14 6 of 1 0 -

Medicaid Eligibility - - - - - + 16 1.053 X Additional incremental amount l Ci Yes (' No + 17 1.107 X 191 I Increment amount + 18 1.174 X I Remove Region I Name of region Description !Rural Areas I All Parishes not listed as rban I Household siLe Standard ( ) I + I 121 X + 2 197 X + J 267 X + 4 329 X + s 389 X + 6 445 X + 7 502 X + s 560 X I + 9 614 X + 10 669 X + II 726 X I + 12 784 X State: Louisiana + 13 846 X Date Received: 27 December, 2013 + 14 907 X Date Approved: 6 March, 2014 + Date Effective: 1 January, 2014 15 967 X Transmittal Number: LA 13-49 + 16 1.028 X - TN: 13 - 49 Approva l Da t e : 3 - 6 - 14 Effective Date : 1-1-14 State : Louisiana Page Number : 814 7 of 10

Medicaid Eligibility + 17 1.087 X Additional incremental amount I Ci Yes ('No + 18 1.147 X s!ss I I Increment amount I Add Region I The dollar amounts increase automatically each year (' Yes (i No AFDC Need Standard in Effect As of July 16,1996 Income Standard Entry- Dollar Amount -Automatic Increase Option SlJa The standard is as follows: I Statewide standard (' tandard varies by region (' Standard varies by th-ing arrangement (' Standard vari<=S in some other way The dollar amounts increase automatically each year (' Yes I No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase ia the Consumer Price Index for urban consumen (CPl·U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option SIJa The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' tandard varies in some other way The dollar amounts increase automatically each year (' Yes (' No TN: 13-49 Approval Date: 3 - 6- 14 State : Louisiana Page Number : 814 State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Effective Date: 1-1-14 8 of 10

Medicaid Eligibility MAGI-equivalent AFDC Payment Standard in EO'eet As of July 16, 1996, increased by no more than the pereentage increase in the Con umer Price lnde for urban consumers (CPI-U) ince such date lncome Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is a.~ tollows: (' Statewide standard r tandard varies by region r tandard varies by living arrangement r tandard varies in some other \ uy The dollar amounts increase automatically each year (' Ye (' No T ANF payment standard Income Standard Entry- Dollar Amount -Automatic Increase Option Sl3a The standard is as follows: r 'tatewide standard r ' tandard \'aries by region State: Louisiana (' Standard varies by living arrangement Date Received: 27 December, 2013 r tandard varies in some other way Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 The dollar amounts increase automatically each year (' Yes (' No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option 13a The standard is tts follows: (' Statewide standard r tandard varies by region (' Standard varies by living arrangement (' Standard \'arit:s in some other way - TN: 13-49 Approval Date: 3 - 6-14 State: Louisiana Page Number : 814 Effective Date : 1 - 1 - 14 9 of 10

Medicaid Eligibility The dollar amounts increase automatically each year r Yes r No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection or information unless it displa} s a valid OMB control number. The valid OMB control number lor this information collection is 0938-1148. The time required to complete this infonnation collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources. gather the data needed. and complete and review the inlom1ation collection. If you have comments concerning the accuracy or the time estimatc(s) or suggestions for improving this form. please write to: CM . 7500 ecurity Boulevard. Attn: PRA Repo1ts Clearance Officer. Mail Stop C4-26-05. Baltimore. Maryland 21244-1850. TN: 13 -4 9 Approval Date : 3 - 6 - 14 State: Louisiana Page Number : 814 State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Effective Date: 10 of 10 1-1-14 -

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility OMB ontrol Number 0938-1141! OMI3 Expiration date: I 0/31'20 14 Eligibility Groups- Mandatory Coverage Parents and Other Caretaker Relatives 42 CFR 435.110 1902(a)( IOl(Al(i)(l) 193 1(b) and (d) S25 [!] Parents and Other Caretaker Relatives- Parents and other caretaker relatives of dependent children with household income at nr • below a standard established by the state. 0 The state altc ts that it operutcs this eligibility group in accordance with the following provisions: [!] Individuals qualifYing under this eligibility group must meet the foil \dng criteria: [!] Are parents or other caretaker relatives {defined at42 CFR 435.4). including pregnant women. of dependent children (defined at 42 CFR 435.4) under age 18 .• pouses of parents and other caretaker relatives are also included. The state elects the foliO\ ing options: This eligibility group includes individuals who arc parents or other caretakers of children who are Ill years old. 1:8] provided the children are full-time students in a secondary school or the equivalent level of ocational or technical training. 0 Options relating to the definition of caretaker relative (select any that apply): 181 Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental suppo11 or (i' care by reason of the death, physical or mental incapacity. or absence from the home or unemployment of at least one parent. \ The child must be deprived of parental support or care. but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): ~ Have household income at or below the standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please reler as necessary to 10 MAGI- Based Income Methodologies. completed by the state. ~ Income standard used for this group [!] Minimum inwmc standard The minimum income standard used for this group is the state's AFD payment standard in effect a.~ of May I. 1988. convened to MAGI-equivalent amounts by household si7..c. The standard is described in 14 AFDC Income Standards. 0 The state certifies that it has submitted and recci cd approval for its convened May I, 19881\FD payment standard. An attarhment i ubmltted. [!] M1lXimum income standard - TN: 13-49 Approval Date : 3-6 - 14 Effective Date: 1 - 1 - 14 State: Louisiana Page Number : 825 1 of 3

TN: 13-49 State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility The state certifies that it has submitted and received appro al for its convened income standard(s) for parents and 0 other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. An •ttachmenl i submitted. The state's maximum income standard for this eligibility group is: (i' The state's effective income level for .. cction 1931 families under the Medicaid state plan as of March 23. 2010. convened to a MAGI-equivalent percent of FPL or amounts by household size. (' The state's effective income level for section 1931 families under the Medicaid state plan a of December 31. 2013, convened to a MAGI-equivalent percent of FPL or amounts by household si7.c. The state's etlcctive income level for any population ofparenLo;/earetaker reluti es under a Medicaid 1115 { demonstration a.~ of March 23, 20 I 0. converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's etlectivc income level for any population of parents/caretaker relatives under a Medicaid II 15 (' demonstration as of December 3 I. 2013. converted to a MAGI-equivalent percent ofFPL or amounts by household size. Enter the amount of the ma.ximum income standard: r percentage of the federal poverty level: 0 % (i' The state's AFDC payment standard in effect as of July 16, 1996. convened to a IAGI-equivalent standard. Th~ standard is described in 14 AFDC Income Standards. The tate's AFD payment standard in effect as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MA('iJ- equivalent standard. The standard is described in 14 AFDC Income Standards. (' The state's TANF payment tandard. convened to a MAGI-equivalent standard. The standard is described in S I-I AFDC Income Standards. (' Other dollar amount (!] Income standard chosen: Indicate the state's income standard used for this eligibility group: (' The minimum income standard (' The maximum income standard The state's AFDC payment standard in efTcct as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index lor urban consumers (CPI- ) since such date. The standard is described in ' 14 AFD Income Standards. (i' Another income standard in-between the minimum and maximum standards allowed (' The stale's AFD paymelll standard in effect as of July 16, 1996, not converted to a MAGI-equivalent standard. The tandard is described inS 14 FDC Income tandards. Approval Date: 3 - 6-14 Effective Date: 1 - 1 - 14 - State: Louisiana Page Number: 825 2 of 3

Medicaid Eligibility (' The state's TA F payment standard, not converted to a MAGI-equivalent standard. The standard is d..:scrib.:d in 14 AFDC Income tandards. (' The state's AFDC payment standard in effect a~ of July 16. 1996. converted to a MA<il-cquivalcnt standard. The standard is described in S 14 FDC Income tandards. (' The state's TA P payment standard. converted to a MAGI-equivalent standard. The standard is described in , 14 AFDC Income tandards. (i' Other income standard in-between the minimum and the maximum standards allowed. The amount of the income standard for this eligibility group is: (i' A percentage of the federal poverty level: ~ % (' A dollar amount [!] There is no resource test for this eligibility group. [!] Pre. umptive Eligibility The stale covers individuals under this group when determined presumptively eligible by a qualified entity. The state a~s ures it also covers individuals under the l>rcgnant Women (42 CFR 435.116) and/or lntimts and Children under Age 19 (42 CPR 435.1 18) eligibility groups when detennined presumptively eligible. (' Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of I 995. no persons are required to respond to a collection of information unless it displays a valid OMR control number. Tile valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response. including the time to review instructions, search existing data resources. gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the lime estimate(s) or suggestions for improving this form , please write to: CM . 7500 Securit) Boulevard. Attn: PRA Reports Clearam:e Officer. 1ail top C4-26-05. Baltimore. Maryland 2 I 244-1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN: 13-49 Approval Date: 3-6-14 State: Louisiana Page Number: 825 Effective Date: 1-1-14 3 of 3 -

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility OMR ontrol Number 0938-1141< OMI3 Expiration date· 10/31/2014 Eligibility Group - Mandatory Coverage Pregnant Women 42 FR 435.116 1902(a){IO)(A)(i)(lll) and (IV) 1902(a)( IO)(A)(ii)(l). (IV) and (IX) 1931(b) and (d) 1920 28 ~ Pregnant Women - Women who arc pregnant or post-partum. with household income at or below a standard established by the state. 0 The state attests that it operates this eligibility group in accordance with the tollowing provisions: ~ Individuals qualifying under this eligibility group must be pregnant or po;t-partum, as defined in 42 CFR 435A. Pregnant women in the last trimester of their pregnancy without dependent children are eligible li:1r lull benefits under this group in accordance with section 193 1 of the Act. i fthey meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. (i Yes (' No ~MAGI-based income methodologies arc used in calculating household income. Please refer as necessary to S 10 MAGI-Based • Income Methodologies. completed by the state. [!] ln~Jome standard used tor this group [!]Minimum income standard (Once entered and approved by CMS. the minimum income standard cannot be changed.) The state had an income standard higher than 133% FPL established as of December 19, 1989 1br determining eligibility for pregnant women. or as of July I. 1989. had authorizing legislation to do so. (' Yes (i o The minimum income standard for this eligibility group is 133% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(sl tor pregnant IZJ wvmcn to MAGI-equivalent standards and the determination of the maximum income standard to be used fvr pregnant women under this eligibility group. An •ttathment is ubmitted. nlc state's maximum income standard for this eligibility group is: (i The state's highest etlcctivc income level tor ~Joverage of pregnant women under sections 193 1 (low-income families), 1902(a)( IO)(A)(i)(lll) (qualified pregnant women). 1902(a)( 10)(1\)(i)(l V) (mandatory poverty level- related pregnant women), 1902(a)( IO)(A)(ii)(IX) (optional poverty level-related pregnant women). 1902(a)( IOi (A}(ii)(l) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)( IO)!A)(ii)(IV) (institutionalized pregnant women) in efTect under the Medicaid state plan as of March 23. 2010. converted to u MAGI-equivalent percent of FJ>L. - TN: 13-49 Approval Date: 3 - 6-14 State: Louisiana Page Number : 828 1 of 2 Effective Date: 1 - 1 - 14

Medicaid Eligibility TI1e state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families). !902(a)( IO)(A)(i)(lll) (qualilied pregnant women). 1902(a)( IO)(A )(i)(l ) (mandatory povc1ty Ievel- l related pregnant women), !902(a)( I O)(A )(ii)(IX) (optional poverty level-related pregnant women). 1902(a){ I OJ (A)(ii){l) (pregnant women 11ho meet AFD financial eligibility criteria) and I Q02(a)( IOl(A)(ii)(IV) (institutionalized pregnant women) in cflectundcr the 1cdkaid state plan as of December 31. 2013. converted to n MAGI-equivalent percent of FPL. l The state' etlectivc income level for any population of pregnant women under a Medicaid II 15 demonstration as of March 23. 2010. converted to a MAGI-equivalent percent of FPL. l The state's etlcctivc income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31. 2013. converted to a MAGI-equivalent percent of FPL. ( 185% FPL The amount of the maximum income standard is :~ % FPL ~ Income standard chosen Indicate the state's income standard used for this eligibility group: (i' The minimum income standard ( The maximum income standard r nother income standard in-between the minimum and maximum standards allowed. ~There is no resource test for thi eligibility group. ~Benefits for individuals in this eligibility group consist of the following: (i' All pregnant women eligible under this group receive full Medicaid coverage under this state plan. r Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. ~Presumptive Eligibility The state covers ambulatory prenatal care tor individuals under this group when detennined presumptively eligible by a qualified entity. l Yes (i' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of infommtion unless it displa) s a valid OMB control number. The valid OMD control number for this information collection is 0938-1148. The lime required to comple1e this information collection is estimated to average 40 hours per response. including the lime to review instructions. search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accunlC) of the lime cstimatc(s) or suggestions for improving this fonn, please write to: CMS, 7500 ·ecurity Boulevard, Attn: I'RA Rcpo11s Clearance Ofliccr. Mail top C4-26·05, 13altimore, Maryland 21244· 1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 - TN: 13-49 Approval Date: 3-6-14 Effective Date: 1-1-14 2 of 2 State: Louisiana Page Number: 828

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility OMB ontrol Number0938-ll4K 0Ml3 Expiration date· 10/3 1'2014 Eligibility Group - Mandatory Coverage Infants and Children under Ate 19 42CFR435. 118 1902(al( IO)(A)(i)(lll ). (IV), (VI) and (VII) 1902(a)( I O)(A)(ii)(IV) and (IX) 193 1(b) and (d) 30 [!] Infant and C hildren under Age 19 - Infants and children under age 19 with household income at or below standards establi hcd by the state based on age group. 0 The state attests that it operates this eligibility group in accordance with the foliO\\ ing provisions: [!] Children qualifying under this eligibility group must meet the following criteria: [!] Are under age 19 [!] I lave household income at or below the standard established by the tate. [!] MAGI-based income methodologies arc used in calculating household income. Please refer as necessary to ' I 0 MAGI· Based Income Methodologies. completed by the state. [!] Income tandard used for infants under age one [!] Minimum income standard fhc state had an income standard higher than 133% FPL established as ofDceembcr 19. 19K9 for determining eligibility for infants under age one. or as of July I, 1989. had authorizing legislation to do so. (' Yes le o The minimum income standard lor infimts under age one is 133% FPL. [!] Ma. imum income standard The state ccrtilies that it has submitted and received approval for its converted income standard( s) for inlimts 0 under age one to MAGI-equivalent standards anJ the detem1ination of the rna ·imum income standard to be used for infants under age one. An attachment i submitt~. The state's maximum income standard for this age group is: The state's highest enective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)( IO)(A)(i)(lll) (qualified children), 1902(a)( I O)(A)(i){IV) (mandatory PO\ crty level-related (' inlants). 1902(a)( IO)(A)(ii)(IX) (optional poverty level-related inlants) and t902(a)( IO)(A)(ii)(l ) (institutionalized children). in effect under the Medicaid state plan as of March 23, 20 I 0. converted to a MAGI- equivalent percent of FPL. TN: 13 - 49 Approval Date: 3-6 - 14 State : Louisiana Page Number : 830 1 of 5 Effective Date: 1-1-14 -

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility The state's highc.st eflectivc income level for coverage of infants under age one under sections 1931 (low-income families). 1902(a)( IO)(A )(i )(Ill) (qualified children). 1902(aJ{ I O)(A)(i)(l V) (mandatory poverty lcvel-rclmed (' infants), J902(a)( I O)(A)(ii) IX) (optional poverty level-related intanl~) and J902(a)( IO)(A J{ii)(IV) (institutionalized children). in cflect under the Medicaid state plan as ofDeccmb~o:r 31.2013. converted to a MAGI-equi,·alent percent of FPL. (' The state's effective income level for any population of infants under age one under a Medicaid 11 15 demonstration as of I\•! arch 23. 20 I 0. converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of infants under age one under a Medicaid 11 15 demonstration as ofDeeember 31. 2013. converted to a 1AGI-equivalenl percent of Fl'L. (e' 185% FPL ~ Income standard chosen The state' income standard used for infants under age one is: (' The maximum income standard If not chosen as the maximum income standard. the state's highest effective income level for coverage of infants under age on.: under s~-ctions 1931 (low-income fumilie ). 1902(a)( IO)(A)(i)(lll) (qunlitied children). 1902(a)( 10) (e' (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)( I O)(A)(ii)(IX) (optional poverty level-related inlants) and I<J02(a)( I O)(A)(ii)(IV) (in titutionalizt!d children). in effect under the Medicaid state plan as of March 23. 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest etl'ective income level for this age group under the state plan us of March 23. 20 I 0, and if not chosen as the maximum income standard. the state's highest efl'cctive income level for coverJgc nf infanb (' under age one under sections 1931 (low-income lilmilies). 1902(a)( I O)(A)(i)(lll) (qLtalified children). 1902(<~)( I 0) (A )(il(IV) (mandatory poverty level-related infants). 1902(a){ IO)(A){iil(IX) {optional poverty level-related infants) and 1902{a)( 10)(/\)(ii)(IV) (institutionalized children). in effect under the Medicaid state plan us of December 3 1, 2013. converted to a MAGI-equivalent percent of Ff'L. If higher than the highest effective income level for this age group under the state plan as of March 23. 20 I 0. and (' if not chosen as the maximum income tandard. the state's efl'ective income le el for any population of infants under age one under a Medicaid IllS demonstration as of March 23.2010. converted to a MAGI-equivalent percent of Fl'L. If higher than the highest ctl'ectivc income level for this age group under the state plan as of March 23. 20 t 0. and (' if not chosen as the maximum income standard. the state's eiTectivc income le el tor any population of infants under age one under a Medicaid II 15 demonstration as of December 31. 2013, converted to a MAGI-equivalent percent of FPL. r nothcr income standard in-between the minimum and maximum standards allowed. provided it is higher than the effective income standard lor this age group in the state plan as of March 23. 20 I 0. The amount of the in1.-ome standard tor infants under one is: ~ % FPL ~ lncomt: standard lor children age one Lhrough age live. inclusive ~ Minimum income standard TN : 13-49 Approval Date : 3 -6-14 Effective Date : 1- 1-14llllll• State : Loui s iana Page Number : 830 2 o f 5

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. ~ Maximum income standard The Slllte certifies that it has ubmitted and received approval for its converted income standard(s) for children IZJ age one through five to MAGI-equivalent standards nnd the d~termination of the maximum income standard to be u ed for children age one through five. An attachment i ubmitted. The state's rna ·imum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under section 1931 (!oll- Ie income families), 1902(a)( IO)(A)(il(lll) (qualified children), 1902(a)( IO)(Al(i)(VI) (mandatory po1cny level- related children age one through five). und J902(a)( IO)(A)(ii)(IV) (institutionalized children). in effect under the Medicaid tate plan as of March 23, 20 I 0. converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through fiv.: under sections 193 I (lo\\- l income families), 1902(a)(I0)(A)(i)(lll) (qualified children), 1902(a)(I0)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)( I O)(A )(ii)(IV) (institutionalized children). in effect under the Medicaid state plan as of December 31. 2013. convened to a MAGI-equivalem percent of FPL. r The state's effective income level for any population of children age one through five undcr a Medicaid 11 15 demonstration as of March 23. 20 I 0. converted to a MAGI-equivalent percent of FI'L. r The state's eiTcctive income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31. 2013. converted to a MAGI-equivalent percent ofi'PI .. Enter the amount of the maximum income standard :~ % FPL ~ Income standard chosen The state's income standard used for children age one through live is: (e' The maximum income standard If not chosen as the maximum income standard. the state's hight!st effective in.:ome levt!l lor coverage of children age one through live under sections 1931 (low-income families). J902(a)(IO)(A)(i)(lll) (qualified children). l 1902(a)( IO)(A)(i)(VI) (mandatory poverty le\cl-related children age one through five). and 1902(a)( IO)(A)(ii) (IV) (institutionalized children). in etlcct under the Medicaid state plan as of March 23, 2010. converted to a MAGI-equi\ alent percent of FPL. If higher than the highest ctTeetive income level for this age group under the state plan as of March 23. 20 I 0. and if not chosen as the maximum income tandard. the state's highest effecti\e income level lor coverage of children l age one through five under sections 1931 (low-income families). 1902(a)( IO)(A)(i)(lll)(qualificd children). 1902(a)( IO)(A}(i)(VI)(mandatory poverty level-related children age one through live), and 1902(a)( I O)(A)(ii) (IV) (institutionalized children). in efkct under the Medicaid state plan as of December 3 1. 201 3. corwcned to u MAGI-equivalent percent of FPL. Effe ctive Dat e: TN : 13- 49 Appr ova l Da t e : 3-6 - 14 Sta t e: Louisiana Page Number : 83 0 3 of 5 1-1-14 -

TN: 13-49 State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility I fhigher than the highest ctrective income level for this age group under the st:ne plan as of March 23. 20 I 0. and (' if not Chosen as the maximum income standard, the State's effective income leveltiJr any population of children age one through five under a Mt:dicaid I I 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest cll'cctive income level for this age group under the state plan as of March 23, 20 I 0. and r if not chosen as the maximum income standard. the state's em:ctive income level tor any population or children age one through fi e under a Medicaid 1115 demonstration as of December 3 I. 2013. con"erted to aM Gl- equivalcnt percent of FPL. (' Another income standard in-between the minimum and maJo.imum standards allowed. provided it is higher than the etlcctive income . Ulndard for this age group in the state plan as of March 23. 20 I 0. 00 Income standard lo r children age six through age eighteen. inclusive 00 Minimum inc me standard The minimum income standard used for this age group is 133% FPL. 00 Ma imum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for children age 0 six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to he used for children age six through age eighteen. An atfachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level lor coverage of children age six through eighteen under sections 193 1 (' (low-income families). 1902(a)( IO)(A)(i)(ffl) (qualified children). 1902(a)( 10)(1\)(i)(Vff ) (mandatory po' erty le cl-rclatcd children age six through eighteen) and 1902(a){ IO)(A)(ii)(IV) (institutionalized children). in effect under the Medicaid state plan as of March 23.2010. converted to a MAGI-equivalent percent of!- PL. The state' highest etl'ectivc income level for coverage of children age ix through eighteen under sections 1931 le (low-income tami lies). 1902(a)( IO)(A)(i){lll ) (qualified children). 1902(a)( IO)(A)(i){ II) (mandatory poverty level-related children age six through eighteen) and 1902(a)( I O)(A)(ii)(IV) (institutionalized children). in effect under the Medicaid sUite plan as of December 31. 2013. converted to a MAGI-equivalent percent of FPL. (' The state's c!Tective income level for any population of children age six through eighteen under a Medicaid I 115 demonstration as of March 23.20 10. converted to a MAGI-equivalent percent ofFPI.. (' The state's etlective income level for nn. population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31. 2013. converted to a MAGI-equivalent percent of FPL. (' 133% FPL Enter the amount of the maximum income standard : ~ % FPL 00 Income tandard chosen Approval Date: 3- 6 - 14 Effective Date : 1 - 1 - 141111111 State : Louis i ana Page Number: 830 4 of 5

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility The state's income standard used for children age six through eighteen is: { The maximum income standard If not chosen a the maximum income standard, the state's highest effective income level for coven1ge of children age six through eighteen under sections 193 I (low-income families), 1902(a)( IO)(A)(i)(lll) (qualified children). { 1902(a)( IOXA)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)( IO)(A l (ii)(IV) (institutionali7..cd children), in effect under the Medicaid state plan as of March 23, 20 I 0. converted to a MAGI-equivalent percent of FPL. (i" If higher than the highest ctlcctivc income level for this age group under the state plan as of March 23.2010. and if not cho en as the maximum income tandard. the state' highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families). 1902(a)( IO)(A)(i)(lll) (qualified children). 1902(a}( I O)(A )(i)(VII )(mandatory poverty level-related children age six through eighteen) and 1902(a)( I 0)( A l (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31.2013. conYcrted to a MAGI-equivalent percent ofFPL. If higher than the highest effective income level for this age group under the state plan as of March 23. 2010. and r if not chosen us the maximum income standard. the state's etlectivc income level tor any population of children age six through eighteen under a Medicaid 1115 dcmonstmtion as of March 23.2010. converted to a MAGI- equivalent percent of F'PL. If higher than the highest effective income level for this age group under the state plan as of March 23. 20 10. and r if not chosen as the maximum income standard. the state's dfective income level for any population ofchildn:n age six through eighteen under a Medicaid 1115 demonstmtion as of December 31. 20 IJ, converted to a MAGI- equivalent percent of FPL. { Another income standard in-between the minimum and maximum standards allowed. provided it is higher than the effective income standard for this age group in the state plan as of March 23. 2010. The amount of the income standard for children age six through eighteen is: ~ % FPL 00 There is no resource test for this eligibility group. 00 Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity. { Yes (i No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons arc requirl-d to respond to a collection of information unless it displa) s a valid OMB control number. The vulid OMR control number for this information collection is 0938- 1148. The time required to t'omplctc this information collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources. gather the data needed, and complete and review the infonnation collt."Clion. If you have comments concerning the m:curaC) of the time estimate(s) or uggestions tor improving this form. please write to: CMS. 7500 ecurity Boulevard. Attn: PRA Reports CIC'Jranee Officer. Mail Stop 4-26-05. Baltimore. Maryland 21244- 1850. TN: 13-49 Approval Date: 3- 6- 14 Eff ective Date : 1 - 1 - 14 State: Louisiana Page Number: 830 5 of 5 -

TN: Medicaid Eligibility Eligibility Groups- Mandatory Coverage Adult Group 1902(a)( IO)(Al(il(VIIl) 42 CFR 435.119 The state co1rers the Adult Group as described at 42 CFR 435.119. (' Yes (i o PRA Disclosure Statement OMB ontrol Numbcr0938-1 14!! OMB Expiration date: 10/3111014 S32 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displa} s a valid OMB control number. The valid OMB control number for this infonnation collection is 093!1-I 141!. The time required to complete this information collection is estimated to average 40 hours per rt-sponse. 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 uccurac~ of the time estimate(s) or suggestion for improving this form, please \Hitc to: CM. , 7500 Security Boulevard, Attn: PRA Reports Clearam:c Officer. Mail top C4-26-05, Baltimore, Maryland 21244-1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 13-49 Approval Date: 3-6-14 Effective Date: 1-1-14 State: Louisiana Page Number: 832 1 of 1 -

Medicaid Eligibility OMB 'ontrol Number 0938-1148 OMB Expiration date· I 0/31 120 I-I Eligibility Groups- Mandatory Coverage Former Foster Care Children 42CFR435.150 1902(a)( IO)(A )(i)(IX) ~ Former Fosler Care Children - lndi iduals under the age of26. not otherwise mandatorily eligible. who were on Medicaid and • in foster care when the) turned age 18 or aged out of foster care. IZJ The state attests that it operates this eligibility group under the following provisions: ~ Individuals qualilying under this eligibility group must meet the following criteria: ~ Are under age 26. ~ Arc not otherwise eligible for and enrolled for mandatory coverage under the state plan. except that eligibility under this group Lakes precedence over eligibility under the Adult Group. Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state ~plan or 1115 demonstration \\hen they turned 18 or at the time of aging out of that state's or Tribe's foster care program. The state elects to cover children who were in foster care and on Medicaid in • state at the time they turned 18 or aged out of the foster care system. (i" Yes (' o The state covers individuals under this group when detennined presumptively eligible by a qualitied entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.11 6) and/or Infants and Childn:n under Age 19 (42 CFR 435.1 18) eligibility groups when determined presumptively eligible. (' Yes (i" o PRA Disclosure Statement 33 According to the Paperwork Reduction Act of 1995, no persons arc required to respond to a collection of iniimnation unless it displa~ s a valid OMB control number. The valid OMB control number for U1is inforn1ation collection is 0938-1148. The time required to complete this intonnation collection is e ·timated to average 40 hours per response, including the time to review instructions, earch existing data resources. gather the data needed. and complete and review the infom1ation collection. If you have comments concerning the accurac~ of the time estimatc(s) or suggestions for improving this fom1, please write to: MS. 7500 Security Boulevard, Attn: PRA Reports Clearance Oflicer. Mail Stop C4-26-05. Baltimore. Maryland 21244-1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN : 13- 49 Appr oval Date: 3 -6-14 Effective Date: 1 - 1-14 State : Louis i ana Page Number: 833 1 of 1 -

TN: Medicaid Eligibility OMB ontrol Number 0938-1141! OMB Expiration date: 10/3 11201-1 Eligibility Groups- Options for Coverage Individuals above 133% FPL 1902(u )( IO)(A)(ii)(XX) 1902(hh) 42 CFR 435.2 18 Individuals above 133% FPL- The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible. with inc me above 13 % FI'L and at or below a standard established by the state nnd in accordance \ ith provisions described at 42 CFR 435.2 18. (' Yes (i No sso According to the Paperwork Reduction Act of 1995. no persons arc 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- 11 48. The time n.:quired to complete this information collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources. gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy or the time estimatc(s) or suggestions for improving this form, please write to: M ·. 7500 'ecurity Boulevard, A lin: PRA Reports CIC'arancc Otlicer. Mail Stop C4-26-05. Baltimore, Maryland 21244-1 850. 13-49 Approval Date: State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 3-6-14 Effective Date: 1-1-14 State: Louisiana Page Number: 850 1 of 1 -

Medicaid Eligibility Eligibility Groups· Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives 42 FR 435.220 1902(a)( IO)(A)(iiXI ) OMR ontrol Number 0938- 1141! OMB Expiration date: 10/3 1120 14 51 Optional Coventge of Parents and Other Caretaker Relatives- The state elects to cover individuals qualifying us parents or other caretaker relatives who arc not mandatorily eligible and who have income at or below a standard cstabli hed by the state and in accordance with provisions described at 42 CFR 435.220. r Yes (i" No PRA Disclosure Statement coording to the Paperwork Reduction Act of 1995. no persons arc required to respond to a collection of intonnation unless it di spla~ sa valid OMB control number. The valid OMB control number lor this information collection is 0938-tt 4R. The time required to complete this infonnation collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources. gather the duta needed. and complete and review the inlonnation collection. If you have comments concerning the uccuracy of the time estimate(s) or suggestions for improving this form. please \lfite to: CMS. 7500 ecurity Boulevard. Alln: PRA Repons Clearance Officer. tail Stop 4-26-05. Baltimore. Maryland 21244-1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN: 13-49 Approval Date: 3-6-14 Effective Date: 1-1-14 State: Louisiana Page Number: 850 1 of 1 -

Medicaid Eligibility OMR ontrol Number 0938-1141! OMI3 Expiration date· 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification oflndividuals under Age 21 42 CFR 435.222 1902(a)( IO)(A)(ii)(l) 1902(u)( IO)(A)(ii)(IV) 52 Rea onable Cia sification of Individual under Age 21 -The state elects to cover one or more reasonable classi lications of individuals under uge 21 who arc not mandatorily eligible and who have income at or below a tandurd established by the state and in accordance with provisions described :ll 42 CFR 435.222. {. Yes (' No 0The state attests that it operates this eligibility group in accordance with the lollowing provisions: [!] ln~iv~duals qualifying under this eligibility group must quuli(y under a reasonable classilication b) meeting the following en ten a: [!] Be under age 21. or a lower age. as defined within the reasonable classilicution. [!] II a c household income at or bcl01 the standard established bv the state. if the state has an income standard lor the • reasonable classification. . [!] ot be eligible and enrolled for mandatory coverage under the state plan. [!] MAGI-based income methodologies are used in calculating household income. Please refer as necessal)' to 10 MAGI- Based Income Methodologies. completed by the tate. The state co ered at least one reasonable classification under this eligibility group under its Medicaid tate plan as of Decem her 31.2013. or under a Medicaid 11 15 Demonstration as of March 23,2010 or December 31, 2013, with income standards higher (including disregarding all income) than the CUITcnt mandatory income standards for the individual's age. (i" Yes (' o The tate also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23. 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. (i" Yes (' o Reasonable Classifications Covered in the Medicaid State Plan as of March 23.2010 The tate allachcs the approved pages from the Medicaid state plan as of March 23. 20 I 0 to indicate the age 0 groups. reasonable classifications. and income standards used at that time lor this eligibility group. An attachment i submitted. Current Coverage of All Children under a Speci lied Age State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 - TN: 13 - 49 Approval Date : 3 - 6- 14 Effective Date: 1-1-14 State : Louisiana Page Number : 852 1 of 8

TN: 13 - 49 State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility The state covers all children under a specified age limit. equal to or higher than the age limit and/or income standard used in the Medicaid state plan as ofMareh 23. 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid tate plan as of December 31. 2013 or under a Medicaid 1115 Demonstration as of March 23. 20 I 0 or December 31. 2013. Higher income standards may include the disregard of all income. ( Yes (i' Nu Current Coverage of Reasonable Classifications Covered in the Medicaid Stuts: Plan as of March 23. 20 I 0 The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23. 2010, with income standards higher than the current mandatory income standard tor the age group. Age limits and income standards arc equal to or highcrthan the Medicaid state plan as of March 23.2010. but no higher than any age limit and/or income standard for this classi fieation covered in the Medicaid state plan as of December 31. 2013 or under a ~cdicaid 1115 Demonstration as of March 23. 2010 or December 31. 2013. Higher income standards may include the disregard of all income. (i' Yes ( o Indicate the reasonable classifications of children that were covered in the state plan in eiT'ect a of March 23. 2010 with income standards higher than the mandatory standards used for the child's ngc. using age limits and income standards that are not more restrictive than used in the state plan as of as March 23.2010 and are not less restrictive than used in the Medicaid state plan as of December 31. 2013 or under a Medicaid I 115 Demonstration as of March 23.2010 or December 3 1.2013. Current Coycracc of Reasonable Classifications Covered in the Medicaid State Plan as of March 23 20 !0 Reasonable Classifications of Children 18Jtndividuals for whom public agencie arc assuming full or partial financial responsibility. 18J tndividuals placed in foster care homes by public agencies Indicate the age which applies: (i' Underage21 l' Underage20 ( nderage 19 l' Under age 18 0 Individuals placed in tbster care homes by private. non-profit agencies I8J individuals placed in private institutions by public agencies Indicate the age which applies: (i' Under age 21 l' Under age 20 l' nder age 19 l' Under age 18 0 Individuals placed in pri ate institutions by private, non-profit agencies 0 Individuals in adoptions. ubsidized in full or part by a public agency O Individuals in nursing facilities, if nursing facility services are provided under this plan O Individuals receiving active treatment as inpatients in psychiatric lacilitie or programs. if such services are provided under this plan Approval Date: 3-6-14 Effective Date: Sll 1 - 1-14 - State: Louisiana Page Number : 852 2 of 8

TN: 13 - 49 State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility 0 Other reasonable classifications Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23. 20 I 0 and no higher than the highest standard used in the Medicaid state plan as of December 31. 2013 or under a Medicaid 11 15 Demonstration a of March 23.2010 or December 31.2013. Click here once 511 form above Is complete to view the Income standards form. Individuals placed in foster care homes by public agencies (j) I ncomc standard used (j) Minimum income standard The minimum income standard for this classilication of children is the AFDC payment standard in cncct as of July 16. 1996. not converted to MAGI-equivalent. This standard is described in "14 AFDC Income tandards. (j) Maximum income standard o income test was used (all income was disregarded) for this classillcation either in tht: Medicaid staw plan as of December 31. 2013. or under a Medicaid I 11 5 Demonstration as of March 23. 20 I 0 or December 31. 20 13. I Yes \e o The state certifies that it has submitted and received approval for its converted income standards for this classilication of children to MAGI-equivalent standards and the determination of the 0 maximum income standard to be used lor this classification of children under this eligibility group. An attachm~nt is submitted. The state' maximum income tandard lor this classification of children (\~hich must exceed the minimum tor the clas ification) i : The stole's effective income level for this classification of children under the Medicaid state plan (i" as of March 23, 2010, converted to a MAGI-equivalent percent ofFPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan I as ofDeeember 31.2013, converted to a MAGI-equivalent percent ofFPL or amounts b household size. The state's effective income lc el lor this classification of children under a Medicaid 1115 I Demonstration as of March 23.2010, converted to aM Gl-cquivalcnt percent ofFPL or amounts by household size. I Approval Date: 3 - 6 - 14 Effective Date: 1 - 1 - 14 State : Louisiana Page Number: 852 3 of 8 -

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility The state's effecti\ e income level for this classification of children under a Medicaid Ill- (' Demon tration a of December 31.2013. converted to a MAGI-equivalent percent ofFPL or amounts by household size. Enter ihc amount of the maximum income standard: (' A percentage of the federal poverty level: D % The SUite's AFD payment standard in effect as of July 16. 1996. converted 10 a MAGI- (i equivalent standard. Thi standard is described in S 14 AFDC Income tandards. This option should only be selected for children 19 and older. and only if the state has not elected to cover the Adult Group. The slate's TANF payment standard. converted ton MAGI-equivalent standard. This standard is (' described in 14 AFDC lncomt: Standard~ . This option should only be sel.:ch:d lor children 19 and older, and only if the state has not elected to cover the Adult Group. (' Other dollar amount [!]I nco me standard chosen lndi idual qualify under this classification under the following income standard: (' The minimum standard. (i The maximum income standard. If not chosen as the maximum income stundard. the stat.:'s effective income level for this (' classi lic.:ation under the Medicaid state plan as of March 23. 20 I 0. converted to a MAGI-t:quivulent percent ofFPL or amounts by household size. If not chosen as the maximum income tandard. and if higher than the effecti e income level used (' under the Medicaid ~tale plan as of March 23. 20 I 0. the state's effective income level for this classification under the Medicaid slate plan a. of December 31 , 2013. converted to a MA ,). equivalent percent of I'PL or amounts by household size. If not cho en a~ the maximum income standard. and if higher than the effective income level used (' under the Medicaid stale plan as of March 23. 20 I 0, the state's eiTective income level for this classitication under a Medicaid IllS Demonstration as of March 23.2010, converted to a MAGI- equivalent percent of I'PL or amounts by household size. If not chosen as the maximum income standard. and if higher than the etlcctive income level used (' under the Medicaid state plan as of March 23, 20 I 0. the state's effective income le~el lor this classification under a Medicaid 1115 Demonstration as of December 31. 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. nothcr income standard in-between the minimum and ma imum tandards allowed. provided it is (' higher than the clTcctivc income level for this classilieation in the state plan as of March 23. 20 I 0. eonvetted to a MA II equivalent. Individual placed in private in titutions by public agencies TN : 13 - 49 Appr oval Date : 3-6-14 Effective Date : 1- 1- 1411111111 State: Loui s i ana Page Number : 852 4 of 8

Medicaid Eligibility (!] Income standard used State: Louisiana (!] Minimum income standard The minimum income standard lor this classilication of children is the AFD payment standard in effect as of July 16. 1996. not converted to MAGI-equivalent. This standard is described in Sl4 AFDC Income Standards. (!] Maximum income tandard No income test was used (all income was disregarded) for this classilication either in the Medicaid state plan as of December 31. 2013, or under a Medicaid 1115 Demonstration as of March 23. 20 I 0 or December 3 I. 20 13. ( Yes (i' o The stale certifies that it has submitted and received approval for its converted income standards for thi clas ilication of children to MAGI-equivalent standards and the determination of the [{] maximum income standard to be used for this classification of children under this eligibility group. I An attacbmrnt I ubmltted. I The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level lor this classilication of children under the Medicaid state plan (i' as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts b. household size. The state's effective income level for this classification of children under the Medicaid ·tate plan ( as of December 31 . 2013. converted to a MAGI-equivalent percent ofFPL or amounts by household size. The state's ellective income level for this classilication of children under a Medicaid I I 1- ( Demonstration as of March 23.2010. converted to a MAGI-equivalent percent of'FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 ( Demonstration as of December 31.2013. converted to a MAGI-cquhalent percent ofFPL or amounts by household size. Enter the amount of the maximum income standard: Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN : 13-49 Approval Date: 3-6-14 State: Louisiana Page Number: 852 Effec t ive Date: 1-1-1411111111 5 of 8

TN: 13 - 49 State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility r A percentage of the federal poverty level: D % The state's AFD payment standard in cflcct as of July 16. 1996. converted to a MAGI- (. equivalent standard. This standard is described in S 14 AFDC Income tandards. This option should only be selected tor children 19 and older. and only if the state has not elected to cover the Adult Group. The state's TANF payment standard. converted to a MAGI-equivalent standard. This standard is \ described in 14 AFD Income tandards. This option should only be selected for children 19 and older. and only if the state has not elect.cd to cover the Adult Group. \ Other dollar amount ~ Income standard cho en Individuals qualify under this classification under the following income standard: I The minimum standard. (i' The maximum income standard. If not chosen as the maximum income standard. the state's efl"ective income level for this \ classification under the Mcdicuid stale plan as of March 23. 2010. converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard. nnd if higher than the dTective income level used \ under the Medicaid state plan as of March 23, 20 I 0, the state' etlcctive income level for this classification under the Medicaid state plan as of December 31. 2013, converted to a MAGI- equi\'alent percent ofFPL or amounts by household size. If not chosen as the maximum income standard. nnd if higher than the efli:ctive income h:vel used (' under the Medicaid state plan as of March 23, 20 I 0. the state's eflcctivc income level lor this classification under a Medicaid 1115 Demonstmtion as of March 23.2010. converted to a MAGI- equivalent percent of FPL or amounts by household size. If not cho en as the maximum income standard. and if higher than the effective income level used I under the Medicaid ;1atc plan as of March 23.2010, the state's efl"cctive income le el for this classilicat.ion under a Medicaid 1115 Demonstration as of December 3 1. 2013, converted to a MAGI- equi\'alent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed. provided it is (' higher than the effective income level for this classification in the stale plan as of March 23. 20 I 0. converted to a MAGI equivalent. Other Reasonable Classi l;,.otinn< Pr<•vin .. <lv f'nvN<>fl The state covers reasonable classifications of children lll!l. covered in the Medicaid tate plan as of March 23, 2010, but co ered under the Medicaid state plan as of December 31, 2013 or under a Medicaid I 115 Demonstration as of March 23, 20 I 0 or December 3 1. 2013 with an income standard higher than the current mandatory income standard for the age group. (e Yes \ No Approval Date : 3-6-14 Effective Date: 1-1-14 State: Louisiana Page Number : 852 6 of 8

TN : 13- 4 9 State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility The additional previously covered reasonable classifications to be included arc: Addilioniill Pn;viQysly CQVS:fl:d B i:II~Q n i!llhl C:lll~~ifi~:llliQD~ )D!;IYI.!i:d Reasonable Classifications of Children 0 Individuals for whom public agencies are assuming full or partial financial responsibility. 0 Individuals in adoptions subsidiLed in full or part by a public agency 0 Individuals in nursing facilities. if nursing facility services are pro ided under this plan O Individuals receiving active treatment as inpatients in psychiatric facilities or progrdms. if such ser ices are provided under this plan ~ Other reasonable classifications Name of classification Description Age Limit + Pregnant teens Pregnant teens I Under age 19 Sll I X Enter the income standard used lo r these classifications (which must be higher than the mandatory standard for the chi I d's age but may be no higher than the highe L standard used in the tate plan as of December 31. 20 13 or under a Medicaid 1115 Demonstration as of March 23, 20 I 0 or December 31. 2013 ). Click here once 511 form above is complete to view the income standards form. Pregnant teens [!) Income standard used [!) Minimum income standard The minimum income standard for this classitication of children must exceed the lowest income standard cho.cn for children under this age under the Infants and hildren under Age 19 eligibility group. [i] Maximum income standard No income test \\as used (all income was disregarded) for this classilication either in the Medicaid state plan as of December 31. 2013. or under a Medicaid 1115 Demonstration as of March 23. 20 I 0 or December 3 1. 2013. (i Yes r 0 [!) No income test was used (all income was disregarded) for this classification under: (check all that apply) 0 The Medicaid state plan as of March 23, 2010. ~ The Medicaid tate plan as ofOeccmber 31,2013. 0 A Medicaid 1115 Demonstration as of March 23. 20 I 0. I - Approval Date: 3 -6 - 14 Effective Date: 1-1-14 State : Louisiana Page Number: 852 7 of 8

Medicaid Eligibility 0 A Medicaid IllS Demonstration as of December 31. 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). ~ Income standard chosen Individuals qualify under thi classilication under the lbllo\.\ing income standard: le This classilication docs not usc an income test (all income is disregarded). (' Another income standard higher than both the minimum income standard and the etTective income level for this classification in the slate plan as of March 23, 2010. converted to a MAGI equivalent. Additional new a~e aroups or reasonable classifications covered If the state hasJlQl elected to cover the Adult Group (42 FR 435.119). it may elect to cover additional new age groups or reasonable classificutions that have not been covered pn:viousl •. lfthe state covers the Adult Group. this additional option is not available. a the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state docs IlQ1 cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classitications that ha"c not been co cred previously in the state plan or under a Medicaid 1115 DemonsLrntion. Any additionHl age groups or reasonable clnssitications not previously covered are restricted to !h.: AFDC income standard from July II\. 1996, not converted to a MA rl-cquivalent standard. (' Yes 1e No ~ There is no resource tc t for this eligibility group. PRA Di closure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of inlorrnation unless it displa) sa valid OMB control number. The valid OMB control number tor this information collection is 0938-1148. The time required to complete this inlormution collection is estimated to avemge 40 hours per response. including the time to review instructions, search existing data resources. gather the data necJed, and complete and review the information collection. If you have comments concerning the accumcy or the time cstimatc(s) or uggestions for improving this form. please write to: CMS. 7500 ccurity Boulevard, Attn: PRA Rcpons lcarancc Ofliccr. Mail Stop C4-26-05. Baltimore. Mal)• land 21244-1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN: 13 - 49 Approval Date: 3 - 6 - 14 Effective Date: 1-1-14 State: Louisiana Page Number: 852 8 of 8

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility OMR ontrol umber 0\138-1141! OMI3 Expiration date· 10/3 112014 Eligibility Group -Option for Coverage Children with Non IV-E Adoption Assistance 42 CFR 435.227 1902(a)(l0)( )(ii)(VIII) C hildren with Non IV-E Adoption Assistance- The state elects to cover children with sp<Jeial ne.:ds lor whom there is a non lY-E adoption assistance agr.:ement in efrect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. (i" Yes (' No IZJ The state attests that it operates this eligibility group in accordance with the following provisions: 00 Individuals qualifying under this eligibility group must meet the following criteria: OO The state adoption agency has determined that they cannot be placed\ ithoui Medicaid coverage because of special • needs for medical or rehabilitative care; 00 Are under the following age (sec the Guidance for restrictions on the selection of an age): r nderage 21 (' Under age 20 r Under age 19 Ia nder age 18 OO MAGI-based income methodologies are used in calculating household income. Please refer as necessarY to SIO MAGI- Based Income Methodologies. completed by the state. The state covered this eligibility group in the Medicaid state plan as of December 3 1. 20 I J. or under a Medicaid 1115 Demonstration as of March 23, 2010 or Occcmbcr 31. 2013. (i" Yes (' o The state also covered this eligibility group in the Medicaid state plan as of March 23.2010. (i" Yes (' No OO lndi iduals qualify under this eligibility group if they were eligible under the state's appro cd state plan prior tn • the execution of the adoption agreement. 53 The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 20 I 0 or December 3 1, 2013. or under a l!cdicaid I 115 Demonstration as of March 23, 20 I 0 or December 3 1. 2013. (' Yes (i" o @ There is no resource test for this eligibility group. PRA Disclosure Statement According to the Papt:rwork Reduction Act of 1995. no persons are required to respond to a collection of intonnation unless it displa) sa valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this infonnation collection is estimated to average 40 hours per n:sponsc, including the time to review instructions. search existing data resources. gather the data needed. and complete and review the infom1ation collection. If you have comments concerning the accu;.Jcy of the time estimate(s) or suggestions for improving this form, please write to: CM . 7500 Security Boulevard. Attn: PRA ReportS Cleamnce Officer. Mail Stop 4-26-05. Baltimore. Maryland 2 1244-1850. - TN: 13-49 Approval Date: 3 - 6 - 14 Effective Date: 1-1-14 State : Louisiana Page Number: 853 1 of 1

Medicaid Eligibility OMB ontrol Number 0938-1 148 OM13 Expiration date· I 0/3112014 Eligibility Groups- Options for Coverage Optional Tar£efed Low Income Children 1902(u)( IO)(A)(ii)(XI V) 42 CFR 435.229 and 435.4 1905(u)(2)(B) S54 Optional Targeted Low Income hildren - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 FR 435.4. who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. (i Yes (' No 0 The state atte ts that it operates this eligibility group in accordance with the following pro isions: [!] Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. [!] MAGI-based income methodologies are used in calculating household income. Please refer as necessary to 10 MAGI- Based Income Methodologies, completed hy the state. The state covered this eligibility group in the state plan as of December 31. 2013. or under a Medicaid 1115 Demonstration :tS of March 23.2010 or December 31.2013. (e Yes (' o The state also covered this eligibility group in the state plan as of March 23. 2010. (i Yes (' No Until October I. 2019, states must include at least those individuals covered as of March 23, 2010, but ma co,cr [!] additional individuals. Effective October I, 2019. states may reduce or cl iminate co erage for this group. [!] Individuals are co ered under this eligibility group, as follows: (e All children under age 18 or 19 arc covered: (i Under age 19 (' nder age 18 (' The reasonable classification of children covered is: [!] Income standard used for this classilication [!] Minimum income standard The income standard for this classification of children must exceed the lowest income standard chosen for children in the age group selected above. under the mandatory Infants and Children under Age 19 eligibility group. [!] Maximum income standard State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN : 13-49 Approval Date : 3-6-14 Effective Date: 1- 1- 14 State: Louisiana Page Number : 854 1 of 3 -

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility The sUite ccrtilics that it has submitted and received approval tor its converted income . tandard(s) tor this 0 classification of children to MAGI-equivalent swndards and the determination of the maximum income standard to be used for this classification of children undcr this eligibility group. An atta~hment il ubmltted. The sUite's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: (i The state's em:ctive income level lor this cl.assitication ofch.il~ren under the Medicaid state plan as of March 23. 20 I 0. converted to a MAGI-equtvalcnt percent of F PL. r The state's eflective income level for this classification of children under the edicaid tme Plan as of December 3 I. 2013. converted to a MAGI-equivalent percent ofFPL. r The state's cflectivc income level for this classification of children under a Medicaid 1115 d.:monstration as of March 23.2010. converted to a MA !-equivalent percent ofF PL. r The state's effective income level for this classification of children under a Medicaid 1115 demonstration a..~ of Dc.:ccmbcr 31. 2013. converted to a MAGI-equivalent percent of FPL. r 200% FPL. r A percentage ofthc FPL which may exceed the Medicaid Applicable Income Levd. dt:fineu in section 2 110(b)(4) of the Act. hut by no more than 50 percentage points. ~ ll1e statt!'s maximum income tandard for this classification of children (which must exceed the • minimum for the classification) is: ~%FPL ~ Income standard chosen. which must exceed the minimum income standard Individuals qualify under the lolfowing income standard: (i The ma.~imum income standard. r The state's cffecti\ e income lc el for this eligibility group under the Medicaid tate plan as of March 2J. 2010. convened to a MAGI-equivalent percent ofFPL. If higher than the eflective income level used under the state plan as of March 23, 2010, the state's elledive r income le,·cl lor this eligihility group under the Medicaid state plan a..s of December 31. 20 I 3, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23. 2010. the state's effccth·e r income level for this eligibility group under a Medicaid Ill S demonstration as of March 23. 20 I 0. converted to a MAGI-ec1uivalent percent ofFPL. If higher than the etTective income level used under the state plan as of March 23. 2010.thc state's etTcctive r income le' d for this elig.ibility group under a Medicaid 1115 demonstration as of D.:c.:mber 31. 20 13. converted to a MAGI-equivalent percent ofFPL. r If higher than the elTective income level used under the state plan as of March 23.2010, 200% FPL. TN: 13 - 49 Approval Date : 3 - 6- 14 Effective Date: 1 - 1 - 14 State: Louisiana Page 854 2 of 3

TN: Medicaid Eligibility If higher than the ell'ective income level used under the state plan as of March 23.2010. a perco:ntage of the \ FPL which may exceed the Medicaid Applicable Income Level. defined in section 2110(b)(4) of the Ac.:l. but by no more than 50 percentage points. (' Another income standard in-between the minimum and maximum standards allow<.'<!. provided it is higher than the eiTectivc income level for this eligibility group in the state plan as of March 23.2010. The income standard for this eligibility group is: ~ % FPL ~ There is no resource test for this eligibility group. ~ Presumptive Eligibility Prcsumpti e eligibility tor this group depends upon the selection of presumptive eligibility lor the Infants and Children ~ under Age 19 eligibility group. If presumptive eligibility is done lor that group. it is done lor this group under the same provision . PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of inlormation unless it displays a v<diJ OMB control number. The valid OMB control number lor this information collection is 0938-1148. The time r<-quired to complete this intormati n collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources. gather the data needed, and complete and re iew the information collection. I f you have comments concerning the accuracy of the time estimatc(s) or suggestions for improving this form, please write to: MS, 7500 Security Boulevard. A !In: PRA Reports Clearance Ollicer. Mail top C4-26-05. Baltimore, Maryland 21244-1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 13 - 49 Approval Date: 3- 6-14 Effective Date: 1-1-14 State: Louisiana Page Number 854 3 of 3 -

Medicaid Eligibility OMB ontrol Number 0938-1 14!! OM13 Expiration date· 10/3112014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis 1902(a)( IOl(Al(ii)(XII) J902(L) S55 Individuals with Tuberculosis- The state elects to cover individuals infected with tuberculosis who have income at or below a standard establi ·hed by the state. limited to tuberculosis-related services. (i Yes (' No IZJ The stale attests that it operates this .:ligibility group in a~cordance with the lollowing provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ rc infected wiU1 tuberculosis. ~ Are not otherwise eligible tor mandatory coverage under the Medicaid state plan. ~ I lave household income under a standard established by the stale. ~ MAGI-based income methodologies are u ed in calculating household income. Please refer as necessary to S I 0 MAGI- Based Income Methodologies. completed by the stale. ~ Income standard used for this group ~ Maximum income standard First indicate the maximum income standard that ~ used for this group and then indicate the income standard the state uses fbr the group. The state clccL~ to convert the effective income level for eo ernge of this eligibility group in effect in the Medicaid state plan as of March 23. 2010 and December 3 1. 2013 to MA .!-equivalent standards. (' Yes (i o The state's maximum in com~! standard lor this eligibility group is: (i The break-even point lor earned income under the I program. (' The ctfective income level for this eligibility group under the Medicaid state plan in elTcct as of March 23.2010, not converted to a MAGI-equivalent standard. (' The ellcctive income level for this eligibility group under the Medicaid state plan in effect as of December J I. 2013. not ~:onverted to a MAGI-equivalent standard. ~ Income standard chosen The state's income standard used lor this eligibility group i : (' The maximum income standard. (' 1 f not chosen as the maximum income standard, the break-even point lor earned income under the I program. (i AnoU1er income standard less than the maximwn standard allowed. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN: 13-49 Approval Date: 3 - 6 - 14 State : Louisiana Page Number : 855 1 of 2 - Effe c t i ve Da t e : 1- 1 - 14

Medicaid Eligibility The amount of the income slllndard is: r. A percentage of the federal poverty level: ~% (" A dollar amount [!] Individuals qualifying under this group are eligible only lor the following services, provided the service is rdated to the diagnosis. treatment or management of the indi idual's tuberculosis. [!] Prescribed drugs, described in 42 CFR 440.120 [!] Physician services. described in 42 CFR 440.50 [!] Outpatient hospital and rural health clinic described in 42 CFR 440.20 and Federally-quulilied health center services [!] Laboratory and x-ray services (including services to conlirm the presence ofthc infection). described in 42 CFR 440.30 [!] linic ser ices, described in 42 FR 440.90 [!] ase management services defined in 42 CFR 440.169 [!] . ervices other than room and board designed to encourage completion of regimens of prescribed drugs by out-patienl~ . including services to observe directly the intake of prescription drugs. [!] Limillltions related to tuberculosis-related ervices may be found in the Benefits section. According to the Paperwork Reduction Act of 1995, no persons are required 10 respond to a ollection of information unless it displa> s a valid OMB control number. The valid OMR control number for this information collection is 09 8-11 48. The time required to complete this inti>Jmation collection is estimated 10 average 40 hours per response. including the time to review instructions. search existing data resources. gather the data needed. and complett: and review tht: inli>rmation collt:ction. I fyou have comments concerning the accura ·y of the time estimatc(s) or suggestions for improving this form. please write to: MS. 7500 ecurity Boulevard. Aun: PRA Repons lea ranee Omcer. Mail Stop C4-26-05. Baltimore. Maryland 21244-1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN: 13-49 Approval Date : 3-6-14 Effective Date : 1- 1 -14 State: Louisiana Page Number : 855 2 of 2 -

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 Medicaid Eligibility OMB ontrol Numbcr0938-1148 OMB Expiration date· 10/31 120 1-1 Eligibility Groups- Option for Coverage Independent Foster Care Adolescents 42 CFR 435.226 1902(a)( IO)(A)(ii)(XVII) Independent Foster Care Adolestents- The state elects to cover individuals under an age specified by the state. less than age 21. who were in state-sponsored fo ter care on their 18th binhday and who meet the income standard c tablishcd by the state and in accordance with the provisions described at 42 FR 435.226. (i Yes I No 0 The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are under the following age (i ndcr age 21 I ndcrage20 I nder age 19 ~ Were in foster curl! under the responsibility of a state on their 18th binhday. ~ Arc not eligible and enrolled lor mandatory coverage under the Medicaid state plan. ~ Ha e household income at or below a standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please refer a necessary to S 10 MAGI- Based Income Methodologies. completed by the state. The state covered thi eligibility group under its Medicaid state plan as of December 31.2013. or under a Medicaid Ill" demonstration as of March 23, 20 I 0 or December 31. 2013. (i Yes I o The state also CO\ cred this eligibility group in the Medicaid state plan as of March 23. 20 I 0. (i Yes I o The state co crs children under this eligibility group. as follows ( election may nm be more restrictive than the ~ c_overage in the r:'edicaid s~te. plan as of March 23.20 10 until October I, 2019. nor ~1o:e liberJithan the ~ost liberal coverage 10 the Medtcatd state plan a of December 31.2013. or under a Medtcatd IllS demonstration as of March 23. 2010 or December 31. 2013 ): (i All children under the age sel.:ctcd I A reasonable classification of children under the age selected: ~ Income standard used for this eligibility group ~ Minimum income standard The minimum income standard for this classification of children is the AFDC payment standard in o.:ffttt as of Jul) 16. 1996. not convetted to MAGI-equivalent. This standard is described inS 14 FD Income Standard~ . S57 TN : 13-49 Approval Date: 3 -6-14 Effective Date: 1-1-14 State: Louisiana Page Number: S57 1 of 2 -

TN: Medicaid Eligibility l!J Maximum income standard No income test \\aS used (all income was disregarded) lor this eligibilit. group either in the Medicaid state plan as of March 23.2010 or December 31. 2013. or under a Medicaid 1115 Demonstration a~ of March 23. 2010 or Deccmher 3 1. 2013. (i' Yes (' o l!J No income test was used (all income was disregarded) for this eligibility group under (check all that apply): 181 The Medicaid state plan as of March 23. 2010. 181 The Medicaid state plan as of Decemher 31, 2013. 0 A Medicaid 1115 demonstration as of March 23. 2010. 0 A Medicaid 11 15 demonstration as of December 31.2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). ~ Income standard chosen lndi iduals qual if)' under this eligibility group under lhe following income standaru: This cligibilit. group does not usc an income test (all income is disregarded). ~ There is no resource test for this eligibilit. group. PRA Disclosure Statement According to the Paperwork Reduction Act of I 995, no persons are required to respond to a collection of infonnation unless it displays a valid OMB control number. The valid OMI:l control number for this information collection is 0938-1148. The time required to compktt: this information collection is estimnted to average 40 hours per re ponse. including the time to review instructions. search existing data resources. gather the data needed. and complete and review the intonnation collection. I fyou have comments concerning the accuracy of the time estimate(s) or suggestions for impro ing this form. please \ rite to: M . 7500 ecurity Boulevard, Attn: PRA Reports learance Officer. Mail Stop C4-26-05. Aaltimorc. Maryland 21244-IRSO. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 13-49 Approval Date: 3-6-14 Effective Date: 1-1-14 State: Louisiana Page Numbe r: 857 2 of 2 -

Medicaid Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services 1902(11)( IO)(Al(ii)(XXI) 42 CFR 435.214 OMR ontrol umber 09"8-1141! OMB Expiration date: 10/31/2014 S59 Individual Eligible for Family Planning ervice - The state elects to cover individuals who are not pregnant. and have household income at or below a standard established by the state. whose coverage is limited to family planning and related services and in accordance with provisions dl!scribed at 42 FR 435.214. (' Yes (i' No According to the Paperwork Reduction Act of 1995. no persons arc required to respond to a collection ofinfonnation unless it displays a valid OMB control number. ·nte ~alid OMB control number for this information collection is 0938-1 148. The time required to compleu: this intonnation collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources. gather the data needed. and complete and review the infomtation collection. If you ha've comment~ concerning the accuracy of the time cstimatc(s) or suggestions for improving this form, please write to: M . 7500 Security Boulevard. Ann: PRA Reports Clearance Offic.:r. lui! Stop C4-26-05. Baltimore. Mm)•land 21244-1850. State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-49 TN: 13 - 49 Approval Date: 3 - 6 - 14 Effective Date : 1 - 1-14 State : Louis iana Page Number: 859 1 of 1 -

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 13-50 MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

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

Dallas Regional Office

1301 Young Street, Suite 833

Dallas, TX 75202

CMS

(CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 13, 2014

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4" Street

Post Office Box 91030

Baton Rouge, LA 70821-9030

Attn: Darlene Adams Jodie Hebert

RE: S-94 — Eligibility Process State Plan Amendment (SPA), LA-13-0050-MM2

Dear Ms. Kennedy:

Enclosed is an approved copy of Louisiana’s state plan amendment (SPA) LA-13-0050-MM2, which was submitted to CMS on December 27, 2013. SPA LA-13-0050-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Louisiana’s Medicaid state plan in accordance with the Affordable Care Act.

The effective date of this SPA is October 1, 2013.

The approval of SPA LA-13-0050-MM2 includes full approval of your state’s model single streamlined paper and online applications.

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

e $94, pages $94-1 and $94-2 ¢ Attachment | — State of Louisiana’s single streamlined paper application

e Attachment 2 — State of Louisiana’s single streamlined online application

In addition, enclosed is a summary of state plan pages which are superseded by LA-13-0050- MM2, which should also be incorporated into a separate section in the front of the state plan.

e Superseding Pages of State Plan Material, LA-13-0050-MM2

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan

Page 2 — LA-13-0050-MM2

amendment. If you have any questions concerning this SPA, please contact Ford Blunt at Ford.Blunt@cms.hhs.gov or (214) 767-6381.

Sincerely,

Bill Brooks Associate Regional Administrator

Enclosure

Ce:

LA Redacted SPAs Page 2

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

LA-13-0050-MM2 STATE:

Louisiana

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 – Eligibility Process

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

Section 2.1 Page 11a (Same as TN 91-21)

TN: LA 13-50

Approved: 3-14-14 Effective: 10-1-13 Supersedes None: Page 1 or 1 State: Louisiana Date Received: 12-27-13 Date Approved: 3-14-14 Date Effective: 10-1-13 Transmittal Number: 13-50 MM2

TN: LA 13-50 Approved: 3/13/14 Effective: 10/1/13 Supersedes None: S94 page 1 of 2 State: Louisiana Date Approved: 3/13/14 Date Received: 12/27/13 Date Effective: 10/1/13 TN: LA 13-50

TN: LA 13-50 Approved: 3/13/14 Effective: Supersedes None: S94 page 2 of 2 State: Louisiana Date Approved: 3/13/14 Date Received: 12/27/13 Date Effective: 10/1/13 TN: LA 13-50

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 13-51 MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office « &

1301 Young Street, Suite 833 CENTERS FOR MEDICARE & MEDICAID SERVICES

Dallas, Texas 75202 aamnasniiia bee Meanie & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

March 26, 2014 Our Reference: SPA LA 13-0051-MM3

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4" Street

Post Office Box 91030

Baton Rouge, LA 70821-9030

Attn: Darlene Adams Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 13-0051-MM3. This Modified Adjusted Gross Income (MAGI) state plan designates the income options Louisiana is electing for 2014 in accordance with the Affordable Care Act (ACA) and federal regulations. This state plan amendment is in the new Medicaid Model Data Lab (MMDL) format.

Transmittal Number 13-0051-MM3 is approved with an effective date of January 1, 2014 as requested. A copy of the HCFA-179, Transmittal No. 13-0051-MM3 dated December 27, 2013 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks Associate Regional Administrator

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Ts name:

Louisiana Transmi

Please en

ritory

Number:

A-13-0051

Proposed Effective Date

01/01/2014 (mm/da.

he 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.

Federal Statute/Regulation Citation | 1902(c)14, 42 CFR 435.603 Federal Budget Impact Federal Fiscal Year Amount

Subject of Amendment

This SPA submission designates the income options the state elects in 2014 to incorporate the MAGI Income Standards.

Governor's Office Review

O Governor's office reported no comment

O Comments of Governor's office received

Describe

O No reply received within 45 days of submittal © Other, as specified

Signa

D:

Describe

The Governor's office does not review State Plan material.

¢ of State Agency Official State: Submitted By: arlene Adams Last Revision Date: Mar 10, 2014

Submit Date:

Dec 27, 2013

Printed Name: BILL BROOKS Title: Associate Regional Administrator,

Louisiana

Date Received: 27 Dec, 2013 Date Approved: 26 Mar, 2014 Date Effective: 1 Jan, 2014 Transmittal Number: 13-51 MM3

Div of Medicaid & Children's Health

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

LA-13-0051-MM3 STATE:

Louisiana

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

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

Notwithstanding any other provisions of the Louisiana Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment LA-13-0051-MM3 will apply to all MAGI-based eligibility groups covered under Louisiana’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

State: Louisiana Date Received: 27 December, 2013 Date Approved: 26 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: 13-51 MM3

State: Louisiana Date Received: 27 December, 2013 Date Approved: 26 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: 13-51 MM3 TN: LA 13-51 MM3 Approved: 3/26/14

Effective: 1/1/14 Supersedes TN: None

State: Louisiana Date Received: 27 December, 2013 Date Approved: 26 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: 13-51 MM3 TN: LA 13-51 MM3 Approved: 3/26/14 Effective: 1/1/14 Supersedes TN: None

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: LA 13-53 MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

LA Redacted SPAs Page 2

LA Redacted SPAs Page 2

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-53 MM5 TN: 13-53 Approval Date: 3-6-14

Effective Date: 1-1-14 State: Louisiana Page Number: S88 1 of 4

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-53 MM5 TN: 13-53 Approval Date: 3-6-14

Effective Date: 1-1-14 State: Louisiana Page Number S88 2 of 4

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-53 MM5 TN: 13-53 Approval Date: 3-6-14

Effective Date: 1-1-14 State: Louisiana Page Number S88 3 of 4

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 1 January, 2014 Transmittal Number: LA 13-53 MM5 TN: 13-53 Approval Date: 3-6-14

Effective Date: 1-1-14 State: Louisiana Page Number: S88 4 of 4

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: LA 13-54 MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: LA 13-54 MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office « &

1301 Young Street, Suite 833 CENTERS FOR MEDICARE & MEDICAID SERVICES

Dallas, Texas 75202 aamnasniiia bee Meanie & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

March 6, 2014 Our Reference: SPA LA 13-0054-MM6

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4" Street

Post Office Box 91030

Baton Rouge, LA 70821-9030

Attn: Darlene Adams Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 13-0054-MM6. This MAGI state plan submitted in the Medicaid Model Data Lab (MMDL) affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance with the Patient Protection and Affordable Care Act (PPACA).

Transmittal Number 13-0054-MM6 is approved with an effective date of December 31, 2013 as requested. A copy from the MMDL of the HCFA-179, Transmittal No. 13-0054-MM6 dated December 27, 2013 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks Associate Regional Administrator

Enclosures

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office « &

1301 Young Street, Suite 833 CENTERS FOR MEDICARE & MEDICAID SERVICES

Dallas, Texas 75202 aamnasniiia bee Meanie & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

March 6, 2014 Our Reference: SPA LA 13-0054-MM6

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4" Street

Post Office Box 91030

Baton Rouge, LA 70821-9030

Attn: Darlene Adams Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 13-0054-MM6. This MAGI state plan submitted in the Medicaid Model Data Lab (MMDL) affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance with the Patient Protection and Affordable Care Act (PPACA).

Transmittal Number 13-0054-MM6 is approved with an effective date of December 31, 2013 as requested. A copy from the MMDL of the HCFA-179, Transmittal No. 13-0054-MM6 dated December 27, 2013 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks Associate Regional Administrator

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Ts name:

ritory

Louisiana Transmittal N Please en

mber: he 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-13-0054

Proposed Effective Date

12/31/2013 (mm/dd.

Federal Statute/Regulation C

ion

| 1902(a)(46)(B), 8 U.S.C. 1611-1613 and 1641, 1903(v)(2), (3) and (4), 42 CFR 435.4, 42 CFR 435.406, 42 CFR 435.956

Federal Budget Impact

Federal Fiscal Year Amount First Year $] 0.00 Second Year $] 0.00

Subject of Amendment

This SPA affirms the State's citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility

Governor's Office Review O Governor's office reported no comment O Comments of Governor's office received Describe

O No reply received within 45 days of submittal © Other, as specified Describe

The Governor's office does not review State Plan material.

re of State Agency Official Date Received: 27 December, 2013 Submitted By:

Roberta Diaz Date Approved: 6 March, 2014 Last Revision Date: Date Effective: 31 December, 2013

Jan 31, 2014 Transmittal Number: LA 13-54 MM6 Submit Date:

Dec 27, 2013

Printed Name and Title: Bill Brooks, Associate Regional Administrator Division of Medicaid & Children's Health

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Ts name:

ritory

Louisiana Transmittal N Please en

mber: he 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-13-0054

Proposed Effective Date

12/31/2013 (mm/dd.

Federal Statute/Regulation C

ion

| 1902(a)(46)(B), 8 U.S.C. 1611-1613 and 1641, 1903(v)(2), (3) and (4), 42 CFR 435.4, 42 CFR 435.406, 42 CFR 435.956

Federal Budget Impact

Federal Fiscal Year Amount First Year $] 0.00 Second Year $] 0.00

Subject of Amendment

This SPA affirms the State's citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility

Governor's Office Review O Governor's office reported no comment O Comments of Governor's office received Describe

O No reply received within 45 days of submittal © Other, as specified Describe

The Governor's office does not review State Plan material.

re of State Agency Official Date Received: 27 December, 2013 Submitted By:

Roberta Diaz Date Approved: 6 March, 2014 Last Revision Date: Date Effective: 31 December, 2013

Jan 31, 2014 Transmittal Number: LA 13-54 MM6 Submit Date:

Dec 27, 2013

Printed Name and Title: Bill Brooks, Associate Regional Administrator Division of Medicaid & Children's Health

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 31 December, 2013 Transmittal Number: LA 13-54 TN: LA 13-54 Approval Date: 3/6/14 Effective Date: 12/31/13 State: Louisiana Page Number: S89 1 of 3

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 31 December, 2013 Transmittal Number: LA 13-54 TN: LA 13-54 Approval Date: 3/6/14 Effective Date: 12/31/13 State: Louisiana Page Number: S89 1 of 3

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 31 December, 2013 Transmittal Number: LA 13-54 TN: LA 13-54 Approval Date: 3/6/14 Effective Date: 12/31/13 State: Louisiana Page Number: S89 1 of 3

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 31 December, 2013 Transmittal Number: LA 13-54 TN: LA 13-54 Approval Date: 3/6/14 Effective Date: 12/31/13 State: Louisiana Page Number: S89 1 of 3

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 31 December, 2013 Transmittal Number: LA 13-54 TN: LA 13-54 Approval Date: 3/6/14 Effective Date: 12/31/13 State: Louisiana Page Number: S89 1 of 3

State: Louisiana Date Received: 27 December, 2013 Date Approved: 6 March, 2014 Date Effective: 31 December, 2013 Transmittal Number: LA 13-54 TN: LA 13-54 Approval Date: 3/6/14 Effective Date: 12/31/13 State: Louisiana Page Number: S89 1 of 3

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 13-55 MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office « &

1301 Young Street, Suite 833 CENTERS FOR MEDICARE & MEDICAID SERVICES

Dallas, Texas 75202 aamnasniiia bee Meanie & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

March 13, 2014 Our Reference: SPA LA 13-0055-MM7

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4" Street

Post Office Box 91030

Baton Rouge, LA 70821-9030

Attn: Darlene Adams Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 13-0055-MM7. This MAGI state plan submitted in the Medicaid Model Data Lab (MMDL) specifies options for presumptive eligibility conducted by hospitals according to the Patient Protection and Affordable Care Act (PPACA) and 42 Code of Federal Regulations (CFR) 435.1110.

Transmittal Number 13-0055-MM7 is approved with an effective date of January 1, 2014 as requested. A copy from the MMDL of the HCFA-179, Transmittal No. 13-0055-MM7 dated December 27, 2013 is enclosed along with the approved plan pages in MMDL format.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks Associate Regional Administrator

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Ts name:

ritory

Louisiana

smi Number: Please en he 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-13-0055

Proposed Effective Date

01/01/2014 (mm/da.

Federal Statute/Regulation C

ion

[42 CFR 435.1110

Federal Budget Impact Federal Fiscal Year Amount

$] 0.00

First Year

Second Year

Subject of Amendment

This SPA adopts provisions to allow the State to provide Medicaid coverage for individuals who have been determined by qualified hospitals to meet presumptive eligibility criteria,

Governor's Office Review O Governor's office reported no comment O Comments of Governor's office received

Describe

O No reply received within 45 days of submittal © Other, as specified Describe

The Governor's Office does not review SPAs.

Signa State: Louisiana

¢ of State Agency Official

Submitted By: Darlene Adams Last Revision Date: Mar 18, 2014 Submit Date:

Date Received: 12-27-13 Date Approved: 3-13-14 Date Effective: 1-1-14

Transmittal Number: 13-55-MM7 Dec 27, 2013

Printed Name: BILL BROOKS Title: Associate Regional Administrator; Div of Medicaid & Children's Health

State: Louisiana Date Received: 12-27-13 Date Approved: 3-13-14 Date Effective; 1-1-14 Transmittal Number: 13-55-MM7 TN: 13-55 -MM7 Approved: 3/13/14 Effective: 1/1/14 Supersedes: None Page 1 of 3

State: Louisiana Date Received: 12-27-13 Date Approved: 3-13-14 Date Effective; 1-1-14 Transmittal Number: 13-55-MM7 TN: 13-55 -MM7 Approved: 3/13/14 Effective: 1/1/14 Supersedes: None Page 2 of 3

State: Louisiana Date Received: 12-27-13 Date Approved: 3-13-14 Date Effective; 1-1-14 Transmittal Number: 13-55-MM7 TN: 13-55-MM7 Approved: 3/13/14 Effective: 1/1/14 Supersedes: None Page 3 of 3

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 13-56 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

LA Redacted SPAs Page 2

LA Redacted SPAs Page 2

Revision: HCFA-PM-91-4 (BPD) SUPPLEMENT 1 to ATTACHMENT 2.2-A

AUGUST 1991 Page 1

OMB No.: 0938-

TN# _______________ Approval Date _______________Effective Date _______________ Supersedes TN# _______________

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: ___LOUISIANA___ REASONABLE CLASSIFICATION OF INDIVIDUALS UNDER THE AGE OF 21, 20, 19 AND 18

42 CFR 435.222

Pregnant women under age 19. 13-56 91-23 2/12/14 12/31/13 State: Louisiana Date Received: 12/27/13 Date Approved: 2/12/14 Date Effective: 12/31/13 Transmittal Number: LA 13-56

TN# _______________ Approval Date _______________ Effective Date _______________ Supersedes TN# _________________

Revision: HCFA-PM-91-4 (BPD) SUPPLEMENT 8a to ATTACHMENT 2.6-A

AUGUST 1991 Page 2

OMB No.: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: ___LOUISIANA___ MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902 (r) (2) OF THE ACT*

Section 1902 (f) State

Non-Section 1902 (f) State

All income is disregarded for the reasonable classification under 42 CFR 435.222 of pregnant women under the age of 19, as defined on Supplement 1 to Attachment 2.2-A Page 1. State: Louisiana Date Received: 12/27/13 Date Approved: 2/12/14 Date Effective: 12/31/13 Transmittal Number: LA 13-56 13-56 2/12/14 12/31/13 New Page

State: Louisiana Date Received: 12/27/13 Date Approved: 2/12/14 Date Effective: 12/31/13 Transmittal Number: LA 13-56 13-56 91-23 2/12/14 12/31/13

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 14-10 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

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

CENTERS FOR MEDICARE & MEDICAID SERVICES

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

JUN 30 2014

Ms. Ruth Kennedy, Director

Bureau of Health Services Financing Department of Health and Hospitals Post Office Box 91030

Baton Rouge, Louisiana 70821-9030

RE: Louisiana 14-10 Dear Ms. Kennedy:

We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 14-10. This amendment increases the allowable cost of the provider tax that can be recognized for reimbursement purposes from $14.30 to $16.15 per day, for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID).

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. As part of the review process the State was asked to provide information regarding funding of the State share of expenditures under Attachment 4.19-D.

Based upon your assurances, Medicaid State plan amendment 14-10 is approved effective April 1, 2014. We are enclosing the HCFA-179 and the new plan page.

If you have any questions, please call Tamara Sampson at (214) 767-6431.

indy Mann Director

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: 2. STATE

14-10 Louisiana

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

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

4. PROPOSED EFFECTIVE DATE April 1, 2014

5. TYPE OF PLAN MATERIAL (Check One): (NEW STATE PLAN

[-] AMENDMENT TO BE CONSIDERED AS NEW PLAN

{@] AMENDMENT |

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR Part 447 Subpart F

7. FEDERAL BUDGET IMPACT:

FFY 2014, $660.60 FFY _2015_ $1,349.47

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-D, Page 15

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ff Applicable): Same (TN 06-26)

10. SUBJECT OF AMENDMENT: The SPA proposes to revise the reimbursement methodology for intermediate

care facilities for persons with intellectual disabilities ((CFs/ID) by increasing the provider fee to $16.15 per

day.

11. GOVERNOR’S REVIEW (Check One):

(1 GOVERNOR’S OFFICE REPORTED NO COMMENT

COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

f& OTHER, AS SPECIFIED: The Governor does not review state plan material.

NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

16. RETURN TO: .

J. Ruth Kennedy, Medicaid Director State of Louisiana Department of Health and Hospitals

628 N. 4" Street

15. DATE SUBMITTED:

May 15,2014

PO Box 91030 Baton Rouge, LA 70821-9030

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

14 May, 2014

PLAN APPROVED — ONE COPY ATTACHED

19, EFFECTIVE DATE OF APPROVED MATERIAL:

20. SIGNA’ CIAL:

,

22. TITLE:

APR.O1 2014 21. TYPED NAME

70> Dronpsor

23, REMARKS:

The State requests a pen and ink change to box 10.

the provider fee from $16.25 to $

(tu Fanci | Me. @nes

Please change

16.15.

FORM HCFA-179 (07-92)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT ATTACHMENT 4.19-D MEDICAL ASSISTANCE PROGRAM Page 15

Direct Care Floor

A facility wide direct care floor may be enforced upon deficiencies related to direct care staffing requirements noted during the Health Standards Section (HSS) annual review or during a complaint investigation in accordance with LAC 50:1.5501 et seq.

For providers receiving pervasive plus supplements and other client specific adjustments to the rate in accordance with Section 5b., the facility wide direct care floor is established at 94 percent of the per diem direct care payment, the pervasive plus supplement, and other client specific adjustments to the rate. The direct care floor will be applied to the cost reporting year in which the facility receives a pervasive plus supplement and/or client specific rate adjustment. In no case shall a facility receiving a pervasive plus supplement and/or client specific rate adjustment have total facility payments reduced to less than 104 percent of the total facility cost as a result of imposition of the direct care floor.

For facilities for which the direct care floor applies, if the direct care cost the facility incurred on a per diem basis is less than the appropriate facility direct care floor, the facility shall remit to the Bureau the difference between these two amounts times the number of facility Medicaid days paid

during the cost reporting period. This remittance shall be payable to the Bureau upon submission of the cost report.

Upon completion of desk reviews or audits, facilities will be notified by the Bureau of any changes in amounts due based on audit or desk review adjustments.

. Rate Determination

Resident specific per diem rates are calculated based on information reported on the cost report. The rates are based on cost components appropriate for an economic and efficient ICF/ID providing quality service. The resident per diem rates represent the best judgment of the State to provide reasonable and adequate reimbursement required to cover the costs of economic and efficient ICFs/ID.

The cost data used in setting base rates will be from the latest available audited or desk reviewed cost reports. The initial rates will be adjusted to maintain budget neutrality upon transition to the ICAP reimbursement methodology. To adjust to budget neutrality, at implementation, the Direct Care component is multiplied by 105% of the previously stated calculation. For rate periods between rebasing, the rates will be trended forward using the index factor.

For dates of service on or after October 1, 2005 a resident’s per diem will be the sum of: a. direct care per diem rate; b. care related per diem rate; c. administrative and operating per diem rate; d. capital rate; and e. provider fee.

Effective for dates of service on or after April 1, 2014, the add-on amount to each ICF/ID’s per diem rate for the provider fee shall be increased to $16.15 per day.

State: Louisiana

14-10 JUN 309 Date Received: 14 May, 2014 TN# Approval Date O14 Ef ys Supersedes " Date Approved: JUN 30 2014 TNH 06-26 Effective Date: 4/1/14 |Date Effective: 1 April, 2014

Transmittal Number: 14-10

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 14-13 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office g Ss

1301 Young Street, Suite 833 CENTERS FOR MEDICARE & MEDICAID SERVICES

Dallas, Texas 75202 poorest ypc pad & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

July 16, 2014 Our Reference: SPA LA 14-13

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4" Street

Post Office Box 91030

Baton Rouge, LA 70821-9030

Attn: Darlene Budgewater Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 14-13. The SPA proposes to adopt provisions to establish a new optional eligibility group under the Medicaid State Plan to provide coverage for family planning services and supplies to eligible men and non-pregnant women.

Transmittal Number 14-13 is approved with an effective date of July 1, 2014 as requested. A copy of the HCFA-179, Transmittal No. 14-13 dated May 23, 2014 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks Associate Regional Administrator

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | |. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 14-13 Louisiana

FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES July 1, 2014 5. TYPE OF PLAN MATERIAL (Check One): (NEW STATE PLAN (. AMENDMENT TO BE CONSIDERED AS NEW PLAN _[@] AMENDMENT. COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1927(d) of Social Security Act a. FFY 2014 $2,688.96 b. FFY _2015_ $2,216.87

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

Attachment 3.1-A Item 4c, Page 1 Same (TN 13-17) Attachment 4.19-B, Item 4.c Same (TN 74-15)

10. SUBJECT OF AMENDMENT: The SPA proposes to adopt provisions to establish a new optional eligibility group under the Medicaid State Plan to provide coverage for family planning services and supplies to eligible men and non-pregnant women.

11. GOVERNOR’S REVIEW (Check One):

(J GOVERNOR'S OFFICE REPORTED NO COMMENT (& OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED The Governor does not review state plan material. NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL ICY OFFICIAL: 16. RETURN TO: a J. Ruth Kennedy, Medicaid Director NAME: Or State of Louisiana Kathy H. Kliebert Department of Health and Hospitals 14, TITLE: 628 N. 4" Street Secretary 15. DATE SUBMITTED: Bo nn 21030 LA 70821-9030 May 23, 2014 ‘afon Nouge, - FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: way 23, 2014 18.DATE APPROVED: July 16, 2014 PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATI FICIAL: July 1, 2014 21. TYPED NAME: 22. TITLE: Associate Regional Administrator

Bill Brooks Division of Medicaid and Children's Health

23. REMARKS:

FORM HCFA-179 (07-92)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT ATTACHMENT 3.1-A Item 4 c, Page 1

STATE OF LOUISIANA AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATIONS ON THE AMOUNT, DURATION, AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED AS FOLLOWS: ====================================================================================================

TN#________________________ Approval Date_____________________ Effective Date______________ Supersedes TN# _______________________ 1905(a)(4)(C) Family Planning Services

Covered Services

The primary goals of family planning services are to increase access to services which will allow improved reproductive and physical health, improved perinatal outcomes, and reduction in the number of unintended pregnancies. Medicaid covered family planning services include: 1. Seven office visits per year for physical examinations or medically necessary re-visits as it relates to family planning or family planning-related services for both males and females of child bearing age; a. A comprehensive patient history; b. Physical, including breast exam; c. Laboratory tests; and d. Contraceptive counseling; 2. Contraceptive counseling (including natural family planning), education, follow-ups and referrals; 3. Laboratory examinations and tests for the purposes of family planning and management of sexual health; 4. Pharmaceutical supplies and devices to prevent conception, including all methods of contraception approved by the Federal Food and Drug Administration; and 5. Male and female sterilization procedures and follow up tests provided in accordance with 42 CFR 441, Subpart F. Family Planning Related Services Provided under State Eligibility Option Family planning-related services include the diagnosis and treatment of sexually transmitted diseases or infections, regardless of the purpose of the visit at which the disease or infection was discovered. Medicaid covered family planning-related services include: 1. Diagnostic procedures, drugs and follow-up visits to treat a sexually transmitted disease, infection or disorder identified or diagnosed at a family planning visit (other than HIV/AIDS or hepatitis);

2. Vaccine to prevent cervical cancer;

3. Treatment of major complications from certain family planning procedures; and

4. Transportation services

Service Delivery Family Planning services may be delivered through any enrolled Medicaid provider whose scope of practice includes family planning services. 14-13 07-16-14 07-01-14 13-17 State: Louisiana Date Received: 23 May 2014 Date Approved: 16 July 2014 Date Effective: 1 July 2014 Transmittal Number: 14-13

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

Attachment 4.19-B MEDICAL ASSISTANCE PROGRAM Item 4.c STATE OF LOUISIANA

PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICES METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES -- OTHER TYPES OF CARE OR SERVICES LISTED IN SECTION 1905(A) OF THE ACT THAT IS INCLUDED IN THE PROGRAM UNDER THE PLAN ARE DESCRIBED AS FOLLOWS:

TN#________________________ Approval Date_____________________ Effective Date______________ Supersedes TN# _______________________

Citation

Medical and Remedial Care and Services 1905(a)(4)(C)

Family Planning Services and supplies are reimbursed as follows:

All Medicaid providers, including federally qualified health centers, rural health clinics and tribal 638 facilities, shall be reimbursed according to the established fee-for-service rates published in the Medicaid fee schedule for family planning services.

The agency's fee schedule rate is in effect for services provided on or after July 1, 2014. 14-13 07-16-14 07-01-14 74-15 State: Louisiana Date Received: 23 May 2014 Date Approved: 16 July 2014 Date Effective: 1 July 2014 Transmittal Number: 14-13

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 14-15 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

January 22, 2015

Our Reference: SPA LA 14-0015

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building 628 North 4th Street Post Office Box 91030 Baton Rouge, LA 70821-9030

Attn: Darlene Budgewater Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 14-0015. The state plan makes individuals receiving hospice services mandatory participants in BAYOU HEALTH and individuals receiving home and community based waiver services voluntary participants.

Transmittal Number 14-0015 is approved with an effective date of July 20, 2014 as requested. A copy of the HCFA-179, Transmittal No. 14-0015 dated September 30, 2014 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks

Associate Regional Administrator

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 14-15 FORM APPROVED OMB NO. 0938-0193 2. STATE Louisiana 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEAL TH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES July 20, 2014 5. TYPE OF PLAN MATERIAL (Check One): 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1932(a)(4) of Social Security Act a. FFY 2014 1!! 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.1-F, Pages 4, 4a, 5, 7 and 10 Attachment 3.1-F, Page 8 and Sa Attachment 3.1-F, Page 12 b. FFY 2015 i!! 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Same (TN 11-21) remove pages 7a and 12a Same (TN 12-57) Same (TN 12-65) 10. SUBJECT OF AMENDMENT: The SPA proposes to make individuals receiving hospice services mandatory participants in BAYOU HEAL TH and individuals receiving home and community based waiver services voluntary participants. 11 . GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED [8J OTHER, AS SPECIFIED: The Governor does not review state plan material. 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 13. TYPEDN Kath H. Kliebert 14. TITLE: Secretar 15. DATE SUBMITTED: September 30, 2014 17. DATE RECEIVED: Y OFFICIAL: 16. RETURN TO: J. Ruth Kennedy, Medicaid Director State of Louisiana Department of Health and Hospitals 628 N. 4th Street PO Box 91030 Baton Rouge, LA 70821-9030 FOR REGIONAL OFFICE USE ONLY 118. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNAT FICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM HCF A-179 (07-92) Bill Brooks Associate Regional Administrator Division of Medicaid and Children's Health January 22, 2015 July 20, 2014 September 30, 2014

State: Louisiana Citation 1932(a){l)(A) 6. 42 CFR 438.6(c) 42 CFR 438.50(c)(6) 1932(a)(l)(A) 7. 447.362 42 CFR 438.50(c)(6) 45 CFR 74.40 8. Condition or Requirement ATTACHMENT 3.1-F Page4 OMB No.:0938- _x_ The state assures that all applicable requirements of 42 CFR 438.6(c) for payments under any risk contracts will be met. NI A The state assures that all applicable requirements of 42 CFR 44 7 .362 for 42 CFR payments under any non-risk contracts will be met. _L The state assures that all applicable requirements of 45 CFR 92.36 for procurement of contracts will be met. D. Eligible groups l 932(a)( 1 )(A)(i) 1. List all eligible groups that will be enrolled on a mandatory basis. • Children (under 19 years of age) including those eligible under Section 1931 poverty- level related groups and optional groups of older children; • Parents, including those eligible under Section 1931 and optional groups of caretaker relatives; • CHIP (Title XXI) children enrolled in Medicaid-expansion CHIP (LaCHIP Phase I, II, & III); • CHIP (Title XXI) unborn option (Phase 4) • Pregnant Women: Individuals whose basis of eligibility is pregnancy, who are only eligible for pregnancy-related services, and whose eligibility extends 60 days after the end of the pregnancy; • Uninsured women under the age of 65 who have been screened through the Centers for Disease Control National Breast and Cervical Cancer Early Detection Program and identified as being in need of treatment for breast and/or cervical cancer, including pre- cancerous conditions and early stage cancer, and are not otherwise eligible for Medicaid; • Non-dually eligible Aged, Blind & Disabled Adults age 19 or older (note: dual eligibles are exempt and children are voluntary as noted below). • Individuals and families who have more income than is allowed for Medicaid eligibility, but who meet the standards for the Regular Medically Needy Program. • Individuals receiving hospice services who are not otherwise excluded because of their status as a Medicare dual eligible recipient, or a resident of a long-term care facility (nursing facility or intermediate care facility for persons with intellectual disabilities). 2. Mandatory exempt groups identified in 1932(a)(l)(A)(i) and 42 CFR 438.50. l 932(a)(2)(B) i. 42 CFR 438(d){l) TN# _____ _ Supersedes TN# ------- Use a check mark to affirm if there is voluntary enrollment of any of the following mandatory exempt groups. _ _ Recipients who are also eligible for Medicare If enrollment is voluntary, describe the circumstances of enrollment. (Example: Recipients who become Medicare eligible during mid-enrollment, remain eligible for managed care and are not disenrolled into fee-for-service.) Approval Date ______ Effective Date ________ _ State: Louisiana Date Received: September 30, 2014 Date Approved: January 22, 2015 Date Effective: July 20, 2014 Transmittal Number: 14-0015 14-0015 1-22-15 11-0021 07-20-14

State: Louisiana Citation l 932(a)(2)(C) 42 CFR 438(d)(2) Condition or Requirement ATTACHMENT 3.1-F Page 4a OMB No.:0938- it. ~ An Indian Health program or urban Indian program operated by a tribe or tribal organization under a contract, grant, cooperative agreement or compact with the Indian Health Service. All enrollees are informed through required member materials that if they are a member of a federally recognized Tribe they may self-identify, provide documentation of Tribal membership, and request disenrollment through the enrollment broker. l 932(a)(2)(A)(i) m. ~Children under the age of 19 years, who are eligible for Supplemental Security Income (SSI) under title XVI. 42 CFR 438.50(d)(3)(i) l 932(a)(2)(A)(iii) IV. NI A Children under the age of 19 years who are eligible under 1902(e)(3) of the Act. 42 CFR 438.50(d)(3)(ii) v. _x_ Individuals who receive home and community-based waiver services. Note: Voluntary enrollment is allowed under the CCN Program. TN# _____ _ Approval Date ____ __ Effective Date ________ _ Supersedes TN# _____ _ State: Louisiana Date Received: September 30, 2014 Date Approved: January 22, 2015 Date Effective: July 20, 2014 Transmittal Number: 14-0015 14-0015 01-22-15 07-20-14 11-0021

State: Louisiana Citation l 932(a)(2)(A)(v) 42 CFR 438.50(3)(iii) l 932(a)(2)(A)(iv) 42 CFR 438.50(3)(iv) l 932(a)(2)(A)(ii) 42 CFR 438.50 (3)(v) Condition or Requirement Louisiana does not cover these optional groups. ATTACHMENT 3.1-F Page 5 OMB No.:0938- ___x__ Children under the age of 19 years who are in foster care or other out-of- home placement. ___x_ Children under the age of 19 years who are receiving foster care or adoption assistance under title IV-E. ___x__ Children under the age of 19 years who are receiving services through a family-centered, community based, coordinated care system that receives grant funds under section 50l(a)(l)(D) of title V, and is defined by the state in terms of either program participation or special health care needs. E. Identification of Mandatory Exempt Groups l 932(a)(2) 42 CFR 438.50(d) l 932(a)(2) 42 CFR 438.50(d) 1932(a)(2) 42 CFR 438.50(d) TN# _____ _ Supersedes TN# ------- 1. Describe how the state defines children who receive services that are funded under section 50l(a)(l)(D) of title V. (Examples: children receiving services at a specific clinic or enrolled in a particular program.) The State defines the above referenced children as those children receiving services at a Children's Special Health Services (CSHS) clinic Operated by the Louisiana Department of Public Health. 2. Place a check mark to affirm ifthe state's definition of title V children is determined by: ___x_ i. program participation (receipt of services at a CSHS clinic), ii. special health care needs, or 111. both 3. Place a check mark to affirm ifthe scope of these title V services is received through a family-centered, community-based, and coordinated care system. ___x_ i. yes 1i. no Approval Date ______ Effective Date _______ _ State: Louisiana Date Received: September 30, 2014 Date Approved: January 22, 2015 Date Effective: July 20, 2014 Transmittal Number: 14-0015 14-0015 01-22-15 07-20-14 11-0021

State: Louisiana Citation 1932(a)(2) 42 CFR 438.SO(d) Condition or Requirement ATTACHMENT 3.1-F Page 7 OMB No.:0938- 6. Describe how the state identifies the following groups who are exempt from mandatory enrollment into managed care: (Examples: usage of aid codes in the eligibility system, self- identification). The following Medicaid and/or CHIP recipients are excluded from participation in a CCN and cannot voluntarily enroll in a CCN. Individuals who: • are both Medicaid and Medicare recipients (identified by Medicare Indicator in the MMIS recipient file); • reside in a long-term care facility (nursing facility or intermediate care facility for persons with intellectual disabilities); • receive services through the Program of All-Inclusive Care for the Elderly (PACE); • have a limited period of eligibility such as eligibility through the Spend-down Medically Needy Program or Emergency Services Only; • are participants in the Take Charge Family Planning Waiver Program; • are eligible through the Tuberculosis Infected Individual Program; or • are enrolled in the Louisiana Health Insurance Premium Payment (LaHIPP) Program. 42 CFR 438.50 F. List other eligible groups (not previously mentioned) who will be exempt (excluded) from mandatory enrollment. TN# _____ _ Supersedes TN# ------- • Individuals under the age of 21 otherwise eligible for Medicaid who are listed on the New Opportunities Waiver (NOW) Request for Services Registry, also known as Chisholm Class Members; • For purposes of these provisions, Chisholm class members shall be defined as those children identified in the Melanie Chisholm, et al vs. Kathy Kliebert (or her successor) class action litigation. Approval Date ______ Effective Date ________ _ State: Louisiana Date Received: September 30, 2014 Date Approved: January 22, 2015 Date Effective: July 20, 2014 Transmittal Number: 14-0015 14-0015 01-22-15 07-20-14 11-0021

State: Louisiana Citation Condition or Requirement ATTACHMENT 3.1-F Page 8 OMB No.:0938- 42 CFR 438.50 G. List all other eligible groups who will be permitted to enroll on a voluntary basis NIA H. Enrollment process. 1932(a)(4) 1. Definitions 42 CFR 438.50 1932(a)(4) 42 CFR 438.50 TN# ------- Supersedes TN# _____ _ i. An existing provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous year. This may be established through state records of previous managed care enrollment or fee-for-service experience, or through contact with the recipient. ii. A provider is considered to have "traditionally served" Medicaid recipients if it has experience in serving the Medicaid population. 2. State process for enrollment by default. Describe how the state's default enrollment process will preserve: i. the existing provider-recipient relationship (as defined in H. l .i). As part of the financial Medicaid and LaCHIP application process, applicants may be given the option to indicate their preferred choice of CCN and PCP. If the choice of CCN and PCP is not indicated on the new enrollee me transmitted by DHH to the Enrollment Broker, the Enrollment Broker shall contact the enrollee to request their choice of CCN and PCP. The Enrollment Broker shall encourage the continuation of any existing satisfactory provider/patient relationship with their current PCP who is in a CCN. Enrollment Broker staff will be available by telephone to assist program enrollees. Program enrollees will be offered multilingual enrollment materials or materials in alternative formats, large print, and/or Braille when needed. The enrollment broker shall assist the Medicaid enrollee with the selection of a CCN that meets the enrollee's needs by explaining in a non-biased manner the criteria that may be considered when selecting a CCN. If no CCN choice is made, the enrollment broker will utilize available information about relationships with existing PCPs in the assignment process. Medicaid potential enrollees who are eligible for CCN, excluding those whose Medicaid eligibility is predicated upon determination of pregnancy, will have thirty (30) calendar days from the postmark date that an enrollment form is sent to them by the Enrollment Broker to select a CCN. Pregnant recipients with Medicaid eligibility limited to prenatal, delivery, and post-partum services will immediately be automatically assigned to a CCN by the enrollment broker. All members of a family unit will be encouraged to select the same CCN. With the implementation of the CCNs in a geographic service area, enrollees will be given the chance to choose a CCN. Enrollees have 90 days from the initial date of enrollment into a CCN in which they may change the CCN for any reason. If the enrollee does not request disenrollment from the CCN within 90 days, the enrollee will be locked-in to the CCN for up to 12 months, or until their next open enrollment period unless they are disenrolled for cause. Approval Date ____ __ Effective Date ________ _ State: Louisiana Date Received: September 30, 2014 Date Approved: January 22, 2015 Date Effective: July 20, 2014 Transmittal Number: 14-0015 14-0015 12-0057 01-22-15 07-20-14

State: Louisiana ATTACHMENT 3.1-F Page 8a OMB No.:0938- Citation Condition or Requirement TN# _____ _ Supersedes TN# _____ _ ii. the relationship with providers that have traditionally served Medicaid recipients (as defined in H.2.ii). All CCNs will contract with providers who have traditionally served Medicaid recipients and will be available for choice and default assignment. Preexisting relationships are a factor in the auto-assignment algorithm. Recipients who fail to choose a CCN shall be automatically assigned to a CCN by the enrollment broker and the CCN shall be responsible to assign the member to a PCP if a PCP is not selected at the time of enrollment into the CCN. Recipients of home and community-based services shall be exempt from automatic assignment to a CCN. Approval Date _______ Effective Date ________ _ State: Louisiana Date Received: September 30, 2014 Date Approved: January 22, 2015 Date Effective: July 20, 2014 Transmittal Number: 14-0015 14-0015 01-22-15 07-20-14 12-0057

State: Louisiana Citation 1932(a)(4) I. 42 CFR 438.50 TN# _____ _ Supersedes TN# ------- ATTACHMENT 3.1-F Page 10 OMB No.:0938- Condition or Requirement v. Describe the default assignment algorithm used for auto-assignment. (Examples: ratio of plans in a geographic service area to potential enrollees, usage of quality indicators.) Mandatory CCN participants that fail to select a CCN and voluntary participants that do not exercise their option not to participate in the CCN program within the minimum 30 day window, with the exception of recipients of home and community- based services, shall be auto-assigned to a CCN. Potential enrollees are auto-assigned based on the State's algorithm taking into consideration: • • • • • • The member's previous CCN; Inclusion in the CCN provider network of the member's historic provider as identified by Medicaid claims history; If the provider with which the member has a historic provider relationship contracts with more than one CCN, the member will be assigned to a CCN with which the provider contracts, on a round robin basis; If the provider with which the family member has a current or historic provider relationship contracts with more than one CCN, the member will be assigned to a CCN with which that provider contracts, on a round robin basis; If neither the member nor a family member has a current or historic provider relationship, the member will be auto- assigned to a CCN with one or more PCPs accepting new patients in the member's parish of residence, on a round robin basis subject to CCN capacity; and Beginning in October 2014, the CCN's quality measures will be factored into the algorithm for automatic assignment. v1. Describe how the state will monitor any changes in the rate of default assignment. (Example: usage of the Medical Management Information System (MMIS), monthly reports generated by the enrollment broker) The State will use regular reports generated by the enrollment broker to monitor CCN choice rates, auto-assignments, and disenrollmen ts. State assurances on the enrollment process Place a check mark to affirm the state has met all of the applicable requirements of choice, enrollment, and re-enrollment. 1. __L The state assures it has an enrollment system that allows recipients who are already enrolled to be given priority to continue that enrollment if the MCO or PCCM does not have capacity to accept all who are seeking enrollment under the program. Approval Date _ _ ___ __ Effective Date _ _ ___ ___ _ State: Louisiana Date Received: September 30, 2014 Date Approved: January 22, 2015 Date Effective: July 20, 2014 Transmittal Number: 14-0015 14-0015 01-22-15 07-20-14 11-0021

State: Louisiana Citation 1932(a)(5)(D) 1905(t) TN# ------ Supersedes TN# ------ Condition or Requirement ATTACHMENT 3.1-F Page 12 OMB No.:0938- L. List all services that are excluded for each model (MCO & PCCM) The following services are excluded from coverage under the CCN-P Model: • Dental; • ICF/DD Services*; • Personal Care Services; • Nursing Facility Services*; • Individualized Education Plan (IEP) Services provided by a school district and billed through the intermediate school district, or school-based services funded with certified public expenditures (these services are not provided by OPH certified school-based health clinics); • Specialized Behavioral Health; • Targeted Case Management Services including Nurse Family Partnership; and • Services provided through DHH's Early-Steps Program (Individuals with Disabilities Education Act (IDEA) Part C Program Services) *Individuals receiving these services are excluded from enrollment or will be disenrolled from the CCN-P. Medicaid state plan covered services other than primary care case management services are covered and reimbursed outside of the CCN through the Medicaid fee-for-service payment system or other managed care programs. The CCN-S is responsible for authorizing all State plan covered service, except: • Services provided through DHH's Early Step Services (IDEA Part C Program Services) • Dental Services • Personal Care Services (EPSDT and LT-PCS) • Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) Services* • Non-Emergency Transportation • School-based Individualized Education Plan (IEP) Services provided by a school district and billed through the intermediate school district • Nursing Facility Services* • Specialized Behavioral Health Services • Targeted Case Management • Durable Medical Equipment and certain supplies • Prosthetics and orthotics *Individuals receiving these services are excluded from enrollment or will be disenrolled from the CCN-S. Approval Date ______ Effective Date _______ _ State: Louisiana Date Received: September 30, 2014 Date Approved: January 22, 2015 Date Effective: July 20, 2014 Transmittal Number: 14-0015 12-0065 14-0015 01-22-15 07-20-14

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 14-22 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

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

Dallas Regional Office G RI &

1301 Young Street, Suite 833 CENTERS FOR MEDICARE & MEDICAID SERVICES

Dallas, Texas 75202 aaamaimaia tae hehe & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

July 9, 2014 Our Reference: SPA LA 14-22

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4" Street

Post Office Box 91030

Baton Rouge, LA 70821-9030

Attn: Darlene Budgewater Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 14-22. The SPA proposes to amend the provisions governing outpatient hospital services to remove the visit limits on emergency room services.

Transmittal Number 14-22 is approved with an effective date of June 1, 2014 as requested. A copy of the HCFA-179, Transmittal No. 14-22 dated May 30, 2014 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks Associate Regional Administrator

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION

OMB NO. 0938-0193 _ TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTALNUMBER: | 2. STATE STATE PLAN MATERIAL 14-22 | Louisiana

FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES June 1, 2014 5. TYPE OF PLAN MATERIAL (Check One): [CUNEW STATE PLAN (AMENDMENT TO BE CONSIDERED AS NEW PLAN 9 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS ANAMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR 440.20 a. FFY _2014_ $0 205.00 b. FFY _2015 $0 625.24

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT ({f Applicable):

Attachment 3.1-A, Item 2a, Pages 1 & la Same (TN 09-54)

10, SUBJECT OF AMENDMENT: The purpose of this SPA is to amend the provisions governing outpatient hospital _ services to remove the visit limits on emergency room services.

11, GOVERNOR’S REVIEW (Check One): (1 GOVERNOR'S OFFICE REPORTED NO COMMENT & OTHER, AS SPECIFIED: [J COMMENTS OF GOVERNOR’S OFFICE ENCLOSED The Governor does not review state plan material. (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATU ATE AGENCY OFFICIAL: 16. RETURN TO: a “a J. Ruth Kennedy, Medicaid Director . TYP E: RE State of Louisiana

Kathy H. Kliebert Department of Health and Hospitals

14. panel 628 N. 4" Street ecretary. PO Box 91030

15. DATE SUBMITTED:

May 30, 2014 Baton Rouge, LA 70821-9030

FOR REGIONAL OFFICE USE ONLY 30 May, 2014 18. DATE APPROVED: 9 July, 2014

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNAI FICIAL: 1 June, 2014

21. TYPED NAME: ; 22. TITLE: Associate Regional Administrator Bill Brooks Division of Medicaid & Children's Health

23. REMARKS: The State requests a pen and ink change to block 7 as per e-mail dated 7/7/14.

17. DATE RECEIVED:

FORM HCFA-179 (07-92)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM ATTACHMENT 3.1-A ITEM 2a, Page 1 ST A TE OF LOUISIANA AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATION ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED AS FOLLOWS: CITATION 42CFR 440.20(a) MEDICAL AND REMEDIAL CARE AND SERVICES Item 2a OUTPATIENT HOSPITAL SERVICES Effective September 1, 1983, the Bureau of Health Services Financing will make payment to a licensed hospital for outpatient hospital services in accordance with the following limits: A. Rehabilitation services (Physical Therapy, Occupational Therapy, and Speech Therapy - number of visits in accordance with a rehabilitation plan approved by the Prior Authorization Unit of the Bureau of Health Services Financing; and B. Clinic services-services provided by a physician in a clinic in an outpatient hospital setting shall be considered physician services, not outpatient services, and shall be counted toward applicable limitations per year per recipient. Effective January 1, 2006, the applicable visit limitations will be accumulated per calendar year for services rendered to Medicaid recipients who are 21 years of age and older. When the service cap has been reached, any additional services must meet medical necessity criteria established by the Bureau of Health Services Financing, and will be retroactively authorized on a case by case basis. C. All other outpatient services-including, but not limited to, therapeutic and diagnostic radiology services (except for services under the Radiology Utilization Management), chemotherapy, hemodialysis and laboratory services, shall have no limit imposed other than the medical necessity for the service. Radiology Utilization Management - Radiology utilization management establishes provisions requiring prior authorization for certain outpatient high-tech imaging. Prior authorization (PA) is based on best evidence medical practices as TN# l'f-~ Approval Date _ ___ _ _ Effective Date (p - l ·- diO\L\ Supersedes j- TN# 01- 5 State: Louisiana Date Received: 30 May, 2014 Date Approved: 9 July, 2014 Date Effective 1 June, 2014 Transmittal Number: 14-22 7-9-14

ST ATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM ATTACHMENT 3.1-A ITEM 2a, Page 1 a STATE OF LOUISIANA AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATION ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED AS FOLLOWS: TN# llfad- ~;rsedes aq_, c:Jj developed and evaluated by board-certified physician reviewers, including board-certified radiologists and additional medical specialists. Services requiring PA will be published on the agency's provider website at www.lamedicaid.com and shall include, but are not limited to, the following radiology service groups: a. magnetic resonance (MR); b. positron emission tomography (PET); c. computerized tomography (CT); and d. nuclear cardiology. Reimbursement for these services is contingent upon prior authorization. D. Services related to organ transplants to be performed at a designated transplant center must be authorized by the BHSF. Requests for organ transplants for Title XIX recipients will be reviewed on a case by case basis applying the criteria equally to all similarly situated individuals. There are no provisions for any additional visits beyond the limits specified above. EPSDT recipients are excluded from service limits. Approval Date _ _ _ _ _ _ Effective Date _ _ to~---- \ _- ~~ ()~ \ q~- State: Louisiana Date Received: 30 May, 2014 Date Approved: 9 July, 2014 Date Effective 1 June, 2014 Transmittal Number: 14-22 7-9-14

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 14-0028 MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 For 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

Dallas Regional Office G & 1301 Young Street, Suite 833

re CENTERS FOR MEDICARE & MEDICAID SERVICES Dallas, Texas 75202 aaamaimaia tae hehe & CHILDREN’S HEALTH OPERATIONS

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

July 15, 2014 Our Reference: SPA LA 14-0028 MM1

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building

628 North 4" Street

Post Office Box 91030

Baton Rouge, LA 70821-9030

Attn: Darlene Budgewater Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 14-0028 MM1. The SPA proposes to amend TN 13-0049 and template S59 to establish a new optional eligibility group under the Medicaid State Plan to provide coverage for family planning services and supplies to eligible men and non-pregnant women. This SPA is located in the Medicaid Model Data Lab (MMDL).

Transmittal Number 14-0028 MM1 is approved with an effective date of July 1, 2014 as requested. A copy of the HCFA-179, Transmittal No. 14-0028 MMI dated May 30, 2014 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks Associate Regional Administrator

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory nai 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-14-0028

Louisiana

Proposed Effective Date 07/01/2014

Federal Statute/Regulation Citation 1902(a)(10)(A) (i)(XX1)

Federal Budget Impact

Federal Fiscal Year Amount First Year 2015 $ 2688.96 Second Year 2016 $ 2216.87

Subject of Amendment This SPA amends our TN 13-0049 and template S59 to establish a new optional eligibility group under the Medicaid State Plan to provide coverage for family planning services and supplies to eligible men and non- pregnant women

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal Other, as specified Describe

Governor's office review is not required.

nature of State Agency Official

Submitted By: Roberta Diaz Last Revision Date: Jul 2, 2014 Submit Date: May 30, 2014

Date Received: 05/30/2014

Date Approved: 07/15/2014

Signature of Regional Official:

PRINTED NAME and Title: Bill Brooks, Associate Regional Administrator

Division of Medicaid and Children's Health

LA 14-0028 MM1 Page 2

State: Louisiana Date Received: 30 May 2014 Date Approved: 15 July 2014 Date Effective: 1 July 2014 Transmittal Number: 14-0028 MM1 ___________________________________________________________________________ TN No: 14-0028-MM1 APPROVAL DATE: 07/15/2014 EFFECTIVE DATE: 07/1/2014 STATE: Louisiana

PAGE: S59 Page 1

LA 14-0028 MM1 Page 3

State: Louisiana Date Received: 30 May 2014 Date Approved: 15 July 2014 Date Effective: 1 July 2014 Transmittal Number: 14-0028 MM1 ___________________________________________________________________________ TN No: 14-0028-MM1 APPROVAL DATE: 07/15/2014 EFFECTIVE DATE: 07/1/2014 STATE: Louisiana

PAGE: S59 Page 2

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 15-10 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

June 12, 2015

Our Reference: SPA LA 15-0010

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building 628 North 4th Street Post Office Box 91030 Baton Rouge, LA 70821-9030

Attn: Darlene Budgewater Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 15-0010. The state plan amends the provisions governing the coordinated care network and Medicaid managed care in order to change the name and to incorporate programmatic changes resulting from the inclusion of basic behavioral health services in the program and the voluntary enrollment of Medicaid eligible children identified in the Melanie Chisholm, et al vs. Kathy Kliebert class action litigation.

Transmittal Number 15-0010 is approved with an effective date of February 1, 2015 as requested. A copy of the HCFA-179, Transmittal No. 15-0010 dated March 31, 2015 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks

Associate Regional Administrator

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO. 0938-0I93 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE ST ATE PLAN MATERIAL 15-0010 Louisiana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE February 1, 2015 0 NEW ST ATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1932(a)(4) of Social Security Act a. FFY 2015 b. FFY 2016 $19,493.22 $78,760.23 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-F, Pages 1, 2, 2a, 3, 9, lOa, 11, and 13 Same (TN 11-21) remove page 2b Attachment 3.1-F, Page la Same (TN 12-65) Attachment 3.1-F, Page 4, 4a, 5, 7, 8, Sa, 10, and 12 Same (TN 14-0015) Attachment 3.1-F, Pa e 12a None (New Page) 10. SUBJECT OF AMENDMENT: The SPA proposes to amend the provisions governing the coordinated care network and Medicaid managed care in order to change the name and to incorporate programmatic changes resulting from the inclusion of basic behavioral health services in the program and the voluntary enrollment of Medicaid eligible children identified in the Melanie Chisholm, et al vs. Kathy Kliebert class action litigation. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT [8J OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor does not review state plan material. 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 13. T Kath H. Kliebert 14. TITLE: Secretar 15. DATE SUBMITTED: March 31, 2015 17. DATE RECEIVED: 16. RETURN TO: J. Ruth Kennedy, Medicaid Director State of Louisiana Department of Health and Hospitals 628 N. 4th Street PO Box 91030 Baton Rouge, LA 70821-9030 FOR REGIONAL OFFICE USE ONLY 118. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNAT FICIAL: 21 . TYPED NAME: 22. TITLE: 23. REMARKS: FORM HCFA-179 (07-92) March 31, 2015 June 12, 2015 February 1, 2015 Bill Brooks Associate Regional Administrator Division of Medicaid and Children's Health

State: Louisiana Citation Condition or Requirement ATTACHMENT 3.1-F Page 1 OMB No.:0938- 1932(a)(l)(A) A. Section l 932(a)(l )(A) of the Social Security Act. l 932(a)(l )(B)(i) l 932(a)(l )(B)(ii) 42 CFR 438.50(b)(l) TN# _ _ _ __ _ Supersedes TN# ------- The State of Louisiana enrolls Medicaid beneficiaries on a mandatory basis into managed care entities (managed care organization (MCOs) and/or primary care case managers (PCCMs)) in the absence of section 1115 or section 1915(b) waiver authority. This authority is granted under section 1932(a)(l)(A) of the Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance with provisions of section 1902 of the Act on statewideness (42 CFR 431.50), freedom of choice (42 CFR 431.51) or comparability ( 42 CFR 440.230). This authority may not be used to mandate enrollment in Prepaid Inpatient Health Plans (PIHPs), Prepaid Ambulatory Health Plans (PAHPs), nor can it be used to mandate the enrollment of Medicaid beneficiaries who are Medicare eligible, who are Indians (unless they would be enrolled in certain plans- see D.2.ii. below), or who meet certain categories of "special needs" beneficiaries (see D.2.iii. - vii. below) B. General Description of the Program and Public Process. For B. l and B.2, place a check mark on any or all that apply. 1. The State will contract with an _x __ i. MCO ii. PCCM (including capitated PCCMs that qualify as PAHPs) iii. Both The State of Louisiana will contract with and enroll beneficiaries into a risk-bearing managed care organization (MCO): Program Overview Effective for dates of service on or after February 1, 2015, the Department will operate a managed care delivery system for physical and basic behavioral health, named the Bayou Health program, utilizing one model, a risk bearing managed care organization (MCO), hereafter referred to as a "MCO". The capitated MCO model is a managed care model in which entities establish a robust network of providers and receive a monthly per member per month (PMPM) payment for each enrollee to guarantee access to specified Medicaid State Plan services (referred to as core benefits and services) and care management services. The MCO will also provide additional services not included in the Medicaid State Plan and provide incentive programs to their network providers. All plans will be paid the same actuarially determined risk adjusted rates. PMPM payments related to pharmacy services will be adjusted to account for pharmacy rebates. The state program includes significant administrative monitoring and controls to ensure that appropriate access, services and levels of quality are maintained, including sanctions for non-reporting or non-performance. Approval Date _____ _ Effective Date ___ _____ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 15-0010 06-12-15 02-01-15 11-0021

State: Louisiana Citation 42 CFR 438.50(b)(2) 42 CFR 438.50(b)(3) l 905(t) 42 CFR440.168 42 CFR 438.6(c)(5)(iii)(iv) CFR 438.50(b)(4) TN# _____ _ Supersedes TN# ______ _ Condition or Requirement 2. The payment method to the contracting entity will be: i. fee for service; (E-PCCM only) ii. capitation; (MCO only) ATTACHMENT 3.1-F Page la OMB No.:0938- ui. a case management fee; (E-PCCM only) iv. a bonus/incentive payment; (E-PCCM only) v. a supplemental payment, or ** vi. other. (Please provide a description below). *The MCOs will be paid actuarially sound capitation rates subject to actuarial soundness requirements at 42 CFR 438.6(c). **The MCO shall pay a pharmacy dispensing fee, as defined in the contract, at a rate no less than the minimum specified in the terms of the contract. The MCO is not required to reimburse for pharmacy services delivered by out-of- network providers, except for emergency and periods of care transition as defined in the contract. The MCO shall maintain a system that denies the claim at point-of-sale for providers not contracted in the network. 3. For states that pay a PCCM on a fee-for-service basis, incentive payments are permitted as an enhancement to the PCCM's case management fee, if certain conditions are met. If applicable to this state plan, place a check mark to affirm the state has met all of the following conditions (which are identical to the risk incentive rules for managed care contracts published in 42 CFR 438.6(c)(5)(iv)). _i. Incentive payments to the PCCM will not exceed 5% of the total FFS payments for those services provided or authorized by the PCCM for the period covered. _ii. Incentives will be based upon specific activities and targets. iii. Incentives will be based upon a fixed period of time. iv. Incentives will not be renewed automatically. v. Incentives will be made available to both public and private PCCMs. vi. Incentives will not be conditioned on intergovernmental transfer agreements. _x_ vii. Not applicable to this 1932 state plan amendment. 4. Describe the public process utilized for both the design of the program and its initial implementation. In addition, describe what methods the state will use to ensure ongoing public involvement once the state plan program has been implemented. (Example: public meeting, advisory groups.) In February 2012, the State incrementally implemented the managed care model as coordinated care networks in three geographic service areas and completed statewide implementation in June 2012. Approval Date ______ Effective Date _ _ ______ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 12-0065 15-0010 06-12-15 02-01-15

State: Louisiana Citation TN# ------ - Supersedes TN# ------- Condition or Requirement ATTACHMENT 3.1-F Page2 OMB No.:0938- A website (www.MakingMedicaidBetter.com) was established to keep the public informed during the design of the MCO Program and provide current information on progress toward implementation. The website is a "one stop shop" for documents and information regarding MCOs and includes an online form that interested parties can submit electronically to provide suggestions or ask questions. A MCO Resource Guide for Providers was developed and posted on the website to inform providers of the MCO Program and included a program overview, timelines for implementation, how the DUH addressed provider concerns, MCO provider recruitment process, information to know about interacting with MCOs, marketing guidelines, etc. Meetings and presentations were made to legislative committees, advocates such as Covering Kids and Families Coalition, Louisiana Consumer Healthcare Coalition, Louisiana Maternal and Child Health Coalition, Interagency Council on Homelessness, and Office of Developmental Disabilities; associations such as the Louisiana Primary Care Association, Hospital Association, Louisiana Medical Society; health care providers such as physician groups, hospitals, transportation providers and health care plans. Nine public forums were conducted in each of the nine major geographic regions of the state. An emergency rule creating the managed care model was published in the eight major daily newspapers in Louisiana in September 2010 but was withdrawn to obtain greater public input. After obtaining additional input from stakeholders, the Notice of Intent (NOi) was published on February 20, 2011 in the Louisiana Register. DUH solicited written comments and received 24 written comments which were each responded to individually. The public hearing on the Notice of Intent was held on March 30, 2011 with approximately 67 attendees. Feedback received during the administrative rulemaking process was incorporated into both the Request for Proposals issued April 11, 2011 and the Final Rule that was published in the Louisiana Register on June 20, 2011. Public input continued during and after the implementation of the program, through website recommendations, public meetings, provider meetings, and DUH Advisory Council meetings, etc. The State continues to utilize the administrative rulemaking process, as mandated by State law (R.S. 49:950 et seq), to ensure adequate public notice is given, and public comments are solicited for each major change implemented in its managed care program. The final rule and the proposed State Plan Amendment were shared with the four federally recognized Tribes in Louisiana (Coushatta, Chitimacha, Biloxi-Tunica, and Jena Band of Choctaws) prior to the submittal of the State Plan Amendment pages to CMS. The Department provided a notification letter to the tribal contacts for each of the four tribes and gave them time to comment on the proposed amendment. The Department continues to utilize every opportunity to engage the tribes post-implementation through its CMS-approved tribal notification and comment process. Approval Date _______ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 15-0010 11-0021 06-12-15 02-01-15

State: Louisiana Citation TN# _ _ ___ _ Supersedes TN# _____ _ Condition or Requirement ATTACHMENT 3.1-F Page 2a OMB No.:0938- Outreach and education for Medicaid enrollees who would be enrolled began in early October 2011 and robust efforts continue to ensure that consumers are abreast of program changes and to provide information on the benefits available in the MCO. In addition to DHH's marketing strategies to raise awareness of managed care, the Medicaid/CHIP outreach infrastructure (eligibility employees throughout the state in concert with existing contracts with community based organizations) will be utilized to provide information and one-on- one assistance. The Louisiana Medicaid Quality Committee meets quarterly and has been a forum for ongoing public involvement. The website www.MakingMedicaidBetter.com will be continually updated with information about the State's managed care program and enrollment. Approval Date ______ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 15-0010 11-0021 06-12-15 02-01-15

State: Louisiana Citation 1932(a)(l)(A) 1932(a)(l )(A)(i)(I) 1903(m) 42 CFR 438.50(c)(l) 1932(a)(l )(A)(i)(I) 1905(t) 42 CFR 438.50(c)(2) 1902(a)(23)(A) 1932(a)(l)(A) 42 CFR 438.50(c)(3) 1932(a)(l)(A 42 CFR 431.51 1905(a)(4)(C) 1932(a)(l)(A) 42 CFR438 42 CFR 438.50(c)(4) 1903(m) TN# _____ _ Supersedes TN# ------- Condition or Requirement ATTACHMENT 3.1-H Page3 OMB No.:0938- 5. The state plan program will _K_/will not_ implement mandatory enrollment into managed care on a statewide basis. If not statewide, mandatory __ / voluntary __ enrollment will be implemented in the following county/area(s): 1. county/counties (mandatory) ___________ _ n. county/counties (voluntary) ___________ _ iii. area/areas (mandatory) ____ _________ _ iv. area/areas (voluntary) _____ _________ _ C. State Assurances and Compliance with the Statute and Regulations. If applicable to the state plan, place a check mark to affirm that compliance with the following statutes and regulations will be met. 1. _x_ The state assures that all of the applicable requirements of section 1903(m) of the Act, for MCOs and MCO contracts will be met. 2. NIA The state assures that all the applicable requirements of section 1905(t) of the Act for PCCMs and PCCM contracts will be met. 3. _x_ The state assures that all the applicable requirements of section 1932 (including subpart (a)(l)(A)) of the Act, for the state's option to limit freedom of choice by requiring recipients to receive their benefits through managed care entities will be met. 4. _x_ he state assures that all the applicable requirements of 42 CFR 431 .51 regarding freedom of choice for family planning services and supplies as defined in section 1905(a)(4)(C) will be met. 5. ~The state assures that all applicable managed care requirements of 42 CFR Part 438 for MCOs and PCCMs will be met. Approval Date ______ Effective Date ______ _ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 11-0021 15-0010 06-12-15 02-01-15

State: Louisiana Citation 1932(a)(l)(A) 6. 42 CFR 438.6(c) 42 CFR 438.50(c)(6) 1932(a)(l)(A) 7. 447.362 42 CFR 438.50(c)(6) 45 CFR 74.40 8. Condition or Requirement ATTACHMENT 3.1-F Page4 OMB No.:0938- _x__ The state assures that all applicable requirements of 42 CFR 438.6(c) for payments under any risk contracts will be met. NIA The state assures that all applicable requirements of 42 CFR 447.362 for 42 CFR payments under any non-risk contracts will be met. _x_ The state assures that all applicable requirements of 45 CFR 92.36 for procurement of contracts will be met. D. Eligible groups 1932(a)(l )(A)(i) 1. List all eligible groups that will be enrolled on a mandatory basis. • Children (under 19 years of age) including those eligible under Section 1931 poverty- level related groups and optional groups of older children; • Parents, including those eligible under Section 1931 and optional groups of caretaker relatives; • CHIP (Title XXI) children enrolled in Medicaid-expansion CHIP (LaCHIP Phase I, II, III, and V); • CHIP (Title XXI) unborn option (Phase 4) • Pregnant Women: Individuals whose basis of eligibility is pregnancy, who are only eligible for pregnancy-related services, and whose eligibility extends 60 days after the end of the pregnancy; • Uninsured women under the age of 65 who have been screened through the Centers for Disease Control National Breast and Cervical Cancer Early Detection Program and identified as being in need of treatment for breast and/or cervical cancer, including pre-cancerous conditions and early stage cancer, and are not otherwise eligible for Medicaid; • Non-dually eligible Aged, Blind & Disabled Adults age 19 or older (note: dual eligibles are exempt and children are voluntary as noted below). • Individuals and families who have more income than is allowed for Medicaid eligibility, but who meet the standards for the Regular Medically Needy Program. • Persons eligible through the Tuberculosis Infected Individual Program. 2. Mandatory exempt groups identified in 1932(a)(l)(A)(i) and 42 CFR 438.50. 1932(a)(2)(B) i. 42 CFR 438(d)(l) TN# ------- Supersedes TN# _____ _ Use a check mark to affirm if there is voluntary enrollment of any of the following mandatory exempt groups. __ Recipients who are also eligible for Medicare If enrollment is voluntary, describe the circumstances of enrollment. (Example: Recipients who become Medicare eligible during mid-enrollment, remain eligible for managed care and are not disenrolled into fee-for-service.) Approval Date ______ Effective Date _ _______ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 15-0010 06-12-15 02-01-15 14-0015

State: Louisiana Citation 1932(a)(2)(C) 42 CFR 438(d)(2) 1932(a)(2)(A)(i) 42 CFR 438.50(d)(3)(i) l 932(a)(2)(A)(iii) 42 CFR 438.50(d)(3)(ii) TN# _____ _ Supersedes TN# ------- Condition or Requirement ATTACHMENT 3.1-F Page 4a OMB No.:0938- ii. ...X.. An Indian Health program or urban Indian program operated by a tribe or tribal organization under a contract, grant, cooperative agreement or compact with the Indian Health Service. All enrollees are informed through required member materials that if they are a member of a federally recognized Tribe they may self-identify, provide documentation of Tribal membership, and request disenrollment through the enrollment broker. 111. _x_ Children under the age of 19 years who are eligible for Supplemental Security Income (SSI) under title XVI. iv. NIA Children under the age of 19 years who are eligible under 1902(e)(3) of the Act. v. ...X.. Individuals who receive home and community-based waiver services, and who proactively opt in to a MCO. vi. K._ Children under the age of 19 who are: • eligible under §1902(e)(3) of the Act and receiving Supplemental Security Income (SSI); • in foster care or other out-of-home placement; • receiving foster care or adoption assistance under Title IV-E; • receiving services through a family-centered, community based, coordinated care system that receives grant funds under section 501(a)(l)(D) of title V, and is defined by the state in terms of either program participation or special health care needs; or • enrolled in the Family Opportunity Act Medicaid Buy-In Program. vii. _x Children under the age of21 who are listed on the New Opportunities Waiver Request for Services Registry, and who proactively opt in to a MCO. These children are identified as Chisholm class members: • For purposes of these provisions, Chisholm class members shall be defined as those children identified in the Melanie Chisholm, et al vs. Kathy Kliebert (or her successor) class action litigation. Note: Voluntary enrollment is allowed under the MCO Program. Approval Date ___ ___ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 15-0010 14-0015 06-12-15 02-01-15

State: Louisiana Citation l 932(a)(2)(A)(v) 42 CFR 438.50(3)(iii) I 932(a)(2)(A)(iv) 42 CFR 438.50(3)(iv) l 932(a)(2)(A)(ii) 42 CFR 438.50 (3)(v) Condition or Requirement Louisiana does not cover these optional groups. ATTACHMENT 3.1-F Page 5 OMB No.:0938- _Children under the age of 19 years who are in foster care or other out-of- home placement. _ Children under the age of 19 years who are receiving foster care or adoption assistance under title IV-E. _Children under the age of 19 years who are receiving services through a family-centered, community based, coordinated care system that receives grant funds under section 50l(a)(l)(D) of title V, and is defined by the state in terms of either program participation or special health care needs. E. Identification of Mandatory Exempt Groups l 932(a)(2) 42 CFR 438.50(d) I 932(a)(2) 42 CFR 438.50(d) 1932(a)(2) 42 CFR 438.50(d) TN# _____ _ Supersedes TN# ------- I. Describe how the state defines children who receive services that are funded under section 50l(a)(l)(D) oftitle V. (Examples: children receiving services at a specific clinic or enrolled in a particular program.) The State defines the above referenced children as those children receiving services at a Children's Special Health Services (CSHS) clinic operated by the Louisiana DHH, Office of Public Health. 2. Place a check mark to affirm if the state's definition oftitle V children is determined by: l_ i. program participation (receipt of services at a CSHS clinic), 11. special health care needs, or iii. both 3. Place a check mark to affirm ifthe scope of these title V services is received through a family-centered, community-based, and coordinated care system. l_i. yes ii. No Approval Date ______ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 14-0015 15-0010 06-12-15 02-01-15

State: Louisiana Citation l 932(a)(2) 42 CFR 438.50(d) Condition or Requirement ATTACHMENT 3.1-F Page 7 OMB No.:0938- 6. Describe how the state identifies the following groups who are exempt from mandatory enrollment into managed care: (Examples: usage of aid codes in the eligibility system, self- identification). The following Medicaid and/or CHIP recipients are excluded from participation in a CCN and cannot voluntarily enroll in a CCN. Individuals who: • are both Medicaid and Medicare recipients (identified by Medicare Indicator in the MMIS recipient file); • reside in a long-term care facility (nursing facility or intermediate care facility for persons with intellectual disabilities); • receive services through the Program of All-Inclusive Care for the Elderly (PACE); • have a limited period of eligibility such as eligibility through the Spend-down Medically Needy Program or Emergency Services Only; • are participants in the Take Charge Plus Program; or • are participants in the Greater New Orleans Community Health Connection (GNOCHC) Program. 42 CFR 438.50 F. List other eligible groups (not previously mentioned) who will be exempt (excluded) from mandatory enrollment. NIA TN# _____ _ Approval Date ______ Effective Date ________ _ Supersedes TN# ------- State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 14-0015 15-0010 06-12-15 02-01-15

State: Louisiana Citation Condition or Requirement ATTACHMENT 3.1-F Page 8 OMB No.:0938- 42 CFR 438.50 G. List all other eligible groups who will be permitted to enroll on a voluntary basis NIA H. Enrollment process. 1932(a)(4) 1. Definitions 42 CFR 438.50 1932(a)(4) 42 CFR 438.50 TN# ------- Supersedes TN# _____ _ i. An existing provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous six months. This may be established through state records of previous managed care enrollment or fee-for-service experience, or through contact with the recipient. ii. A provider is considered to have "traditionally served" Medicaid recipients if it has experience in serving the Medicaid population. 2. State process for enrollment by default. Describe how the state's default enrollment process will preserve: i. the existing provider-recipient relationship (as defined in H.1.i). As part of the financial Medicaid and LaCHIP application process, applicants may be given the option to indicate their preferred choice of MCO and PCP. If the choice of MCO and PCP is not indicated on the new enrollee ftle transmitted by DHH to the Enrollment Broker, the Enrollment Broker shall contact the enrollee to request their choice of MCO and PCP. The Enrollment Broker shall encourage the continuation of any existing satisfactory provider/patient relationship with their current PCP who is in a MCO. Enrollment Broker staff will be available by telephone to assist program enrollees. Program enrollees will be offered multilingual enrollment materials or materials in alternative formats, large print, and/or Braille when needed. The enrollment broker shall assist the Medicaid enrollee with the selection of a MCO that meets the enrollee's needs by explaining in a non-biased manner the criteria that may be considered when selecting a MCO. If no MCO choice is made, the enrollment broker will utilize available information about relationships with existing PCPs in the assignment process. With the implementation of the MCOs in a geographic service area, enrollees will be given the chance to choose a MCO. Enrollees have 90 days from the initial date of enrollment into a CCN in which they may change the MCO for any reason. If the enrollee does not request disenrollment from the MCO within 90 days, the enrollee will be locked-in to the MCO for up to 12 months, or until their next open enrollment period unless they are disenrolled for cause. Home and community-based waiver recipients and Chisholm class members shall be exempt from the auto-assignment process and must proactively seek enrollment into an available health plan. Approval Date _______ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 14-0015 15-0010 06-12-15 02-01-15

State: Louisiana ATTACHMENT 3.1-F Page 8a OMB No.:0938- Citation Condition or Requirement TN# _____ _ Supersedes TN# _____ _ 11. the relationship with providers that have traditionally served Medicaid recipients (as defined in H.2.ii). All MCOs will contract with providers who have traditionally served Medicaid recipients and will be available for choice and default assignment. Preexisting relationships are a factor in the auto-assignment algorithm. Recipients who fail to choose a MCO shall be automatically assigned to a MCO by the enrollment broker and the MCO shall be responsible to assign the member to a PCP if a PCP is not selected at the time of enrollment into theMCO. Recipients of home and community-based waiver services and Chisholm class members shall be exempt from automatic assignment to a MCO. Approval Date ______ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 14-0015 15-0010 06-12-15 02-01-15

State: Louisiana Citation 1932(a)(4) 42 CFR 438.50 TN# ------- Supersedes TN# ------- Condition or Requirement ATTACHMENT 3.1-F Page9 OMB No.:0938- iii. the equitable distribution of Medicaid recipients among qualified MCOs and PCCMs available to enroll them, (excluding those that are subject to intermediate sanction described in 42 CFR 438.702(a)(4)); and disenrollment for cause in accordance with 42 CFR 438.56 (d)(2). (Example: No auto-assignments will be made if MCO meets a certain percentage of capacity.) If there is capacity, the system then will auto-assign enrollees based on the State's algorithm to ensure an equitable distribution among qualified MCOs. Once a MCO reaches 40% of the market share statewide at the end of a quarter, they will no longer receive auto assignments. (However potential members will be allowed to proactively select the MCO.) 3. As part of the state's discussion on the default enrollment process, include the following information: L The state will _K_/will not __ use a lock-in for mandatory managed care. IL The time frame for recipients to choose a health plan before being auto-assigned will be see below. ___ _ Note: All new recipients, with the exception of home and community-based waiver recipients and Chisholm class members, shall be immediately automatically assigned to a MCO by the enrollment broker if they did not select an MCO during the financial eligibility determination process. ut. Describe the state's process for notifying Medicaid recipients of their auto-assignment. (Example: state generated correspondence.) The State's enrollment broker generates confirmation letters to all enrollees who make a choice, or were auto-assigned to an available MCO. The letters are mailed to reach the enrollees by the 1st of the month that the enrollment is effective, and it provides the MCO contact information. iv. Describe the state's process for notifying the Medicaid recipients who are auto-assigned of their right to disenroll without cause during the first 90 days of their enrollment. (Examples: state generated correspondence, HMO enrollment packets etc.) The confirmation letter that is mailed by the enrollment broker to all enrollees that become linked by choice, change or auto-assignment states the enrollee may change MCO or PCP without cause within 90 days of their enrollment. Approval Date _______ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 15-0010 06-12-15 02-01-15 11-0021

State: Louisiana Citation TN# _ _ ___ _ Supersedes TN# ______ _ Condition or Requirement ATTACHMENT 3.1-F Page 10 OMB No.:0938- v. Describe the default assignment algorithm used for auto-assignment. (Examples: ratio of plans in a geographic service area to potential enrollees, usage of quality indicators.) As part of the eligibility determination process, Medicaid and LaCHIP applicants, for whom the Department determines eligibility, shall receive information and assistance with making informed choices about participating MCOs from the enrollment broker. These individuals will be afforded the opportunity to indicate the plan of their choice on their Medicaid financial application form or in a subsequent contract with the Department prior to determination of Medicaid eligibility. AU new recipients who have made a proactive selection of an MCO shall have that MCO choice transmitted to the Enrollment Broker immediately upon determination of Medicaid or LaCHIP eligibility. The member will be assigned to the MCO of their choosing unless the plan is otherwise restricted by the department. Potential enrollees are auto-assigned based on the State's algorithm taking into consideration: • The member's previous CCN; • Inclusion in the MCO provider network of the member's historic provider as identified by Medicaid claims history; • If the provider with which the member has a historic provider relationship contracts with more than one MCO, the member will be assigned to a MCO with which the provider contracts, on a round robin basis; • If the provider with which the family member has a current or historic provider relationship contracts with more than one MCO, the member will be assigned to a MCO with which that provider contracts, on a round robin basis; • If neither the member nor a family member has a current or historic provider relationship, the member will be auto- assigned to a MCO with one or more PCPs accepting new patients in the member's parish of residence, on a round robin basis subject to MCO capacity. vi. Describe how the state will monitor any changes in the rate of default assignment. (Example: usage of the Medical Management Jn.formation System (MMIS), monthly reports generated by the enrollment broker) The State will use regular reports generated by the enrollment broker to monitor MCO choice rates, auto-assignments, and disenrollmen ts. Approval Date _______ Effective Date _____ ___ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 14-0015 15-0010 06-12-15 02-01-15

State: Louisiana Citation 1932(a)(4) I. 42 CFR 438.50 1932(a)(4) J. 42 CFR 438.50 TN# - - ----- Supersedes TN# _____ _ Condition or Requirement State assurances on the enrollment process ATTACHMENT 3.1-F Page lOa OMB No.:0938- Place a check mark to affirm the state has met all of the applicable requirements of choice, enrollment, and re-enrollment. 1. _x_ The state assures it has an enrollment system that allows recipients who are already enrolled to be given priority to continue that enrollment if the MCO or PCCM does not have capacity to accept all who are seeking enrollment under the program. 2. K_ The state assures that, per the choice requirements in 42 CFR 438.52, Medicaid recipients enrolled in either an MCO or PCCM model will have a choice of at least two entities unless the area is considered rural as defined in 42 CFR 438.52(b)(3). 3. _ The state plan program applies the rural exception to choice requirements of 42 CFR 438.52(a) for MCOs and PCCMs. X..This provision is not applicable to this 1932 State Plan Amendment. 4. __ The state limits enrollment into a single Health Insuring Organization (HIO), if and only if the HIO is one of the entities described in section 1932(a)(3)(C) of the Act; and the recipient has a choice of at least two primary care providers within the entity. (California only.) _X_ This provision is not applicable to this 1932 State Plan Amendment. 5. __x_ The state applies the automatic reenrollment provision in accordance with 42 CFR 438.56(g) ifthe recipient is disenrolled solely because he or she loses Medicaid eligibility for a period of 2 months or less. _This provision is not applicable to this 1932 State Plan Amendment. Disenrollment 1. The state will ___x_ /will not_ use lock-in for mandatory managed care. 2. The lock-in will apply for ..11_ months (up to 12 months). NOTE: Or until the next open enrollment period, whichever occurs first. 3. Place a check mark to affirm state compliance. _X__ The state assures that beneficiary requests for disenrollment (with and without cause) will be permitted in accordance with 42 CFR 438.56(c). 4. Describe any additional circumstances of "cause" for disenrollment (if any). The State will evaluate requests for disenrollment for "cause" after the lock-in period on a case-by-case basis. Examples of additional circumstances for cause include: Approval Date _ _ ____ Effective Date. _____ ___ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 11-0021 15-0010 06-12-15 02-01-15

State: Louisiana Citation 1932(a)(5) 42 CFR 438.50 42 CFR438.10 TN# _____ _ Supersedes TN# ------- Condition or Requirement ATTACHMENT 3.1-F Page 11 OMB No.:0938- • The MCO does not, because of moral or religious objections cover the service the enrollee seeks; • Contract between the MCO and the Department is terminated; • To implement the decision of a hearing officer in an appeal proceeding by the member against the MCO or as ordered by a court of law; and • Other reasons including, but not limited to: • poor quality of care; • lack of access to services covered under the contract; or • documented lack of access to providers experienced in dealing with the enrollee's health care needs. • The member requests to be assigned to the same MCO as family members; or • The member needs related services to be performed at the same time, not all related services are available within the MCO and the member's PCP or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk. K. Information requirements for beneficiaries Place a check mark to affirm state compliance. _X_ The state assures that its state plan program is in compliance with 42 CFR 438. lO(i) for information requirements specific to MCOs and PCCM programs operated under section 1932(a)(l)(A)(i) state plan amendments. (Place a check mark to affirm state compliance.) Approval Date ______ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 11-0021 15-0010 06-12-15 02-01-15

ATTACHMENT 3.1-F Page 12 OMB No.:0938- State: Louisiana Citation Condition or Requirement The following is a summary listing of the core benefits and services that a MCO is required to provide: 1. inpatient hospital services; 2. Outpatient hospital services; 3. Ancillary medical services; 4. Organ transplant-related services; 5. Family planning services as specified in 42 CFR §431.5l(b)(2) (not applicable to MCO operating under a moral and religious objection as specified in the contract); 6. EPSDT/well-child visits; 7. Emergency medical services; 8. Communicable disease services 9. Durable medical equipment and certain supplies; 10. Prosthetics and orthotics; 11. Emergency and non-emergency medical transportation; 12. Home health services; 13. Basic behavioral health services; 14. School-Based health clinic services provided by the DHH Office of Public Health certified school-based health clinics; 15. Physician services; 16. Maternity services; 1 7. Chiropractic services; 18. Rehabilitation therapy services (physical, occupational, and speech therapies); 19. Pharmacy services (outpatient prescription medicines dispensed, with the exception of those prescribed by a specialized health provider, and at the contractual responsibility of another Medicaid managed care entity); 20. Hospice services; 21. Personal care services (Age 0-20); and 22. Pediatric day healthcare services. NOTE: This overview is not all inclusive. The contract, policy transmittals, state plan amendments, regulations, provider bulletins, provider manuals, published fee schedules, and guides issued by the department are the final authority regarding services. TN# ------ Approval Date ______ Effective Date _______ _ Supersedes TN# _____ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 15-0010 06-12-15 02-01-15 14-0015

ATTACHMENT 3.1-F Page 12a OMB No.:0938- State: Louisiana Citation Condition or Requirement 1932 (a)(5)(D) I 905(t) L. List all services that are excluded for each model (MCO & PCCM) The following services will continue to be reimbursed by the Medicaid Program on a fee-for- service basis, with the exception of dental services which will be reimbursed through a dental benefits prepaid ambulatory health plan under the authority of a 1915(b) waiver. The MCO shall provide any appropriate referral that is medically necessary. The department shall have the right to incorporate these services at a later date if the member capitation rates have been adjusted to incorporate the cost of such service. Excluded services include: 1. Services provided through the Early-Steps Program (IDEA Part C Program services); 2. Dental Services; 3. Lnterrnediate care facility for persons with intellectual disabilities; 4. Personal care services (Age 21 and over); 5. Nursing facility services; 6. Individualized Education Plan services provided by a school district and billed through the intermediate school district, or school-based services funded with certified public expenditures; 7. Specialized behavioral health services; 8. Applied behavior analysis therapy services; and 9. Targeted case management services. TN# _____ _ Approval Date ______ Effective Date. _______ _ Supersedes TN# _____ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 None- New Page 15-0010 06-12-15 02-01-15

State: Louisiana Citation 1932 (a){l)(A)(ii) TN# _____ _ Supersedes TN# _____ _ Condition or Requirement M. Selective contracting under a 1932 state plan option ATTACHMENT 3.1-F Page 13 OMB No.:0938- To respond to items #1 and #2, place a check mark. The third item requires a brief narrative. 1. The state will __lL_/will not_ intentionally limit the number of entities it contracts under a 1932 state plan option. 2. X The state assures that if it limits the number of contracting entities, this limitation will not substantially impair beneficiary access to services. 3. Describe the criteria the state uses to limit the number of entities it contracts under a 1932 state plan option. (Example: a limited number of providers and/or enrollees.) Contractors were determined through a competitive procurement process. The State's contracted Medicaid fiscal intermediary, its subsidiary companies, parent, or affiliated entities cannot also participate in the Louisiana Medicaid program as a Medicaid provider. The selective contracting provision is not applicable to this state plan. Approval Date ___ ___ Effective Date ________ _ State: Louisiana Date Received: 31 March, 2015 Date Approved: 12 June, 2015 Effective Date: 1 February, 2015 Transmittal Number: 15-0010 15-0010 06-12-15 02-01-15 11-0021

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 15-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page Listing 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

October 8, 2015

Our Reference: LA SPA 15-0016 MMDL

Ms. Ruth Kennedy, State Medicaid Director Department of Health and Hospitals Bienville Building 628 North 4th Street Post Office Box 91030 Baton Rouge, LA 70821-9030

Attn: Darlene Budgewater Jodie Hebert

Dear Ms. Kennedy:

We have reviewed the proposed amendment to your Medicaid State Plan submitted under Transmittal Number 15-0016. This Medicaid Modernized Data Lab (MMDL) state plan amendment (SPA) proposes to amend the provisions in the Louisiana Medicaid State Plan governing Federally Facilitated Marketplace (FFM) eligibility determinations to become an "assessment" state and only accept eligibility assessment from the FFM rather than accepting Medicaid eligibility determinations made by the FFM.

Transmittal Number 15-0016 is approved with an effective date of November 1, 2015 as requested. A copy of the HCFA-179, Transmittal No. 15-0016 dated July 15, 2015 is enclosed along with the approved plan pages.

If you have any questions, please contact Ford Blunt III at ford.blunt@cms.hhs.gov or by phone at (214) 767-6381.

Sincerely,

Bill Brooks

Associate Regional Administrator

Enclosures

State/Territory name: Louisiana Submitted By: Karen Barnes Last Revision Date: Oct 7, 2015 Submit Date: Jul 15, 2015 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. LA-15-0016 Proposed Effective Date 11/01/2015 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 431.10, 42 CFR 431.11 Federal Budget Impact Federal Fiscal Year Amount First Year 2016 $ 0.00 Second Year 2017 $ 0.00 Subject of Amendment The SPA proposes to adopt provisions to become an assessment state and only accept eligibility assessments from the FFM rather than accepting Medicaid eligibility determinations made by the FFM. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe:   No reply received within 45 days of submittal Other, as specified Describe: The Governor does not review State Plan material. Signature of State Agency Official Page 1 of 1 LA.1878.R00.00 - Nov 01, 2015 Date Received: 15 July, 2015 Date Approved: 8 October, 2015 Signature of Approving Official: Printed Name and Title: Bill Brooks, Associate Regional Administrator Division of Medicaid and Children's Health

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION ( )Paper Application ( X ) Online A pplication TRANSMITTAL NUMBER: LA 15-0016 STATE: Louisiana The SPA proposes to adopt provisions to become an assessment state and only accept eligibility assessments from the FFM rather than accepting Medicaid eligibility determinations made by the FFM. Superseded TN: 13-0052 pages A1-A3

TN: LA 15-0016 Date Approved: 10/8/15 Date Effective: 11/1/15 Supersedes TN: 13 -0052 LA Redacted SPAs Page 2 State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

LA Redacted SPAs Page 3 TN: LA 15-0016 Date Approved: 10/8/15 Date Effective: 11/5/15 Supersedes TN: 13-0052 State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

TN: LA 15-0016 Date Approved: 10/8/15 Date Effective: 11/1/15 Supersedes TN: 13-0052 LA Redacted SPAs Page 5 State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

TN: LA 15-0016 Date Approved: 10/8/15 Date Effective: 11/1/15 Supersedes TN: 13-0052 LA Redacted SPAs Page 6 State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

TN: LA 15-0016 Date Approved: 10/8/15 Date Effective: 11/1/15 Supersedes TN: 13-0052 LA Redacted SPAs Page 7 State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

TN: LA 15-0016 Date Approved: 10/8/15 Date Effective: 11/1/15 Supersedes TN: 13-0052 LA Redacted SPAs Page 8 State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

TN: LA 15-0016 Date Approved: 10/8/15 Date Effective: 11/1/15 Supersedes TN: 13-0052 LA Redacted SPAs Page 9 State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

Attachment 1.1-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State of Louisiana ATTORNEY GENERAL'S CERTIFICATION I certify that: Louisiana Department of Health and Hospitals is the single State agency responsible for: ~ administering the plan. The legal authority under which the agency administers the plan on a Statewide basis is: LA R.S. 36:254D .. (Statutory citation) [] supervising the administration of the plan by local political subdivisions. The legal authority under which the agency supervises the administration of the plan on a Statewide basis is contained in (Statutory citation) The agency's legal authority to make rules and regulations that are binding on the political subdivision administering the plan is 1- 1- lt./ DATE Si J es D."Buddy" Caldwell TTORNEY GENERAL State of Louisiana TN No.: ____________ Approval Date: ________ ~===Effective Date: ______________ __ Supersedes: __________ _ 15-0016 10-08-15 11-01-15 13-0052 State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

Office of the Secretary Secretary Office of the Secretary Deputy Secretary Office of Management & Finance Undersecretary DHH Medical Director & State Health Officer Louisiana Emergency Response Network* Inspector General Bureau of Media & Communications Organizational Chart Bureau of Minority Health Access Legislative and Governmental Relations Executive Council Bureau of Legal Services * These agencies report to a Board of Directors with over-sight from DHH. Jefferson Parish Human Services Authority* Capital Area Human Services District* Florida Parishes Human Services Authority* Metropolitan Human Services District* South Central Louisiana Human Services Authority* Acadiana Area Human Services District * Imperial Calcasieu Human Services Authority* Central Louisiana Human Services District* Office of Aging & Adult Services Assistant Secretary Office for Citizens with Developmental Disabilities Assistant Secretary Office of Behavioral Health Assistant Secretary Office of Public Health Assistant Secretary Louisiana Commission for the Deaf Louisiana Developmental Disabilities Council * Northwest Louisiana Human Services District* Northeast Delta Human Services Authority* Bureau of Health Services Financing (Medicaid) Division of Fiscal Management Division of Health Economics Division of Information Technology Health Standards Section Director Deputy Undersecretary Administrative Review Director Division of Human Resources, Training Division of Planning & Budget Division of Contracts & Procurement Supports Health Education Authority Of Louisiana (HEAL) State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

Medicaid Director Medicaid Behavioral Health Medical Director Medicaid Systems Division Medicaid Deputy Director Eligibility Division Medicaid Deputy Director Medicaid Deputy Director Policy, Waivers & Compliance Division Medicaid Deputy Director Healthcare Delivery Systems Division Medicaid Medical Director Finance Division Medicaid Deputy Director & CFO Executive Management Officer 3 Executive Management Officer 1 Administrative Assistant 6 Medicaid Benefits & Services Medicaid Program Manager 4 Medicaid Quality Mgmt, Statistics & Reporting Medicaid Program Manager 4 Eligibility Systems Medicaid Program Manager 4 Medicaid Management Information Systems Medicaid Program Manager 4 Recovery & Premium Assistance Medicaid Program Manager 4 Eligibility Field Operations Medicaid Program Manager 4 Health Plan Relations Medicaid Program Manager 4 306 Budget and Managed Care Finance Medicaid Program Manager 4 Medicaid Budget 305 & Contracts Medicaid Program Manager 4 Rate Setting & Audit Medicaid Program Manager 4 Medicaid Economics Economist 5 Policy & Compliance Medicaid Program Manager 4 Medicaid Program Support & Waivers Medicaid Program Manager 4 Project Management Office Medicaid Program Manager 1B State: Louisiana Date Received: 7/15/15 Date Approved: 10/8/15 Date Effective: 11/1/15 Transmittal Number: 15-0016

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 16-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page(s)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

July 6, 2016

Our Reference: SPA LA 16-0010 CORRECTED LETTER

Ms. Jen Steele, Interim State Medicaid Director Department of Health and Hospitals 628 North 4th St. Post Office Box 91030 Baton Rouge, LA 70821-9030

Attention: Darlene Budgewater

Dear Ms. Steele:

We have reviewed the State’s proposed amendment to the Louisiana State Plan submitted under Transmittal Number 16-0010 dated April 21, 2016. This state plan amendment amends the provisions governing Medicaid eligibility in order to return to a determination state and accept Medicaid eligibility determinations made by the Federally Facilitated Marketplace.

Based on the information submitted, we have approved the amendment for incorporation into the official Louisiana State Plan with an effective date change of July 1, 2016. A copy of the CMS-179 and approved plan pages are enclosed with this letter.

If you have any questions, please contact Cheryl Rupley at (214) 767-6278 or by email at Cheryl.Rupley@cms.hhs.gov.

Sincerely,

Bill Brooks

Associate Regional Administrator

for

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7KH*RYHUQRUGRHVQRWUHYLHZ6WDWH3ODQPDWHULDO 6LJQDWXUHRI6WDWH$JHQF\2IILFLDO 3DJHRI /$5 $SU Date Received: 21 April, 2016 Date Approved: 28 June, 2016 Date Effective: 1 July, 2016 Signature of Approving Official Printed Name and Title: Bill Brooks, Associated Regional Administrator Division of Medicaid and Children's Health for

Medicaid Director Medicaid Deputy Director Eligibility Medicaid Deputy Director Policy, Waivers, and Compliance Medicaid Deputy Director Medicaid Systems Medicaid Deputy Director Healthcare Delivery Systems Medicaid Deputy Director Finance Medicaid Medical Director Financial Management and Operations Section Managed Care Finance Section Rate Setting and Audit Eligibility System Section Medicaid Management Information Systems Eligibility Field Operations Health Plan Relations Policy and Compliance Medicaid Quality Mgt, Statistics, and Reporting Bureau of Health Services Financing Department of Health and Hospitals Medicaid Program Support and Waivers Health Economics Medicaid Systems Modernization Pharmacy Program Integrity Medicaid Behavioral Health Section State: Louisiana Date Received: 21 April, 2016 Date Approved: 28 June, 2016 Date Effective: 1 July, 2016 Transmittal Number: LA 16-0010 TN: 16-0010

Approval Date: 28 June, 2016 Effective Date: 1 July, 2016 Supersedes TN: LA 15-0016

Page 1 of 7 Medicaid Administration Transmittal Number: LA State Name: Louisiana OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 16 - 0010 State Plan Administration Designation and Authority A1 42 CFR 431.10 Designation and Authority State Name: Louisiana As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Louisiana Department of Health (LDH) Type of Agency: Title IV-A Agency Health Human Resources Other The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: LA R.S. 36:254D The single state agency supervises the administration of the state plan by local political subdivisions. Yes No The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided. ✔ An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). Yes No Waivers of the single state agency requirement have been granted under authority of the Intergovernmental Cooperation Act of 1968. State: Louisiana Date Received: 4-21-16 Date Approved: 6-28-16 Date Effective: 7-1-16 TN: LA 16-0010 LA 16-0010 Date Approved: 6-28-16 Date Effective: 7-1-16 Supersedes TN: 15-0016

Page 2 of 7 Medicaid Administration The waivers are still in effect. Yes No Enter the following information for each waiver: Remove Date waiver granted (MM/DD/YY): 06/18/14 The type of responsibility delegated is (check all that apply): Determining eligibility Conducting fair hearings Other Name of state agency to which responsibility is delegated: Division of Administrative Law (DAL) Describe the organizational arrangement authorized, the nature and extent of responsibility for program administration delegated to the above named agency, and the resources and/or services of such agency to be utilized in administration of the plan: LDH delegates its authority to conduct fair hearings to the DAL. The parties acknowledge that the authority is to conduct the entire Medicaid fair hearing function and issue a recommended decision regarding all applicant, beneficiary, and provider appeal cases as defined in a written Memorandum of Understanding. In the MOU, the DAL also agrees to comply with any and all federal / state notice and hearing requirements contained in the Code of Federal Regulations 42 CFR Section 431, subpart E, the Louisiana Revised Statutes (and the rules properly promulgated there under) and the Louisiana Medicaid State Plan and subsequent amendments. LDH retains the right to review all DAL Medicaid recipient appeals. The State's review will be limited to the proper application of Federal and State Medicaid law and regulations; any changes to any such DAL recipient appeal decision will be made only pursuant to a conclusion of law regarding the proper application of Federal and State Medicaid law and regulations. DAL acknowledges and agrees that it will act as a neutral and impartial decision-maker on behalf of the Medicaid agency in recommending decisions for all Medicaid cases that will comply with all applicable federal and state laws, rules, regulations, policies, and guidance governing the Medicaid program. The methods for coordinating responsibilities among the agencies involved in administration of the plan under the alternate organizational arrangement are as follows: LDH retains oversight of the State Plan and has established a process to monitor the entire appeals process, including the quality and accuracy of the final decisions made by DAL. LDH ensures that every applicant and enrollee is informed, in writing, of the fair hearing process and how to contact either agency to obtain information about fair hearings and that DAL will comply with all applicable federal and state laws, rules, regulations, policies, and guidance governing the Medicaid program. Add The agency that administers or supervises the administration of the plan under Title X of the Act as of January 1, 1965, has been separately designated to administer or supervise the administration of that portion of this plan related to blind individuals. State: Louisiana Date Received: 4-21-16 Date Approved: 6-28-16 Date Effective: 7-1-16 TN: LA 16-0010 LA 16-0010 Date Approved: 6-28-16 Date Effective: 7-1-16 Supersedes TN: 15-0016

Page 3 of 7 Medicaid Administration The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: Medicaid agency Title IV-A agency An Exchange The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Name of entity: Health and Human Services (HHS) Appeals The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes No State Plan Administration Organization and Administration A2 42 CFR 431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency. The Louisiana Department of Health (LDH) is the single State agency designated to administer the Medicaid Program under title XIX of the Social Security Act. The Bureau of Health Services Financing (BHSF) is the agency within LDH that is responsible for administering the State's Medicaid program and is responsible for determining the following: 1) eligibility policy and criteria, State: Louisiana Date Received: 4-21-16 Date Approved: 6-28-16 Date Effective: 7-1-16 TN: LA 16-0010 LA 16-0010 Date Approved: 6-28-16 Date Effective: 7-1-16 Supersedes TN: 15-0016

Page 4 of 7 Medicaid Administration service coverage, and payment policies for the Medicaid and CHIP programs; 2) ensuring the State's health care programs maximize federal funding to finance health care services for the indigent; 3) developing effective methods for managing the utilization of health care services and the cost of care in the State's programs; and 4) analyzing existing health care financing policies to ensure that they promote efficient, effective, and economical provisions of care. BHSF is headed by the State Medicaid Director, who with an executive management team of five (5) Deputy Directors and a Medical Director, provide management, policy direction, strategic and financial planning for the agency as well as disseminating work assignments and coordinating operations for attainment of agency goals and objectives. The five Deputy Directors are as follows: 1) Medicaid Deputy Director of Finance - Financial Management/Operations; Managed Care Finance; Rate Setting and Audits; Health Economics; Pharmacy: Responsible for the oversight and management of the financial aspects of the Medical Vendor Administration (the budgetary operations for BHSF) including the Medical Vendor Payments and Administration budgets; Managed Care Finance; contracts; Rate Setting and Audits; Health Economics and Pharmacy sections. 2) Medicaid Deputy Director of Medicaid Systems - Eligibility Systems Section; MMIS; Medicaid Systems Modernization: Responsible for system administration pertaining to payment of claims, Medicaid eligibility data, and administration of Third Party Liability programs and systems. Responsibilities include management of the Fiscal Intermediary contract, Eligibility Systems maintenance and support contract, Third Party Liability and other administrative contracts; Medicaid Systems Modernization section. 3) Medicaid Deputy Director of Eligibility- Eligibility Field Operations; Health Plan Relations: Responsible for the initial determination and redetermination of eligibility for all Medicaid and CHIP populations, except those determined by the single state IV-A agency and the Federal agency administering the SSI program, at office locations throughout the State; administers the Medicaid Eligibility Quality Control program; and handles Eligibility Field Operations which is divided into eight regional divisions specializing in certain eligibility functions such as initial eligibility determination of MAGI, Non- MAGI, or Long-term care groups and redetermination of eligibility. These regional divisions are state employees within LDH. Health plan relations coordinates provider and member support and maintains a customer support call center. 4) Medicaid Deputy Director of Policy, Waivers & Compliance- Policy and Compliance; Program Supports and Waivers; Behavioral Health; Program Integrity: Responsible for maintaining the Medicaid State Plan and Administrative Rules governing eligibility, scope of benefits, and reimbursement policies; developing policy for, and managing, services and programs administered and/or monitored by LDH; as well as ensuring coordination and consistency among health care reimbursement policies developed by the various administrative sections within LDH; and ensuring compliance with state and federal regulations. Responsibilities also include oversight and management of all aspects of the Medicaid supports and waiver programs, Behavioral Health section and Program Integrity section. 5) Medicaid Deputy Director of Healthcare Delivery Systems– Medicaid Quality Management, Statistics and Reporting: Responsible for ensuring the efficient, effective delivery of quality health care services to individuals served by programs administered by BHSF through informed benefit design; utilization management; continuous program evaluation, quality measurement and improvement practices. These responsibilities encompass preventive, acute, and chronic/long-term care services delivered through both the managed care and fee-for-service delivery systems. The LDH Administrative Review Unit (ARU) is the section within LDH responsible for reviewing legal conclusions for appeal decisions made by the DAL. Additionally, the head of the ARU is the liaison with the DAL. LDH actively works with the DAL to ensure all aspects of the Medicaid fair hearing process comply fully with all federal and state regulations and policy. The relationship between LDH and the DAL is very professional and cooperative, with common goals of protection of the individual’s fair hearing rights and full compliance with the 90 day federal time limit for issuance of a final decision. Upload an organizational chart of the Medicaid agency. An attachment is submitted. State: Louisiana Date Received: 4-21-16 Date Approved: 6-28-16 Date Effective: 7-1-16 TN: LA 16-0010 LA 16-0010 Date Approved: 6-28-16 Date Effective: 7-1-16 Supersedes TN: 15-0016

Page 5 of 7 Medicaid Administration Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. The state's executive branch consist of the governor and nine other state elected officers. Under the governor there are 14 departments/divisions which carry out day-to-day operations of state government and/or provide services to Louisiana citizens. These make up the governor's Cabinet. The Cabinet leaders are appointed by (with the approval of the legislature), and report directly to, the governor. LDH, the single state Medicaid agency, provides health and medical services for uninsured and medically indigent persons. The Division of Administration, which includes the Division of Administrative Law (DAL), is responsible for conducting Medicaid fair hearings and is the central management and administrative support agency for the State. The Department of Children and Family Services (DCFS), which is the state's Title IV-A agency, administers social services programs such as the food stamp program, child welfare, and other public assistance programs. All of these entities are in the governor's Cabinet. Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. The Department of Children and Family Services is the single state agency under Title IV-A. Within DCFS, the Child Welfare Division makes Medicaid eligibility determinations for children who receive adoption assistance and foster care payments. The Child Welfare Division determines adoption assistance and foster care payments for children under Title IV-E of the Social Security Act and for whom Medicaid must be provided under 42 CFR 435.145, Children with Non-IV-E Adoption Assistance group under 42 CFR 435.227, and Reasonable Classification of Individuals under Age 21 placed in foster care homes by public agencies under 42 CFR 435.222. Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. The Federally-Facilitated Marketplace (FFM) will be determining eligibility for Medicaid for groups of individuals whose income eligibility is determined based on MAGI income methodology and who apply through the FFM. The FFM will not be assigning an individual who is determined eligible for Medicaid whose income eligibility is determined using MAGI methodology to a specific eligibility group, determining cost-sharing (if applicable), or assigning a benefit package – functions that will be performed by the single state agency. State: Louisiana Date Received: 4-21-16 Date Approved: 6-28-16 Date Effective: 7-1-16 TN: LA 16-0010 LA 16-0010 Date Approved: 6-28-16 Date Effective: 7-1-16 Supersedes TN: 15-0016

Page 6 of 7 Medicaid Administration Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Security Income recipients. Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) Remove Type of entity that conducts fair hearings: An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. HHS Appeals entity will conduct Medicaid fair hearings for individuals whose Medicaid eligibility has been determined and found ineligible for Medicaid by the Federally-facilitated Marketplace (FFM). These will be individuals whose income eligibility is determined based on MAGI income methodology and who applied for health coverage through the FFM. Add Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? Yes No The types of the local subdivisions that administer the state plan under the supervision of the Medicaid agency are: Counties Parishes Other Are all of the local subdivisions indicated above used to administer the state plan? Yes No State Plan Administration Assurances A3 State: Louisiana Date Received: 4-21-16 Date Approved: 6-28-16 Date Effective: 7-1-16 TN: LA 16-0010 TN: LA 16-0010 Date Approved: 6-28-16 Date Effective: 7-1-16 Supersedes TN: 15-0016TN:

Page 7 of 7 Medicaid Administration 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. ✔ All requirements of 42 CFR 431.10 are met. ✔ There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12. ✔ The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. ✔ Assurance for states that have delegated authority to determine eligibility: There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). ✔ Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). ✔ When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. ✔ Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20141203 State: Louisiana Date Received: 4-21-16 Date Approved: 6-28-16 Date Effective: 7-1-16 TN: LA 16-0010 LA 16-0010 Date Approved: 6-28-16 Date Effective: 7-1-16 Supersedes TN: 15-0016

Table of Contents

State/Territory Name: Louisiana State Plan Amendment (SPA) #: 16-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page(s)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

May 27, 2016

Our Reference: SPA LA 16-0012

Ms. Jen Steele, Interim State Medicaid Director Department of Health and Hospitals 628 North 4th St. Post Office Box 91030 Baton Rouge, LA 70821-9030

Attention: Darlene Budgewater

Dear Ms. Steele:

We have reviewed the State’s proposed amendment to the Louisiana State Plan submitted under Transmittal Number 16-0012 dated May 4, 2016. This state plan amendment establishes provisions to use the Supplemental Nutritional Assistance Program (SNAP) option for the streamlined enrollment of SNAP recipients who meet the eligibility requirements for the new adult group under Medicaid expansion as authorized under the provisions of the Affordable Care Act.

Based on the information submitted, we have approved the amendment for incorporation into the official Louisiana State Plan with an effective date change of July 1, 2016. A copy of the CMS-179 and approved plan pages are enclosed with this letter.

If you have any questions, please contact Cheryl Rupley at (214) 767-6278 or by email at Cheryl.Rupley@cms.hhs.gov.

Sincerely,

Bill Brooks

Associate Regional Administrator

Section 2.1, Pages 11e-11n The State requests a pen and ink change to box 8 above per email dated 5/20/2016 . Bill Brooks May 4, 2016 May 27, 2016 Associate Regional Administrator Division of Medicaid and Children's Health July 1, 2016

11e

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued)

X (f) Using the Income Determination from another Means-Tested Public Benefit Program to Support Medicaid Determinations

(1) The state elects the option to use income determined by the following means- tested public benefits program(s) to support Medicaid eligibility determinations:

X SNAP __ TANF __ Other Means-Tested Program: ________________________

In electing this option, the state assures that it:

(a) Verifies citizenship and non-citizen status consistent with Medicaid statutory and regulatory requirements in Section 1137 of the Social Security Act, 42 CFR 435.406, and 435.407.

(b) Complies with Medicaid reporting requirements with respect to participants enrolled through this strategy.

(c) Provides applicants with program information required under 42 CFR 435.905, such as information about available services and the rights and responsibilities of applicants and beneficiaries.

(d) Has procedures to ensure that eligible individuals are enrolled in the appropriate Medicaid eligibility group. Description:

For initial automated use of the option, appropriate filters are being applied to the full file of Louisiana SNAP households as of March 31, 2016, to identify and target New Adults exclusively, using Relationship codes (which identify parents of minor children) and SNAP gross income.

As part of the ongoing intake process, applicants who receive SNAP benefits will be assessed to determine if they meet all criteria for using the SNAP income determination to support Medicaid eligibility. If yes, persons applying will be certified in the appropriate eligibility group Medicaid Case Type) using progression of eligibility: Child Under Age 19 and Under 138% FPL Parent/Caretaker Relative 19% FPL and Below Pregnant Woman Under 138% FPL New Adult

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 LA 16-0012 5/27/16 7/1/16 None New Page

11f

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued)

(e) Has procedures to ensure that eligible American Indians or Alaska Natives enrolled through this strategy are exempt from cost sharing/and or premiums, consistent with section 1916A(b)(3) of the Social Security Act. Description:

(f) Has post-enrollment procedures to ensure assignment of rights to third party benefits and to secure cooperation in establishing medical support as appropriate, per 42 CFR 435.610.

(2) SNAP-Specific Criteria

X (i) The state will use gross income determined by SNAP to support Medicaid eligibility determinations for all MAGI-based Medicaid eligibility groups at:

X Initial application X Renewal of Medicaid eligibility

In applying this option, all of the following conditions are met:

(a) All members of the SNAP household are eligible for SNAP, other than for SNAP transitional benefits.

(b) No one in the SNAP household has any type of income that is excluded in determining gross income for purposes of eligibility for SNAP, but would be included in MAGI-based income.

(c) No one in the SNAP household is part of a tax household that includes an individual who lives outside the home.

(d) The SNAP household consists of individuals who live alone, parents living with their children, or married couples (with or without children), with the result that they will also be considered a household under Medicaid rules and either: o There are no other members present who would not be considered to be part of the household used for purposes of determining MAGI- based Medicaid eligibility; or Additional information and verifications are necessary to establish American Indians and Alaska Natives who are exempt from cost sharing. The Important Information Sheet enclosed with Offer Letters will include a statement noting the exemption and advising members of a federally- recognized tribe to contact the toll-free Customer Service Line. Upon verification of tribal membership, their eligibility record and MMIS recipient file will be updated to reflect exempt status.

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

11g

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued)

o Other members are present in the household, but the total household income is below the applicable Medicaid standard for a household of one.

(e) Households with self-employment income are excluded from this option if the state uses a state-specific methodology for treating self-employment income in SNAP.

Does the state use a methodology for treating self-employment income that differs from the standard SNAP methodology? __ Yes X No

(f) None of the household’s income is excluded from gross income as payment of child support for children living outside of the household.

Does the state exclude payment of child support for children from gross income when determining eligibility for SNAP? __ Yes, the state adds the amount of child support excluded to the household’s SNAP gross income. __ Yes, these families will be excluded from the method. X No

(g) The state obtains all information necessary for a Medicaid eligibility determination that is not contained in the case record for SNAP. If available, electronic data sources are consulted before paper documentation is requested.

(ii) Collection of Information to Determine Eligibility

(a) The state collects information to ensure that no one in the SNAP household is part of a tax household that includes an individual who lives outside the home through the following: Information is available through electronic data sources. Information is collected on the application or renewal form for the means-tested program.  The state agency provides a form to the individual to complete and return. For renewals only, the state agency provides a renewal notice requesting that the beneficiary notify the agency if household information has changed. Other. Description:

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

11h

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued)

(b) The state identifies individuals who have income which is counted in determining household income using MAGI-based methodologies but is not included in SNAP gross income. This includes, but may not be limited to income received through an AmeriCorps Education Award not used for educational expenses, or income from a minor dependent child above the applicable tax filing threshold. The status uses the following processes: Information is available through electronic data sources. Information is collected on the application or renewal form for the means-tested program.  The state agency provides a form to the individual to complete and

return. For renewals only, the state agency provides a renewal notice requesting that the beneficiary notify the agency if anyone in the household has a new type of income. Other. Description:

(c) The state obtains a signature authorizing a determination of Medicaid eligibility as required under 42 CFR 435.907(f).  The household applies for Medicaid by requesting a Medicaid determination through the application for SNAP.  The household applies for Medicaid at its SNAP recertification by requesting a Medicaid determination on the SNAP recertification form.  Individuals are sent a separate form for signature and return. The state allows the form to be completed:  On paper  By telephone Online  Through other means. Description: Fax, Scan to E- Mail___________ Not applicable. State has only elected option to use strategy at Medicaid renewal. Other. Description:

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

11i

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued) (3) TANF-Specific Criteria

__ (i) The state will use gross income determined by TANF to support Medicaid eligibility determinations for all MAGI-based Medicaid eligibility groups at:

__Initial application __Renewal of Medicaid eligibility

In applying this option, all of the following conditions are met:

(a) The state has completed or obtained a study indicating that the state’s gross income determination under TANF rules is equal to a MAGI-based determination under the circumstances set forth in the SPA.

(b) All members of the TANF assistance unit are eligible for TANF.

(c) No one in the TANF assistance unit has any type of income that is excluded in determining income for purposes of TANF, but would be included in MAGI- based income.

(d) No one in the TANF assistance unit is part of a tax household that includes an individual who lives outside the home.

(e) The TANF assistance unit consists of individuals who live alone, parents living with their children, or married couples (with or without children), with the result that they will also be considered a household under Medicaid rules and either:

o There are no other members present who would not be considered to be part of the household used for purposes of determining MAGI- based Medicaid eligibility; or

o Other members are present in the household, but the total household income is below the applicable Medicaid standard for a household of one.

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

11j

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued)

(f) Households with income from stepparents are excluded from this option if the state uses state-specific methodology to exclude any income from stepparents living the in TANF assistance unit.

Does the state exclude any portion of stepparents’ income from the household income? __ Yes __ No

(g) The criteria described under this strategy are applied statewide in states with TANF eligibility requirements that vary by region.

Does the state have TANF eligibility requirements that vary by region? __ Yes. Description:

__ No

(h) The state obtains all information necessary for a Medicaid eligibility determination that is not contained in the case record for TANF. If available, electronic data sources are consulted before paper documentation is requested.

(ii) Collection of Information to Determine Eligibility

The state obtains all information necessary for a Medicaid eligibility determination that is not contained in the case record for TANF. If available, electronic data sources are consulted before paper documentation is requested.

(a) Describe how the state collects information to ensure that no one in the TANF household is part of a tax household that includes an individual who lives outside the home:

Information is available through electronic data sources. Information is collected on the application or renewal form for TANF. The state agency provides a form to the individual to complete and return. The state agency provides a renewal notice requesting that the beneficiary notify the agency if household information has changed.

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

11k

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued)

Other. Description:

(b) Describe how the state identifies individuals who have income which is counted in determining household income using MAGI-based methodologies but is not included in TANF income:

Information is available through electronic data sources. Information is collected on the application or renewal form for the means-tested program. The state agency provides a form to the individual to complete and return. For renewals only, the state agency provides a renewal notice requesting that the beneficiary notify the agency if anyone in the household has a new type of income. Other. Description:

(c) Describe how the state obtains a signature authorizing a determination of Medicaid eligibility as required under 42 CFR 435.907(f).

The household applies for Medicaid by requesting a Medicaid determination through the application for TANF. The household applies for Medicaid at its TANF recertification by requesting a Medicaid determination on the TANF recertification form. Individuals are sent a separate form for signature and return. The state allows the form to be completed: On paper By telephone Online Through other means. Description: ______________ Not applicable. State has only elected option to use strategy at Medicaid renewal. Other. Description:

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

11l

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued)

(4) Criteria for Other Public Means-Tested Benefit Program

__ (i) The state will use gross income determined by _____________________ to support Medicaid eligibility determinations for all MAGI-based Medicaid eligibility groups at:

__Initial application __Renewal of Medicaid eligibility

In applying this option, the following conditions are met:

(a) The state has completed or obtained a study indicating that the state’s gross income determination for the means-tested benefit program described above is equal to a MAGI-based determination under the circumstances set forth in the SPA.

(b) All members of the household for the [means-tested benefit program name] __________are eligible for that program.

(c) No one in the household for the [means tested benefit program] has any type of income that is excluded in determining gross income for purposes of the program, but would be included in MAGI-based income.

(d) No one in the household for the [means tested benefit program] is part of a tax household that includes an individual who lives outside the home.

(e) The household for the means-tested benefit program consists of individuals who live alone, parents living with their children, or married couples (with or without children), with the result that they will also be considered a household under Medicaid rules and either:

o There are no other members present who would not be considered to be part of the household used for purposes of determining MAGI- based Medicaid eligibility; or

o Other members are present in the household, but the total household income is below the applicable Medicaid standard for a household of one.

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

11m

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid (continued) (f) The household for the means-tested benefit program consists of individuals who live alone, parents living with their children, or married couples (with or without children), with the result that they will also be considered a household under Medicaid rules and either:

o There are no other members present who would not be considered to be part of the household used for purposes of determining MAGI- based Medicaid eligibility; or

o Other members are present in the household, but the total household income is below the applicable Medicaid standard for a household of one. (g) The criteria described under this strategy are applied statewide in states with eligibility requirements for the means-tested program described above that vary by region.

Do the eligibility requirements for the means-tested program vary by region?

__ Yes. Description:

__ No

(h) The state obtains all information necessary for a Medicaid eligibility determination that is not contained in the case record for the means-tested program. If available, electronic data sources are consulted before paper documentation is requested.

(ii) Collection of Information to Determine Eligibility

(a) Describe how the state collects information to ensure that no one in the [means- tested benefit program] household is part of a tax household that includes an individual who lives outside the home: Information is available through electronic data sources. Information is collected on the application or renewal form for the means-tested program. The state agency provides a form to the individual to complete and return.

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

11n

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA

SECTION 2- COVERAGE AND ELIGIBILITY _____________________________________________________________________________________

The state agency provides a renewal notice requesting that the beneficiary notify the agency if household information has changed. Other. Description:

(b) Describe how the state identifies individuals who have income which is counted in determining household income using MAGI-based methodologies but is not included in total income for the means-tested benefit program: Information is available through electronic data sources. Information is collected on the application or renewal form for the means-tested program. The state agency provides a form to the individual to complete and return. For renewals only, the state agency p a renewal notice requesting that the beneficiary notify the agency if anyone in the household has a new type of income. Other. Description:

(c) Describe how the state obtains a signature authorizing a determination of Medicaid eligibility as required under 42 CFR 435.907(f). The household applies for Medicaid by requesting a Medicaid determination through the application for the means-tested benefit program. The household applies for Medicaid at recertification for the means- tested benefit program by requesting a Medicaid determination on the recertification form for the means tested benefit program. Individuals are sent a separate form for signature and return. . The state allows the form to be completed: On paper By telephone Online Through other means. Description: _____________ ______________ Not applicable. State has only elected option to use strategy at Medicaid renewal. Other. Description:

TN

Approval Date

Supersedes TN

Effective Date

State: Louisiana Date Received: 5/4/16 Date Approved: 5/27/16 Date Effective: 7/1/16 Transmittal #: LA 16-0012 16-0012 5/27/16 7/1/16 None New Page

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 17-0025 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202

DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI

February 27, 2018

Our Reference: SPA LA 17-0025

Ms. Jen Steele, State Medicaid Director Department of Health 628 North 4th St. Post Office Box 91030 Baton Rouge, LA 70821-9030

Attention: Karen Barnes

Dear Ms. Steele:

We have reviewed the State’s proposed amendment to the Louisiana State Plan submitted under Transmittal Number 17-0025 dated December 6, 2017. This state plan amendment amends the provisions governing Express Lane Eligibility (ELE) by removing certain agencies from the eligibility determinations process, in compliance with the requirements of the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.

Based on the information submitted, we have approved the amendment for incorporation into the official Louisiana State Plan with an effective date change of December 20, 2017. A copy of the CMS-179 and approved plan pages are enclosed with this letter.

If you have any questions, please contact Cheryl Rupley at (214) 767-6278 or by email at Cheryl.Rupley@cms.hhs.gov.

Sincerely,

Bill Brooks

Associate Regional Administrator

December 6, 2017 February 27, 2018 December 20, 2017 Bill Brooks Division of Medicaid & Children's Health

11b

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:________Louisiana__________________

TN

Approval Date_________________ Effective Date

Supersedes

TN

SECTION 2 – COVERAGE AND ELIGIBILITY ___________________________________________________________________________ Citation(s) ___________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid

(Continued)

1902(e)(13) of X(e) Express Lane Option. This option is effective through September 30, 2017. If the statutory authority for express lane eligibility is reauthorized, this option will continue under the new authority provided that it continues to meet the statutory requirements. The Medicaid State agency elects the Act option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of Medicaid eligibility. The Medicaid State agency agrees to meet all of the Federal statutory and regulatory requirements for this option. This authority may not apply to eligibility determinations made before February 4, 2009 or after September 30, 2013.

(1) The Express Lane option is applied to:

Initial determinations Redeterminations

X Both

(2) A child is defined as younger than age:

X 19 20 21

(3) Effective December 20, 2017, the following public agencies are approved by the Medicaid State agency as Express Lane agencies:

 Food and Nutrition Act of 2008 through an agreement with the Department of Children and Family Services, Office of Economic Stability. 17-0025 09-49 February 27, 2018 December 20, 2017 State: Louisiana Date Received: 12-6-17 Date Approved: 02-27-18 Date Effective: 12-20-17 Transmittal Number: 17-0025

11c

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:________Louisiana__________________

TN

Approval Date_________________ Effective Date

Supersedes

TN

SECTION 2 – COVERAGE AND ELIGIBILITY ______________________________________________________________________________ Citation(s) _____________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid

(Continued)

(4) The following component/components of Medicaid eligibility are determined under the Express Lane option. Also, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between Medicaid eligibility determinations for such children and the determination under the Express Lane option.

The earned income disregards, child care deductions and child care payments outside the home will not be used for Express Lane Eligibility determinations. Eligibility components determined from the Supplemental Nutrition Assistance Program (SNAP) file: income, SSN, age, residence and identity.

(5) Check off which option is used to satisfy the Screen and Enroll requirement before a child may be enrolled under title XXI.

(a) Screening threshold established by the Medicaid agency as: (i) ___ percentage of the Federal poverty level which exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points: specify ____________________________________________; or (ii) ___ percentage of the Federal poverty level (that reflects the value of any differences between income methodologies of Medicaid and the Express Lane); or

(b) Temporary enrollment pending screen and enroll. 17-0025 09-49 February 27, 2018 December 20, 2017 State: Louisiana Date Received: 12-6-17 Date Approved: 02-27-18 Date Effective: 12-20-17 Transmittal Number: 17-0025

11d

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:________Louisiana__________________

TN

Approval Date_________________ Effective Date

Supersedes

TN

SECTION 2 – COVERAGE AND ELIGIBILITY ______________________________________________________________________________ Citation(s) ______________________________________________________________________________

2.1 Application, Determination of Eligibility and Furnishing Medicaid

(Continued)

X (c) State’s regular screen and enroll process for CHIP.

X (6) Check off if the State elects the option for automatic enrollment without a Medicaid application, based on data obtained from other sources and with the child’s or family’s affirmative consent to the child’s Medicaid enrollment.

(7) Check off if the State elects the option to rely on a finding from an Express Lane agency that includes gross income or adjusted gross income shown by state income tax records or returns. 17-0025 09-49 February 27, 2018 December 20, 2017 State: Louisiana Date Received: 12-6-17 Date Approved: 02-27-18 Date Effective: 12-20-17 Transmittal Number: 17-0025

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 18-0027 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

Records / Submission Packages LA - Submission Package - LA2018MS0008O - (LA-18-0027) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID LA2018MS0008O Program Name N/A SPA ID LA-18-0027 Version Number 6 Submitted By MARJORIE JENKINS Package Disposition Priority Code P2 Submission Type Official State LA Region Dallas, TX Package Status Approved Submission Date 12/13/2018 Approval Date 1/8/2020 1:06 PM EST Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions Page 1 of 12 Medicaid State Plan Print View 01/08/2020

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, TX 75202 Division of Medicaid and Children's Health Operations January 08, 2020 Erin Campbell Secretary Louisiana Department of Health 628 North 4th Street P.O. Box 91030 Baton Rouge, LA, LA 70821-9030 Re: Approval of State Plan Amendment LA-18-0027 Dear Erin Campbell: On December 13, 2018, the Centers for Medicare and Medicaid Services (CMS) received Louisiana State Plan Amendment (SPA) LA-18-0027 to update the electronic Medicaid application that was developed as part of the state’s new eligibility and enrollment system.. We approve Louisiana State Plan Amendment (SPA) LA-18-0027 on January 08, 2020 with an effective date(s) of November 13, 2018. This SPA is acceptable. Therefore, we are approving a revised version of the application that was submitted with SPA 18-0027 with an effective date of March 13, 2019, and acknowledge Louisiana has implemented different versions of this application prior to SPA approval. Accompanying the approval of SPA 18-0027 is the enclosed companion letter regarding the need for Louisiana to make modifications to its online alternative single streamlined application. Louisiana will provide dates for completion of outstanding changes within 60 days of approval of this SPA, and will implement the revised online application addressing CMS concerns by the dates listed in the companion letter. Please note that CMS is reviewing the need for the state to collect the detailed marital status options listed on Louisiana’s online application and may provide additional guidance to Louisiana about any required changes. Please also note that we have recently received guidance that the practice described on the state’s application to have beneficiaries pay back money to the state for bills paid is not permissible. CMS will be issuing further guidance on this issue, and will provide additional guidance to Louisiana about required changes. Name Date Created Companion to LA 18-0027 Application SPA Approval_JS_TRG 1/6/2020 4:27 PM EST If you have any questions regarding this amendment, please contact Tobias Griffin at tobias.griffin@cms.hhs.gov. Sincerely, Director Regional Operations Group Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID N/A SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date N/A State Information Page 2 of 12 Medicaid State Plan Print View 01/08/2020

State/Territory Name: Louisiana Medicaid Agency Name: Louisiana Department of Health Submission Component State Plan Amendment Medicaid CHIP Page 3 of 12 Medicaid State Plan Print View 01/08/2020

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID N/A SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date N/A SPA ID and Effective Date SPA ID LA-18-0027 Reviewable Unit Proposed Effective Date Superseded SPA ID Application 11/13/2018 LA-13-0050 Page 4 of 12 Medicaid State Plan Print View 01/08/2020

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID N/A SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The purpose of this SPA is to update the electronic Medicaid application that was developed as part of the State’s new eligibility and enrollment system. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $0 Second 2020 $0 Federal Statute / Regulation Citation 42 CFR 435, Subpart J and Subpart M Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Page 5 of 12 Medicaid State Plan Print View 01/08/2020

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID N/A SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Describe The Governor does not review State Plan material. Page 6 of 12 Medicaid State Plan Print View 01/08/2020

Medicaid State Plan Eligibility General Eligibility Requirements Application MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID LA-13-0050 User-Entered SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date 11/13/2018 A. MAGI Paper Application The state uses the following paper application(s) for individuals applying for coverage based on the applicable modified adjusted gross income (MAGI) standard. 1. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b) (1)(A) of the Affordable Care Act 2. One or more alternative single, streamlined applications developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary 3. One or more alternative applications used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single streamlined application used only for insurance affordability programs to individuals seeking assistance only through such programs 4. Other alternative applications, provided that the agency makes readily available the single streamlined application used only for insurance affordability programs to individuals seeking assistance only through such programs Page 7 of 12 Medicaid State Plan Print View 01/08/2020

Application MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID LA-13-0050 User-Entered SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date 11/13/2018 B. MAGI Online Application The state uses the following online application(s) for individuals applying for coverage based on the applicable MAGI standard. 1. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b) (1)(A) of the Affordable Care Act 2. One or more alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary Name Louisiana MAGI Online Application Screenshots or other documentation of the online application(s) has been uploaded. Document Name Date Created 18-0027 Slides 80-86 1/2/2020 12:13 PM EST 18-0027 Slides 74-79 1/2/2020 12:13 PM EST 18-0027 Slides 66-73 1/2/2020 12:13 PM EST 18-0027 Slides 53-65 1/2/2020 12:13 PM EST 18-0027 Slides 44-52 1/2/2020 12:13 PM EST 1 – 5 of 11 3. One or more alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single application used only for insurance affordability programs to individuals seeking assistance only through such programs 4. Other alternative applications, provided that the agency makes readily available the single streamlined application used only for insurance affordability programs to individuals seeking assistance only through such programs Page 8 of 12 Medicaid State Plan Print View 01/08/2020

Application MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID LA-13-0050 User-Entered SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date 11/13/2018 C. Basis Other than MAGI - Paper Application The state uses the following paper application(s) for individuals applying for coverage on a basis other than the applicable MAGI standard:  1. The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary The supplemental form(s) used to collect additional information has been uploaded. Name Date Created 18-0027 Paper Application 1/2/2020 12:14 PM EST  2. One or more applications designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary Name Medicare Savings Program (MSP) Application The paper application(s) has been uploaded. Document Name Date Created MedicareSavingsProgram Application 12/11/2018 1:05 PM EST 3. One or more applications used to apply for multiple human service programs 4. Other alternative applications Page 9 of 12 Medicaid State Plan Print View 01/08/2020

Application MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID LA-13-0050 User-Entered SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date 11/13/2018 D. Other than MAGI - Online Application The state uses the following online application(s) for individuals applying for coverage who may be eligible on a basis other than the applicable MAGI standard:  1. The single, streamlined application developed by the Secretary or one of the alternate online forms developed by the state and approved by the Secretary, and supplemental online forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary Screenshots or other documentation of the online form(s) used to the collect additional information have been uploaded Name Date Created SSP Application - Redacted - pgs 1-15 12/7/2018 4:04 PM EST SSP Application - Redacted - pgs 16-31 12/7/2018 4:06 PM EST  2. One or more application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary Name Medicare Savings Program (MSP) Application Screenshots or other documentation of the online application(s) has been uploaded. Document Name Date Created MedicareSavingsProgram Application 12/11/2018 1:04 PM EST 3. One or more application used to apply for multiple human service programs 4. Other alternative applications Page 10 of 12 Medicaid State Plan Print View 01/08/2020

Application MEDICAID | Medicaid State Plan | Eligibility | LA2018MS0008O | LA-18-0027 Package Header Package ID LA2018MS0008O Submission Type Official Approval Date 1/8/2020 Superseded SPA ID LA-13-0050 User-Entered SPA ID LA-18-0027 Initial Submission Date 12/13/2018 Effective Date 11/13/2018 E. Additional Information (optional) Louisiana is developing a paper application to mirror the electronic version. Applicants are able to apply for non-MAGI programs using the same electronic version as used for MAGI-basis; however, applicants must use the paper application for the specific non-MAGI programs such as the Medicare Savings Program (MSP). Page 11 of 12 Medicaid State Plan Print View 01/08/2020

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 1/8/2020 5:31 PM EST Page 12 of 12 Medicaid State Plan Print View 01/08/2020

Companion Letter to Louisiana SPA 18-0027 – Alternative Online Single Streamlined Application

Necessary changes to the online alternative single streamlined application Date by which changes will be completed (state to fill in missing dates within 60 days of SPA approval): 1 The state will remove the question whether someone had moved to the state in the last 12 months.

2 The question regarding AI/AN status, included for purposes of identifying individuals exempt from premiums or cost-sharing, will be revised to ask whether the applicant is: ‘eligible to receive or has ever received services.’

3 The Louisiana online system currently requires immigration document type be selected when an eligible immigration status is indicated an applicant is able to proceed through the application. LA will make changes so that individuals who are not able to provide the immigration document type or number are able to proceed through the application, submit it to the state, and provide this information at a later time.

4 The list of non-citizen statuses an applicant may choose from when attesting to being in an eligible immigration status is not comprehensive and does not allow for an attestation of all eligible statutes. Because of this, an applicant whose status is not in the dropdown list would have to choose between electing a status that is not accurate or not being able to proceed with the application. This is inconsistent with the requirement that applicants provide information under penalty of perjury, and contrary to the notice on providing accurate citizenship and non-citizen information (Power Point of application screen shots at Slide 81). LA will add to the list of non- citizen statuses the option to select “other,” so that if an individual has an immigration status not found on the list, an attestation of eligible immigration status can be made.

5 The state will make non-taxable income types dynamic to non-MAGI applicants.

General- Please note that CMS recently issued State Health Official Letter 19-003 explaining changes to Modified Adjusted Gross Income (MAGI)-based Income Methodologies. The link to that SHO is here https://www.medicaid.gov/federal-policy- guidance/downloads/sho19003.pdf. The state may want to consider this guidance as it makes changes to its application.

6 The state will make resources questions non-mandatory until after the MAGI determination is made.

7 The state will include language on the application requesting an applicant’s consent to allow the state to use IRS data to verify income.

8 The application provides notice (at Power Point slide 81) about the requirement to report changes within 10 days. In addition to changes that may affect MAGI eligibility, it requires beneficiaries report “changes in things you own.” CMS recommends that the state clarify that the language about assets will only apply to individuals eligible on a non-MAGI basis (in plain language).

Please submit the revised online application screenshots to CMS for review upon completion of each change identified above. We continue to be available to provide technical assistance. If you have any questions about your applications, please contact Tobias Griffin, tobias.griffin@cms.hhs.gov.

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 19-0009 MMDL This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

3t26t2019 Medicaid State Plan Print View cM5-r 0434 ()[4R 0138-1188 Packågê lnformãtion Pr¡or¡ty Code P2 Påckaße lD Prcgtam Näme SPA ID Version Numbet Subm¡tted By Package Þlsposlt¡on LA20l8rVS00070 N/A 14.19.0009 l\¡ARIORIE JENKINS subm¡srion Type Stat€ Reglon Package Stâtus Submiss¡on Date Approval Date Officiãl Dallâs, fX 1t22/20',19 3t22/2019 12136 PM ED1' ffi 1t12

https://macpro.cms,gov/su¡te/tempo/records/¡tem/lUBgCoojznktuLyQF9e4HpiqLQgQocLS6S6GhhLQgRfsETz-wNvEPlQRVzvbAgHdSvr'tujgqy¡,4OE.,. 2/12 3t26t2019 Medica¡d State Plan Print View DEPARTI\¡ENTOF HEALTH & HUN¡AN SERVIC€S Cenlers for lvledic¿re & Nledicaid Serv¡ces Dallås Regional Office 1301 Young street, Suite 833 Dallãs, TX 75202 Division of Medicaid and Children's Health Operations No items âvailâble lfyou håve any questions re8ardinE this amendment, please contact cheryl Rupley a|2147 67 627I or cheryl.rupley@cms.hhs.gov. NlsJen Sceele state l\ledicâid Director LouJsiana Department of Heãlth 628 North 4th Street Post Office Box 91030 Bãton Rouge, ì-4, LA 70821-9030 Rer Approval of Stâte Plån Amendment LA"1 9.0009 De¿r lVs. steele I On J¿nuary 22, 2019, the Centers for f\¡edicare and À¡ed cãid Services {CMS) received Louisiãn¿ State Plan Âmendmenl (SPÀ) LA-19'0009 to The purpose ofthis Stâte Plãn Amendment (SPA) is to adopt the CHIPRA optio¡ which will provide Nledic¿id coverâge by eliminating the five-year waiting perìod ¿nd provide coverage to lawfully residtng chrldren under the age of 19.. We approve Loulslana State Pfan Amendment {SPA) LA- 19-0009 on fi4arch 22,2019 with ån effect¡ve date(s)of February 01,2019. Name Dåte cre¿ted ffi* Sincerely, BillBrooks Director Centers for Medic¿id & CHIP Services Regionãl Opèr¿tions Group Division of N,ledicaid and Chilclren s Health Operations MIDICA D N4o.lic¡ir] sL¿le Pl¡n Uilitrili(y I l-42018N450007O I LA-]9 0009 Submission - Summary Package Header . Pâckage lD LA2018i\1s0007o subm¡ss¡on Typc officiål approv al D dte 3 I 22/ 2O1 9 Superseded SPA lD N/A state Informätion sPA tD LA-19'0009 lnit¡al subm¡ss¡on Date 1/2212019 Effectlve Date N/A Stâte/Terr¡tory Name: Louisian¿ Medlca¡d AEency Name: Louisiånã Oepãrtmcnt of Health

3t26t2019 Medicald State Plan Print View Submission Component l'}r State Plan Amendment ¡'l tMedicâid i._: cHrP

3126120'19 Medicaid State Plan Print View lrlEDlcAID Medicaid Sl;lte l,l¿¡r ElÍibiliiy I 1 2018r\4s0007() | 1319.000tr Sul¡mission - Summary Package Header Pãckãge lD LÀ2018t\450007O sublllission Type official Approvàl Ddte 3t22/2o19 Superseded SPA lD N/A SPA lD ånd Effective Däte sPA tD 14"19'0009 sPA lD LA-19-0009 tnit¡al submlssloh Dât€ 1/22l2019 Effect¡ve Dat€ N/A Superseded SPA lD LÀ-13-0054 Reviewable Unit Cltizenship and Non'Citi¿en Eligibìlity Proposed Effective Dale 2/1/2019 4t12

3126t2019 M6dicaid Stâte Plan Pr¡nt View lv4ËDìc.,AlD I N4edica d state P ¿n c igibilíry I L/1201 81v4s0007o I LÀ-r9 0009 Submission - Summary Package Header Pãckãte lD LÀ2018[,450007O SubmisslonType OffÌciâl Appfoval Date 3/2212019 Supersed€d sPA lD N/A sPA tD LA-l9-0009 lnit¡al Subm¡ss¡on Dâte 1/22l2019 Effectlvê Date N/A Executive Summäry Summary Descr¡ptlon lnclud¡ng The purposeofthisSPA is toadoptthe cHlPRAoption which willeliminate rhe live-yea r waiting period ànd provide Goals ånd objectives cover¿ge to lawfully residing children, under lhe age of 19. Federal Budget lmpact and Statute/Regulation Citation Federõl Budget lmpact Federal FiscalYear First 2019 Second 2O2O Feder¡l Statute / Regulation Citat¡on 1 903(vX4) of the Socia I secu rity Act. Supportlhg documentåt¡on of bùdEet lmpåct ls uploaded (optional). Nàme $16904 $969906 Dãte Creâted No iter¡s ãvãilable

3126t2019 Medlcaid State Plan Print View lçlEDlCAlD lvlûdic¿1rlst¡tc Plån tlíeihllíty I LA2018MS0Lì07O I t-r\-l9-0009 Submission - Summary Package Header Pâckage lD tA2018t/S0007O Subm¡sslonfype Offici¿l Approval Date 3/22/2019 Supèrseded SPA lD N/A Governor's Office Review f ) No commenl (..ì Comments received (..) No response ú/ithin 45 dâys üi orher sPA tD LA 19-0009 Inlt¡al subm¡ss¡on Date 1/22l2019 Effectlve Date N/Â Describê The Governor does not revlewSt¿te Pl¿n materiål

3t26t2019 Medicaid State Plan Pr¡nt View Medicaid State Plan Eligibility Non-Financial Eligibility Citizenship and Non-Cit¡zen Eligibility fúlDlc^lD Medic¡id SLrLe r,l¿1 I I i8ibiiity I LA2018l\¡5000i'o I l-A 19 0009 Package Header Påckage lD LA2018|\450007O SpA lD LAn9'0009 subm¡ss¡on Type Officlal In¡tiålsubmlssion Date l/2212019 apptovàl Dàte 312212019 Effect¡ve Date 2/1/2019 Superseded SPA lD LA-13-0054 Systonì-Dcrvcd Ì The stãte provides Medicaid to citizens and nationåls oflhe United States ãnd cert¿in non-ci(izens who meet ãll other L4edicaÌd ellgibility ¡equrrements under the state plan, cons¡atentw¡th requ irements of 4 2 CFR 435.406, including during å reasonâble opportunity period pending verific¿tlo n oftheir citizenship. nationãl statùs or satisfactory ir¡miSration status. A. Citizens, Nat¡onâls and Eligible Non-Citizens The st¿te provides Nledicaid eligibiìityto otherw¡se eligible indìviduè1s: 1. Who are citizens or n¿tionals of the United States; or 2. Who are qu¿lifjed non-crtizens as delined in section 431 olthePerson¿lResponsrbilityandWorkOpportunityReconcillatlo¡Act{PRWORA)(8U.S.C.S1641)or who are non-citizens treated ås refl¡gees under other federâl statutes for purposes of l\¡edlcald eligibllity, subject to the requlrements at I U.S.C. S1612(bX2), ãnd åre not restri(ted by section 403 of PRWORA (8 U.S.C, S1613); or who are non-citizens whose eligibility is required by I U,S.C. 1612(b){2XE)¿nd (F); and 3, Who have decl¿red themselves to be citizens or n¿tionãls of the unired St¿tês, or non-clrizens hâving s¿tisfactory imr¡igration st¿tus, during a reåsonãble opportunity period pending verificåtion of their citizenship, nationôlity or salsf¿ctory immlSråtion status consiste¡t with requirements o11903(x), 1137(d), 1902(ee) of the SSA ¿nd 42 CFR 435.406, 911, and 956. The re¿sonable opportunity period begins on and extends 90 dâys irom the dåte the notice ofrcason¿ble opportunity is received by the individLrã1. 'a. The agency provides for an extension ofthe reêson¿ble opportunity period for non-citizens ifthê no¡-citizen is making a good faith effort to resolve any inconslstencles or obtàin any necessary documentãtion, or the êgency neêds more (me to complete th€ verification process. Yes No b. When a reasonable opportu)ìity period fs provided, the ¿gencyfL¡rnishes benefits to otherwise eligÌble indivrdu¿ls on the fo lowing date: The date benefits are furnished isl ü¡ ì.Ihe d¿te ofthe ¿pplìcation conrainlng the declârâtion of citizenship or immigration slåtus, ìl) ii. The first d¿y ofthe month of application.

3t2612019 Medicaid State Plan Prlnt V¡ew Citizenship and Non-Cit¡zen Eligibility Packäge Header lvl[DlcAlD N4edrcaid Slate Plê'ì I Eligibrlìty I L¡201 &l\,1s0007o { LA-19.0009 Packate lD submiss¡on Type App¡ovâl Dâte Superseded SPA lD LÀ2018NtS00070 offici¿l 3122t2019 LA-13-0054 sPA rD LA-l9-0009 lnltlal subm¡ssion Date'l/22l2019 Effective Dãte 2/1/2019 B. Optional Coverage of Qualified Non-Cit¡zens The state provldes Medl.âld coveråge to all otherwlse-ellglble Qualif¡ed Non-C¡tizens whose el¡E¡bil¡ty is not restricted by se€tlon 403 of PRWORA (8 u.s.c, s1613). i¡i Yes f)No

3t26t2019 Medicald State Plan Pr¡nt View Citizenship and Non-Cit¡zen Eligibility Package Header r\4cDlcAiD I flcdÌräid Sr¡re P ¿n i Ëli8ibiliry I LA2018f\4s00070 | LA 19 0009 Package lD Subm¡ssion Type Approval Date Supersêded SPA lD LA2or8tv1s0007o offici¿l 3122/2019 14,13-0054 sPA tD LA-19,0009 ln¡tlal subm¡ss¡on Date 1/2212019 Effect¡v€ Date 2/1/2019 C. Coverage of Lawfully Residing lndividuals The state elects the optìon to provlde Medlcåld coverage to otherwlse el¡glble indlv¡duals, lawfully reslding ln the Uñlted Stâtes, ôs provlded ln sectlon 1903(vx4l ofthe Act. {:,vu' ONo i-.11. Pregnantwomen L 2, lndíviduâls under a specifiecl agel i. .ia. lndividuals under ace 21 i _) b.lndividuals under age 20 ac.lndividuals under age 19 3. An individualis considered to be lãwfully residing in the Urlited States if he or she is l¿Mully presentånd otherwise meets the eliBibility requirements in the 4. An lndiv¡dual is considered to be lâwfully present i¡ the Unrted s(¿tes if he or she is: ¿. A qualif ed non-citizen ¿s defined in I U.s.c. 1641(b) and (c); b. A non-citizen in a vãlid nonimmlgrant status, as defined in 8 U.5.C. 1101(ãX15) or otherwise under the immigr¿tion laws (as de{ined in 8 U.s.c. 1101(¿)(17)); c,Anon'citizen who h¿s been paroled into the United States in accordancewith 8 U.S.C.1182(d)f5)forless than 1ye¿r, except ior ån individual paroled for prosecution, for deferred inspection or pending remova proceedings; d. A non'c tizen who belongsto one ofthe followiñ8 classes: i, Grânted temporary resident st¿tus in ¿ccord¿nce with 8 U,S,C,1160 or 1255a, respeclively; ii. Grãnted Temporary'Protected Status (TPS) in accordance with 8 U.S.c. q1254a, ånd individuãls with pending appfications forTPS who have been grånted employment aulhorization; iil. Gr¿nted employment âutholz¿t¡on under I CFR 214a.1zlcl/) iv, Fåmily Unity beneficiaries in accord¿nce with section 301 oi Pub. L. 10'l- 649, as amended; v. lJnder Deferred Enforced Deparlure (DED) in accordânce with a decisron m¿de by the President; vr. cranted Deferred Action statusi vii, Grânted ¿n ãdministrãtive stay of removal under 8 CFR 241; v¡ii.Beneficiary ofåpproved visâ petilíon who has a pending application for adjustment ofstatus; e.lsàn individu¿lwith ¿ pending¿pplicationforasylum underS U.5.C. 1158. or forw¡thholding ofremov¿luñder 8 U.S.C.1231,or under the Convention Against Torture whol l. Has been gr¿nted employment authorization;or ii, ls under the ¿Be of 14 ¿nd has had an application pendinB for at leâst 180 days; f. Has been granted withholdinS ofremovalunderthe Conventlon AgainstTorture; I. ls ¿ child who has ¿ pending application fo¡ Speclal lmmÍEr¿ntjuvenile status ¿s described ln 8 U,S,C.1101(a){27XJ); h. ls l¿wfully prese¡t in Amerìcån Samoê uñder the immigratlon laws ofAmeric¿n Samoaj or i. ls ¿ victim ofsevere trafficking in persons, in accordance with lhe VictÍms of-Iraffickins and Violence Protection Act of 2000, Pub. L. 106.386, ¿s amended (22 U.S.C,7105(b)). j. glgplþI! An indivÍdualwith deferred action under the Department of Homeland Securitys deferred actìon for the chìldhood arrivâls process, as described in the Secretary of Homelãnd Security'sJune 15, 2012 memor¿ndum, shall not be considered to be lawfully present with respect to any of the ãbove catego¡ies in paragr¿phs (a) through {i) ofthis dcfinit¡on. i k. Other Description: 9t12

312612019 Exceptloñs: 1. lndividuals granted an administrative stay oÍ removål under I cFR 241, desclbed under 4.d.víi. âbove, ¿re not considered to be låwfully prgsent; 2. Individuals grãnted employmeDt authoriz¿tion under 8 CFR 274å.12(cX35) and (cX36), desc¡ibed under paragraph 4.d.iii., ãre not considered to be lawfully present unless they have an lmmlgr¿tion status consldered iar,!,fully present under pêrã8raph 4.a through i.

3t2612019 Medlcald State Plan Print V¡ew Citizenship ând Non-Citizen Eligibil¡ty MËDlCArl) | M"dr åio \rê(Þ Pr,r. | | r8inr'iry | rA.,O18VsOuLr4ì | L4 1q 0009 Package Header Package lD LA2018iVS0007O SPAID 14"19-0009 subm¡ssion Typ€ offici¿l lnit¡alSubmission Date 1/2212019 appfovalDâte 3/2212019 Effectlve Date 2/1/2019 Superseded SPA lD LA-13-0054 5ylLern-Derivcd D. Emergency coverage I The st¿te assures that it Þrovjdes llmlted l\ledic¿id services fortreatment ofan emergency medical condition, not related to an organ transplãnt procedure, ¿s defìned in 1903(vX3) ofthe SocialSecurity Act and implemented at 42 CFR 440.255, to the following indÌvidu¿ls who meet âll ¡edicâid eìi8ibilìty requirements, except documentation ofciuzenship or sãtisfactory immlgrâtiorì st¿tus ånd/or present ¿n SSN: 1. Quallfìed non-citizens subject to the 5 year waiting perlod descrlbed in I U.S.C. 1613(a) 2. Non-qualified non'c¡tlzens, unless covered ¿s â lâwfully residing child or pregnantwom¿n by the state under the option in accordãnce with 1903(vX4)and implemenled at 435.406(b). E. Additional lnformation (optional) ... 11t12

3126120't9 Medicaid State Plan Pr¡nt View { mi'},ìiìit¡ìiÌiil:¡ :.:iilriirirt;;1:i31r,: Repol1s Cle¡r¡ncc Officer. [4arl Stop (4-26 05, ßaltimorê, Ì\¡¿ry|¿nd 2124¡-185Û. This v¡ew was generoted on 3/26/2019 1:54 PM EDT

Reviewable Units Frint Preview Select a rev¡ewøble unit below to view in I prtnteî fríendly forndt. Tov¡ew dllthe pd.koge components ¡n o consoidoted prlnt prcv¡e\ click the "V¡ew Consol¡dqted Print PrevJew" bufton qt the botlom oI the pøge. After Eene¡ãting he consoliddted print prev¡ew you moy use your browser to prht or sove the content. The prevìew w¡ll outonoticoly ternínote afer 5 ¡f'lñutes. Reqùêst Sysl¡¡m Help should Package lnformatlon be lhcluded ¡n the consol¡dated report? ûYes (r No should Approval/Disâpproval not¡ce be ¡ncluded ¡o the consol¡dated Ìeport? 6Yes il; No should RAI data be in(luded ln the consolidated report? OYes ir No by deÍøult. AIso, on cl¡ck o¡ on h1d¡v¡dudl rev¡ewøble unìt ndme, prin@t Íiendly ¡ormdt oÍ thot tevlewdble unlt ddaa øn be vlewed. Submission Form - Rev¡ewäble Un¡ts I I Reviewable Unit g submlssÍon 'surnñary i I submissíon - Public comment i i subrìission - Tribal lnput Medicaid Eligib¡lity SpA - Reviewable Units E Rev¡ewãble Unit Proposed Effecllve Updàted By N¡ARIORIEJENKINS MARJORIE JENKINS ]VARJORIÉ,JENKIN5 Updated Date 3/2212019 11:08 AM ÉDI 1 12212019 3t24 PM ESI 1 12212019 3126 PM ESI st :: & & & or he AP st 'ât ed u' rsl Citizennhip ¡nd Non- Citlzên Ëligibiì¡ty Date 2/1120 t9 Effectìve Dâte 2rt2019 Updated By [,ARJORIEJENKINS Updated oãte && CANCEL 3/1212019 5:56 P[,4 EDT VIEW CONSOLÍDATED PRINT PRÉVIEW

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 19-0011 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202

Regional Operations Group

March 21, 2019

Our Reference: SPA LA 19-0011

Ms. Jen Steele, State Medicaid Director Department of Health 628 North 4th St. Post Office Box 91030 Baton Rouge, LA 70821-9030 Attention: Karen Barnes

Dear Ms. Steele:

We have reviewed the State’s proposed amendment to the Louisiana State Plan submitted under Transmittal Number 19-0011 dated March 13, 2019. This state plan amendment proposes to update the Code of Federal Regulations (CFR) citation on the state plan page.

Based on the information submitted, we have approved the amendment for incorporation into the official Louisiana State Plan with an effective date change of January 1, 2019. A copy of the CMS-179 and approved plan pages are enclosed with this letter.

If you have any questions, please contact Cheryl Rupley at (214) 767-6278 or by email at Cheryl.Rupley@cms.hhs.gov.

Sincerely,

Bill Brooks

Director

Centers for Medicaid & CHIP Services

Regional Operations Group

March 13, 2019 March 21, 2019 January 1, 2019 Bill Brooks Director, Centers for Medicaid & CHIP Services Regional Operations Group

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT ATTACHMENT 3.1-A MEDICAL ASSISTANCE PROGRAM Item 18, Page 7

STATE OF LOUISIANA

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATION ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED AS FOLLOWS:

TN

Approval Date

Effective Date

Supersedes TN

The following are levels of care for reimbursement of hospice services:

A. Inpatient Respite Care Day

An inpatient respite care day is a day on which the individual receives care in an approved facility on a short-term basis, not to exceed five days in any one election period, to relieve the family members or other persons caring for the individual at home. An approved facility is one that meets the standards as provided in 42 CFR Part 418. This service cannot be delivered to individuals already residing in a nursing facility.

B. General Inpatient Care Day

A general inpatient care day is a day on which an individual receives general inpatient care in an inpatient facility that meets the standards as provided in 42 CFR Part 418 and for the purpose of pain control or acute or chronic symptom management which cannot be managed in other settings.

C. Routine Home Care

A routine home care day is a day on which an individual who has elected to receive hospice care is at home and is not receiving continuous home care. The routine home care rate is paid for each day the recipient is under the care of the hospice and not receiving one of the other categories of care. This rate is paid without regard to the volume or intensity of routine home care services provided on any given day.

D. Continuous Home Care

Continuous home care is only furnished during brief periods of medical crisis and only as necessary to maintain the terminally ill recipient at home. A period of medical crisis is when a recipient requires continuous care, which is primarily nursing care to achieve palliation or management of acute medical symptoms. Nursing care must be provided by either a registered nurse or a licensed practical nurse and a nurse must be providing care for more than half of the period of care. 19-0011 13-0047 3-21-19 1-01-19 State: Louisiana Date Received: 3-13-19 Date Approved: 3-21-19 Date Effective: 1-01-19 Transmittal Number: 19-0011

Records / Submission Packages LA - Submission Package - LA2019MS0001O - (LA-19-0023) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID LA2019MS0001O Program Name N/A SPA ID LA-19-0023 Version Number 4 Submitted By MARJORIE JENKINS Package Disposition Priority Code P2 Submission Type Official State LA Region Dallas, TX Package Status Approved Submission Date 10/30/2019 Approval Date 12/20/2019 5:08 AM EST Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions Page 1 of 36 Medicaid State Plan Print View 12/23/2019

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, TX 75202 Division of Medicaid and Children's Health Operations December 20, 2019 Cindy Rives Acting State Medicaid Director Louisiana Department of Health 628 North 4th Street Baton Rouge, LA, LA 70802 Re: Approval of State Plan Amendment LA-19-0023 Dear Cindy Rives: On October 30, 2019, the Centers for Medicare and Medicaid Services (CMS) received Louisiana State Plan Amendment (SPA) LA-19-0023 to amend the provisions governing financial eligibility in the Medical Assistance Program in order to disregard all resources in eligibility determinations for all Medicare Savings Programs.. We approve Louisiana State Plan Amendment (SPA) LA-19-0023 on December 20, 2019 with an effective date(s) of October 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Tobias Griffin at tobias.griffin@cms.hhs.gov. Sincerely, Director Regional Operations Group Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID N/A SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date N/A State Information State/Territory Name: Louisiana Medicaid Agency Name: Louisiana Department of Health Submission Component State Plan Amendment Medicaid CHIP Page 2 of 36 Medicaid State Plan Print View 12/23/2019

Page 3 of 36 Medicaid State Plan Print View 12/23/2019

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID N/A SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date N/A SPA ID and Effective Date SPA ID LA-19-0023 Reviewable Unit Proposed Effective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 10/1/2019 New Non-MAGI Methodologies 10/1/2019 New Mandatory Eligibility Groups 10/1/2019 LA-16-0004 Qualified Medicare Beneficiaries 10/1/2019 LA-11-07 Qualified Disabled and Working Individuals 10/1/2019 LA-11-07 Specified Low Income Medicare Beneficiaries 10/1/2019 LA-11-07 Qualifying Individuals 10/1/2019 LA-11-07 Optional Eligibility Groups 10/1/2019 LA-14-0028 Page Number of the Superseded Plan Section or Attachment (If Applicable): Page 4 of 36 Medicaid State Plan Print View 12/23/2019

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID N/A SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The purpose of this SPA is to amend the provisions governing financial eligibility in the Medical Assistance Program in order to disregard all resources in eligibility determinations for all Medicare Savings Programs. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2020 $171620 Second 2021 $893963 Federal Statute / Regulation Citation Sections 1902(a)(10)(A)(i), 1902(a)(10)(E)(iii) 1902(a)(10)(E)(iv) of the Social Security Act Supporting documentation of budget impact is uploaded (optional). Name Date Created 19-0023 Fiscal Worksheet 9/26/2019 12:34 PM EDT Page 5 of 36 Medicaid State Plan Print View 12/23/2019

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID N/A SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Describe The Governor does not review State Plan material. Page 6 of 36 Medicaid State Plan Print View 12/23/2019

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID New User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: 1. SSA Eligibility Determination State (1634 State) The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneficiaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines financial eligibility based on SSI income and resource methodologies. 2. State Eligibility Determination (SSI Criteria State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility based on SSI income and resource methodologies. 3. State Eligibility Determination (209(b) State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) Page 7 of 36 Medicaid State Plan Print View 12/23/2019

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID New User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831. A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the financial methodologies of either the SSI program or the AFDC program in effect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). Yes No 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group. Page 8 of 36 Medicaid State Plan Print View 12/23/2019

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID New User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 C. Financial Responsibility of Relatives 1. In determining financial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources. ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in effect as of July 16, 1996. Page 9 of 36 Medicaid State Plan Print View 12/23/2019

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID New User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identified below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state defines family size for one or more of the following FPL eligibility groups to include others beyond those identified in D.1. and D.2. Yes No a. Qualified Medicare Beneficiaries (described in section 1902(a)(10)(E)(i) of the Act) b. Specified Low Income Medicare Beneficiaries (described in section 1902(a)(10)(E)(iii) of the Act) c. Qualifying Individuals (described in section 1902(a)(10)(E)(iv) of the Act) d. Qualified Disabled and Working Individuals (described in section 1902(a)(10)(E)(ii) of the Act) e. Age and Disability-Related Poverty Level (described in section 1902(a)(10)(A)(ii)(X) of the Act) f. Work Incentives (described in section 1902(a)(10)(A)(ii)(XIII) of the Act)  g. Family Opportunity Act Children with a Disability (described in section 1902(a)(10)(A)(ii)(XIX) of the Act) h. Individuals Receiving State Plan Home and Community-Based Services (described in 42 CFR 435.219) 4. The state uses the same definition of family size for the selected FPL eligibility groups. Yes No 5. For the selected FPL eligibility groups, family size is defined as follows: a. Family is defined as the individual, the individual's spouse and the individual's children under age 18 living together in the same household. If the individual is a child, the child's parents and siblings under age 18 are also included in the household if living together. b. The state uses another definition of family. Name of other definition: Description: Family Opportunity Act Children with a Disability The Department defines family unit as the following members living in the household: applicant/enrollee child(ren) with disabilities, natural or legal parent(s) and siblings under age 19 (not including step parents or step siblings). Page 10 of 36 Medicaid State Plan Print View 12/23/2019

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID New User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 E. Use of MAGI-like Methodologies 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in effect as of July 16, 1996. Yes No Page 11 of 36 Medicaid State Plan Print View 12/23/2019

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID New User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that would be deducted in determining eligibility under SSI. 2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income. Page 12 of 36 Medicaid State Plan Print View 12/23/2019

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID New User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 G. Additional Information (optional) Page 13 of 36 Medicaid State Plan Print View 12/23/2019

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-16-0004 System-Derived SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW NEW             Page 14 of 36 Medicaid State Plan Print View 12/23/2019

Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Working Individuals under 1619(b) Qualified Medicare Beneficiaries APPROVED Qualified Disabled and Working Individuals APPROVED Specified Low Income Medicare Beneficiaries APPROVED Qualifying Individuals APPROVED         Page 15 of 36 Medicaid State Plan Print View 12/23/2019

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-16-0004 System-Derived SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 B. The state elects the Adult Group, described at 42 CFR 435.119. Yes No Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A  Page 16 of 36 Medicaid State Plan Print View 12/23/2019

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Individuals with income equal to or less than 100% of the FPL, who are entitled to Medicare Part A, and who qualify for Medicare cost-sharing. Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 The state covers the mandatory qualified Medicare beneficiaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are entitled to hospital insurance benefits under part A of title XVIII (Medicare Part A), including individuals who have purchased a premium to enroll in Part A. 2. Have income and resources at or below the standard for this group. Page 17 of 36 Medicaid State Plan Print View 12/23/2019

Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. Yes No The less restrictive income methodologies are:  General income disregard: Name of disregard: Description: In-kind Support and Maintenance In-kind support and maintenance as defined by the federal SSI program in the determination of Medicaid eligibility for Medically Needy, Qualified Medicare Beneficiaries, Specified Low Income Beneficiaries, and Qualified Individuals, is disregarded. 3. Less restrictive methodologies are used in calculating countable resources. Yes No The less restrictive resource methodologies are:  All resources are disregarded. No resource test is applied. Page 18 of 36 Medicaid State Plan Print View 12/23/2019

Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 C. Income Standard Used The amount of the income standard for this group is 100% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-benefit low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment of co-insurance and deductibles for Medicare Parts A, B and C and payment for the premiums for Medicare Parts A and B. Medical assistance begins the first day of the month following the month in which the individual is determined to qualify for this eligibility group. Page 19 of 36 Medicaid State Plan Print View 12/23/2019

Qualified Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 F. Additional Information (optional) Page 20 of 36 Medicaid State Plan Print View 12/23/2019

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualified Disabled and Working Individuals MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Working individuals with a disability, with income equal to or less than 200% of the FPL, who are entitled to Medicare Part A under section 1818A, and who qualify for payment of Medicare Part A premiums. Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 The state covers the mandatory qualified disabled and working individuals group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are entitled to purchase a premium to enroll for hospital insurance benefits under part A of title XVIII (Medicare Part A) pursuant to section 1818A (hospital insurance benefits for disabled individuals who have exhausted other entitlement). 2. Have income and resources at or below the standard for this group. 3. Are not otherwise eligible for medical assistance. B. Financial Methodologies SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. C. Income Standard Used The amount of the income standard for this group is 200% FPL. D. Resource Standard Used The resource standard is two times the standard used in the SSI program. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part A premiums. Page 21 of 36 Medicaid State Plan Print View 12/23/2019

Qualified Disabled and Working Individuals MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 F. Additional Information (optional) Page 22 of 36 Medicaid State Plan Print View 12/23/2019

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Specified Low Income Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Individuals with income greater than 100% and less than or equal to 120% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 The state covers the mandatory specified low income Medicare beneficiaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would qualify as Qualified Medicare Beneficiaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group. 2. Have income and resources at or below the standard for this group. Page 23 of 36 Medicaid State Plan Print View 12/23/2019

Specified Low Income Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. Yes No The less restrictive income methodologies are:  General income disregard: Name of disregard: Description: In-kind Support and Maintenance In-kind support and maintenance as defined by the federal SSI program in the determination of Medicaid eligibility for Medically Needy, Qualified Medicare Beneficiaries, Specified Low Income Beneficiaries, and Qualified Individuals, is disregarded. 3. Less restrictive methodologies are used in calculating countable resources. Yes No The less restrictive resource methodologies are:  All resources are disregarded. No resource test is applied. Page 24 of 36 Medicaid State Plan Print View 12/23/2019

Specified Low Income Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 C. Income Standard Used Family income must be above 100% FPL and at or below 120% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-benefit low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums. Page 25 of 36 Medicaid State Plan Print View 12/23/2019

Specified Low Income Medicare Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 F. Additional Information (optional) Page 26 of 36 Medicaid State Plan Print View 12/23/2019

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Individuals with income between 120% and 135% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 The state covers the mandatory qualifying individuals group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet all of the following criteria: 1. Would qualify as Qualified Medicare Beneficiaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group. 2. Are not otherwise eligible for Medicaid under the state plan. 3. Have income and resources at or below the standard for this group. Page 27 of 36 Medicaid State Plan Print View 12/23/2019

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. Yes No The less restrictive income methodologies are:  General income disregard: Name of disregard: Description: In-kind Support and Maintenance In-kind support and maintenance as defined by the federal SSI program in the determination of Medicaid eligibility for Medically Needy, Qualified Medicare Beneficiaries, Specified Low Income Beneficiaries, and Qualified Individuals, is disregarded. 3. Less restrictive methodologies are used in calculating countable resources. Yes No The less restrictive resource methodologies are:  All resources are disregarded. No resource test is applied. Page 28 of 36 Medicaid State Plan Print View 12/23/2019

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 C. Income Standard Used Family income must be above 120% FPL and at or below 135% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-benefit low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums. Page 29 of 36 Medicaid State Plan Print View 12/23/2019

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-11-07 User-Entered SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 F. Additional Information (optional) Page 30 of 36 Medicaid State Plan Print View 12/23/2019

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-14-0028 System-Derived SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. Yes No The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 CONVERTED Children with Non- IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services CONVERTED Individuals with Tuberculosis CONVERTED Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled        Page 31 of 36 Medicaid State Plan Print View 12/23/2019

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization NEW Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneficiaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW        Page 32 of 36 Medicaid State Plan Print View 12/23/2019

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-14-0028 System-Derived SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. Yes No The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women NEW Medically Needy Children under Age 18 NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classifications of Individuals under Age 21 NEW Medically Needy Parents and Other Caretaker Relatives NEW Aged, Blind and Disabled      Page 33 of 36 Medicaid State Plan Print View 12/23/2019

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Populations Based on Age, Blindness or Disability NEW  Page 34 of 36 Medicaid State Plan Print View 12/23/2019

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | LA2019MS0001O | LA-19-0023 Package Header Package ID LA2019MS0001O Submission Type Official Approval Date 12/20/2019 Superseded SPA ID LA-14-0028 System-Derived SPA ID LA-19-0023 Initial Submission Date 10/30/2019 Effective Date 10/1/2019 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A Page 35 of 36 Medicaid State Plan Print View 12/23/2019

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/23/2019 11:40 AM EST Page 36 of 36 Medicaid State Plan Print View 12/23/2019

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 19-0027 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-26-12 Baltimore, Maryland 21244-1850 (crvrs ctNltns foR MEDTcAtE & MËotc^tD sfnvrcfs CENTEN TOß MEDICAID & CHIP SERVICES Financial Management Group February 10,2020 Ms. Erin Campbell Interim Medicaid Director Bureau of Health Services Financing Department of Health 628 North Fourth Street Post Office Box 91030 Baton Rouge, Louisiana 70821-9030 RE: Louisiana 19-0027 Dear Ms. Campbell: \ü/e have reviewed the proposed amendment to Attachment 4.I9-A of your Medicaid State plan submitted under transmittal number (TN) 19-0027. The SPA proposes to establish qualiffing criteria and a for disproportionate share hospital (DSH) payment methodology for'West Jefferson Hospital, a major medical center located in southeastern area of Louisiana. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. Based upon the information provided by the State, we have approved the amendment for incorporation into the official Louisiana State Plan with an effective date of January l, 2020. A copy of the CMS-179 and the approve plan pages are enclosed with this letter. If you have any questions, please call Tamara Sampson at (214) 767-6431 Sincerely, Director Enclosures

1 , TRANSMITTAL NUi¡BER OEPÁRTMENI OF HEALIH AND HUMAN SERVICES CENTERS MEÐICARE & TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FoR: CENTERS FOR MED|CARE & MEDtcAtD SERVtcES TO: REGIONAL ADMINISÍRAToR CENTERS FOR MEÞICARE & MEDICAID sÉRVtcEs OF OMB No 093t¡ 01t:l SÏATE Louisian¡ 3. PROGRAM IDENTIFICATION: TITLE XiX OF THÊ SOCIAL SECURITY ACT 4. PROPOSED EFFECTIVE DATE January I, 2020 MA T NEW STATE PLAN 8 AMENOMENT TO BÊ CONSIDEREO AS ÑEW PLAN E AMENÞMENT IO IF THIS 6. FEDERAL STATUTE/REGULATION CITATION 42 CFlt 447 Subpnrt t! 8. PAGE NUMEER OF THE PLAN SECTION OR ATTACHMENT Âltnchrncnt 4.I9-Á, Itcnr l, pagc lftl Attachmcnt 4.19-l\, ltcnr l, Page l0k(S)(c) Att¿¡chmont 4.19-4, Itcrn l, l>agc l0k(5)(f) for eâch 7, FEDERAL BUDGET IMPACT a. FFY 2020 b. FFY 2021 $ I3.8lfì.(r74 $ t4.399.5t3 9. PAGE NUMBER OF THE SUPERSEDËD PLAN SECTION OR ATTACHMENT (t/,Apprbab,e) Sanrc (TN 16-0018) Sane (TN I fl-0009) Nonc - ncl pngc 10. SUBJECT OF AMENDMENT pulposc of th¡s SPA is to cstâblish a qunli critcria l¡nd a disproportíon âtc sh¿¡rc hospital (DSlt) paynrcnt nrcthorlology for major nrctlictrl ccntcrs hcatcd in thc southcnstcrn ¿¡rca of Louisiana. 1 1. GOVERNOR'S REVTEW (Check One) Í oovrn¡roR's oFFrcE REpoRTED No I co¡¡r'ururs or GovERNoR,s oFFrcE COMMENI ENCLOSEÞ OF E OTHER, AS SPECIFIED The Governor does not review Slate plan måterial. 12, SIGNATURE OF AGENCY OFFICIAL 13. TYPED NAME 14, TITLE I5, DATE SUBMITÏEÐ Novcmbcr 2 2019 17. DATE RECEIVED 2019 I9, EFFECTIVE DATE OF APPROVED MATERIAL 2I, TYPED NAME 23. REMARKS ld. Gcc M FOR REGIONAL OFFICE USE ONLY PLAN APPROVED . ONE COPY ATTACHED 20. 22 16. RETURN 1O .lcn Slocle, Modjc:¡id D¡rcctor Statc of Louisian¿¡ I)cl)ârtmcnr of' llcalth (r28 North 4rl, Strccf P,O. Iìox 91030 llafon llougo, LA 71821-9030 REGIONAL OFFICIAL Is DATE APPRoVEÞ February lo, 2o2o FORM CMS-170 (07/9?) Kristin Fan lnstructions on Bãck

S'l'A'l'ti l'L^N tJNDlllì 'l'l'l'l-li XIX Ol: 'l'llli SOCrlAl. SliC:Ulì,l'l'Y ^(:'t M IIDICA I, A SSIS'I'ANCI] PIìOGIì.AM ^'l"t'ACr rMt:N't' 4. I 9-^ Itcl¡r l, l,agc l0 <l s]'^'fD otj t.ot Jtst^NA PAYM llN'¡' l;OR M llDlc^ l. ^Nl) llljM lir)l^ l. CA ¡ll: ^N l) Sl::lìV l(tt':S MLl',l't'lol)s AND s'l'ANl)Alì,DS l:Olì tis'l'Alll,tsHrN(ì pAYMrìN'r RA't'tis - tN-1,^'l'il:.N't'ilost,t1'^t, c^tìtì c. Mcet thc clclì¡ritio¡r ol'a public no¡ì-nu'al conuìlunity hospital as delì¡rcd in I.D.3.0. belorv: q l. l:llbctivc Sc¡:tentbcr 15. 200(¡, bc a ¡rrivatc ¡rorr-rural cornrnunily hospital as dclìncd in I.D.3.lì [rclos'; or g. Efïì:ctivc Novcnrbcr 3. 1997, trc a snrall rural lros¡rital as dctinsd in l.l).3.b.: llr h. Illbctivc fbr clatcs t¡l'scrvicc on or aficr.lanuary l. 2008, bc a Mcdicaicl cnrollccl nolt-stalc acutc carc hospital that cx¡rancls tlrcir existing distinct part psyclriatric tlltit or that cnrolls a rìcw clistinct pilrt psychi¿ltric unit. a¡rl signs an atlclclldt¡tn to tltc l)rovitlcr l'lnrollrrrcllt lbrrn (l,lì--50) by April 3. 200tt rvith thc Dcpartmcnt ol'l"lcalth. Ollicc of'llehavi<l¡.al I lcaltlr: g¡ i. lillbctivc li¡r datcs ol'scrvicc o¡r or alìcr January 2 I . 20 I 0. bc a hospital participtting in thc l.,ow lnconrc and Nccdy Carc Collaboration; or .i. Ellbctivc lbr clatcs ol'scrvicc on or allcr May 24, 2014. rrrcct thc delinition of a Lot¡isiana [,orv-lncolnc Âcaclclrric l.los¡lital: or k. IrITL'ctivc fbr <l¡rtcs of'scrviccs o¡l or allcr .lunc 30. 201(r. bc a hos¡rital dcJìned its a nraior lncclical ccrìtcr in tlrc ccntr¿rl ancl nortlrenl arcas ol' [,ouisiana: or l. tìtl'cctivc lìlr clates ol'scrvicc o¡t or nllcr.lunc 30. 2018. bc a nraior nrcctical centcr with a spccializcclcarc t¡¡lit locatccl i¡r thc soutlrwcstcnt area cll'thc stale: or m. llflì:ctivc lìlr datcs ol'sct'r,icc ort or allcr'.f anuary l. 2020, bc a nraior nlcclical centcr locatccl in thc southcastern arca <tl'thc state: and n. ln additio¡l to thc c¡ualification critcria outlincd in LD.l.a.-m. abovc, cll'cctivc .luly l, 1994, thc qualilying clis¡rrcportio¡rate sharc hospital must also havc a Mcdicaid in¡laticnt utilization ratc ol'at lcast olrc ¡rcrccnt. Ocn cral l)rov isions for l)isp ro¡rortion atc S hare I'ay nrcnts a. 'l'ot¿rl culnulativc tlis¡rmpoltionatc sharc paylncnts u¡tdcr an¡,and all DSI-l p¿lymcnt mctltoclologics shall ttot cxcccct thc l'cclcral disproportionatc slrarc state all<ltnlcnt lirr I.ouisiana l'or cach lbdcral liscal ycar. 'l'hc t)e¡lartnlcnt shall makc ncccssary tkxvlrrva¡rl atlj ustrncnts to hos¡ti ttls' cl isproport ion¿rtc shnrc payntcnts to rcnlairt rvithin tlrc lbclcral dis¡rro¡rrtiotìatc sharc allotmsnt. 2. 'f'N tq-oo)j State: Louisiana Date Received: November 27,2019 Date Approved: p¿t¡¡¡¡q lO¡ tô2 Date Effective: January l, /020 'I'ransmittal Number: 19-0027 Su¡lcrscdes 'rN 16-0018 ¡r¡rrovn | ¡;¡¡s 02-10-2020 lìf fcctive l)atc l-l-2020

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE OF LOUISIANA PAYMENT FOR MEDICAI- AND REMEDIAL CARE AND SERVICES ATTACHMENT 4.I9-A Item l, Page l0k(5)(e) METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - IN-PATIENT HOSPITAL CARE 3. Aggregate DSH payments for hospitals that receive payment from this category, and any other DSH category, shall not exceed the hospital's specific DSH limit. If payments calculated under this methodology would cause a hospital's aggregate DSH payment to exceed the limit, the payment from this category shall be capped at the hospital's specific DSH limit. 4. A pro rata decrease, necessitated by conditions specified in B.l, above, for hospitals described in this section, will be calculated based on the ratio determined by dividing the hospital's uncompensated costs by the uncompensated costs for all of the qualifuing hospitals described in this section, then multiplying by the amount of disproportionate share payments calculated in excess of the federal DSH allotment. a. If additional payments or recoupments are required based on the results of the mandated DSH audit report, they shall be made within one year after the final report for the state fiscal year is submitted to the Centers for Medicare and Medicaid Services (CMS). b. Payments shall be limited to the aggregate amount recouped from the qualiffing hospitals described in this section, based on the reported DSH audit results. Major Medical Centers Located in the Southeastern Area of the State A. Qualiffing Criteria Effective for dates of service on or after January l,2lz},hospitals qualiffing for payments as major medical centers located in the southeastern area of the state shall meet the following criteria: l. be a private, non-rural hospital located in Louisiana Department of Health administrative region l; 2. have at least 175 inpatient beds as reported on the Medicare/Medicaid cost report, WorksheetS-3,column2,linesl-lS,forthe(SFY)endingJune30,20l8. Forqualification purposes, inpatient beds shall exclude nursery and Medicare-designated distinct part psychiatric unit beds; 3. is certifìed as an advanced comprehensive stroke center by the Joint Commission as of June 30, 2018; and 4. does not qualify as a Louisiana low-income academic hospital. The only hospital that meets the above criteria is West Jefferson Hospital TN re-oôno 1 Approval Date 02-10-2020 Effective Date 1-l J.ú.0 TN rq-oo, State: Louisiana Date Received: November 27,2019 Date Approved t f ¿Ç¡ ¡¡.t r "l l0 1tU?) Date Effective: January 1f020 'l'ransmittal Number: 19-0027 Supersedes

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE OF LOUISIANA PAYMENT FOR MEDICAL AND REMEDIAL CARE AND SERVICES ATTACHMENT 4.I9-A Item l, Page l0k(5xf) METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - IN-PATIENT HOSPITAL CARE B. Payment Methodology Effective for dates of service on or after January I,2020, each qualiþing hospital shall be paid a DSH adjustment payment which is the pro rata amount calculated by dividing their hospital specific allowable uncompensated care costs by the total allowable uncompensated care costs for all hospitals quali$ing under this category and multiplying by the funding appropriated by the Louisiana Legislature in the applicable SFY for this category of hospitals. l. Costs, patient specific data and documentation that qualifying criteria is met shall be submitted in a format specified by the Department. 2. Reported uncompensated care costs shall be reviewed by the Department to ensure compliance with the reasonable costs defìnition in the Medicare Provider Reimbursement Manual. Allowable uncompensated care costs must be calculated using the Medicare/Medicaid cost report methodology. 3. Aggregate DSH payments for hospitals that receive payment from this category, and any other DSH category, shall not exceed the hospital's specific DSH limit. If payments calculated under this methodology would cause a hospital's aggregate DSH payment to exceed the limit, the payment from this category shall be capped at the hospital's specific DSH limit. 4. A pro rata decrease, necessitated by conditions specified in 8.3, above, for hospitals described in this Section, will be calculated based on the ratio determined by dividing the hospital's uncompensated costs by the uncompensated costs for all of the qualifuing hospitals described in this Section, then multiplying by the amount of disproportionate share payments calculated in excess of the federal DSH allotment. a. If additional payments or recoupments are required based on the results of the mandated DSH audit report, they shall may be made within one year after the final report for the SFY is submitted to the Centers for Medicare and Medicaid Services (CMS). b. Additional payments shall be limited to the aggregate amount recouped from the qualifuing hospitals described in this section, based on the reported DSH audit results. TN 19-0027 Supersedes TN New Page Effective Date Received: November 27, 2019 A,ppr ov ed : ( ¿þ fiiþ.t q I ot Effective: January l, /020 Transmittal Number: 19-0027 Louisiana ApprovalDate 02-10-2020

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 20-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, MD 21244-1850 Financial Management Group May 27, 2020 Ms. Erin Campbell Interim Medicaid Director Bureau of Health Services Financing Department of Health 628 North Fourth Street Post Office Box 91030 Baton Rouge, Louisiana 70821-9030 RE: Louisiana State Plan Amendment (SPA) 20-0003 Dear Ms. Campbell: We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid state plan submitted under transmittal number (TN) 20-0003 effective for services on or after January 1, 2020. This SPA is to amend the provisions governing the definition of a public, non- rural community hospital, to include Thibodaux Regional Medical Center, formerly owned by a parish, city or other local government or instrumentality, after January 1, 2019. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the regulations at 42 CFR 447 Subpart C. We hereby inform you that Medicaid State plan amendment 20-0003 is approved effective January 1,2020. We are enclosing the HCFA-179 and the amended plan pages. If you have any questions, please call Tom Caughey at (517) 487-8598. Sincerely, Kristin Fan Director Enclosure

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

FORM APPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

1. TRANSMITTAL NUMBER 2. STATE 20-0003 Louisiana

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

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

4. PROPOSED EFFECTIVE DATE January 1, 2020

5. TYPE OF PLAN MATERIAL (Check One) © NEW STATE PLAN

OC AMENDMENT TO BE CONSIDERED AS NEW PLAN

& AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION

42 CFR 447 Subpart E

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

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Attachment 4.19-A, Item 1, Page 10k(2) Attachment 4.19-A, Item 1, Page 10k(3)

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

Same (TN 14-0012) Same (TN 16-0014)

10. SUBJECT OF AMENDMENT The purpose of this SPA is to amend the provisions governing the definition of a public, non-rural community hospital, to include Thibodaux Regional Medical Center, formerly owned by a parish, city or other local government or instrumentality, after January 1, 2019.

11. GOVERNOR'S REVIEW (Check One)

O GOVERNOR'S OFFICE REPORTED NO COMMENT O COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

& OTHER, AS SPECIFIED The Governor does not review State Plan material.

FFICIAL

13. TYPED NAME Cindy Rives, designee for Stephen R. Russo, JD

14, TITLE Interim Secretary

15. DATE SUBMITTED March 9, 2020

16. RETURN TO Erin Campbell, Acting Medicaid Director State of Louisiana Department of Health 628 North 4" Street P.O. Box 91030 Baton Rouge, LA 70821-9030

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED

18. DATE APPROVED 05/27/20

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL 01/01/20

a

21. TYPED NAME sys Kristin Fan

22. TITLE Director, FMG

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

ST A TE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM ATTACHMENT 4.19-A Item 1, Page 10 k(2) STATE OF LOUISIANA PAYMENT FOR MEDICAL AND REMEDIAL CARE AND SERVICES METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RA TES - INPATIENT HOSP IT AL CARE (ii) supporting patient specific demographic data that does not identify individuals, but is sufficient for audit of the hospitals' compliance with the Medicaid ineligibility requirement as required by the Department, including: (a) patient age; (b) family size; ( c) number of dependent children; and (d) household income. e. Non-state (public), Non-Rural Community Hospitals Disproportionate Share Hospital (DSH) 1) A public, non-rural community hospital is defined as any non-state, non-rural hospital (including hospitals with distinct part psychiatric units, long term care hospitals, rehabilitation, and free standing psychiatric hospitals) that meets the qualifying criteria for disproportionate share hospital in I.D. l. and is either: (i) owned by a parish, city, or other local governmental agency or instrumentality; or (ii) Thibodaux Regional Medical Center, formerly owned by a parish, city, or other local government or instrumentality after January 1, 2019. 2) Uncompensated care costs are defined as the hospital's costs of furnishing inpatient and outpatient hospital services, net of Medicare costs, Medicaid payments (excluding disproportionate share payments), costs associated with patients who have insurance for services provided, private payer payments, and all other inpatient and outpatient payments received from patients. Uncompensated care costs payments for the period(s) covering the state fiscal year to which the payment is applicable shall be calculated as follows: (i) Initial Payment - Based on data per the most recently filed Medicare cost report. (ii) Interim Reconciliation Payment - Based on as filed cost report(s) for applicable state fiscal year. (iii) Final Payment - Based on the final uncompensated care costs as calculated per the CMS mandated audit for the state fiscal year. TN ______ _ Approval Date ______ _ Effective Date ------ Supersedes TN ______ _ 1-1-2020 14-0012 20-003 05/27/20

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT ATTACHMENT 4.19-A MEDICAL ASSISTANCE PROGRAM Item 1, Page 10 k(3)

STATE OF LOUISIANA

PAYMENT FOR MEDICAL AND REMEDIAL CARE AND SERVICES

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL CARE

3)

4)

5)

6)

DSH payments to individual public non-rural community hospitals shall be equal to 100 percent of the hospital’s uncompensated costs. DSH payments under this payment methodology shall be subject to the adjustment provision below in §3. Payments will be made annually.

In the event it is necessary to reduce the amount of disproportionate share payments to remain within the federal disproportionate share allotment for this group, the Department shall calculate a pro rata decrease for each public non-rural community hospital based on the ratio determined by dividing that hospital's uncompensated cost by the total uncompensated cost for all qualifying public non- tural community hospitals during the state fiscal year; and then multiplying by the amount of disproportionate share payments calculated in excess of the federal disproportionate allotment.

It is mandatory that hospitals seek all third party payments including Medicare, Medicaid and other third party carriers and payments from patients. Hospitals must certify that excluded from net uncompensated cost are any costs for the care of persons eligible for Medicaid at the time of registration. Hospitals must maintain a log documenting the provision of uninsured care as directed by the Department. Hospitals must adjust uninsured charges to reflect retroactive Medicaid eligibility determination.

A hospital receiving DSH payments shall furnish emergency and nonemergency services to uninsured persons with family incomes less than or equal to 100 percent of the federal poverty level on an equal basis to insured patients.

Aggregate DSH payments for hospitals that receive payment from this category, and any other DSH category, shall not exceed the hospital’s specific DSH limit. If payments calculated under this methodology would cause a hospital’s aggregate DSH payment to exceed the limit, the payment from this category shall be capped at the hospital’s specific DSH limit. The remaining payments shall be redistributed to the other hospitals in accordance with these provisions.

TN _ 20-0003

Supersedes ™ 16-0014

Approval Date _ 05/27/20 Effective Date 1-1-2020

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 20-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 April 20, 2020 Ms. Ruth Johnson Medicaid Director State of Louisiana, Department of Health 628 N 4th St. P.O. Box 91030 Baton Rouge, LA 70821-9030 Re: Louisiana State Plan Amendment (SPA) 20-0004 Dear Ms. Johnson: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID- 19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20- 0004. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. The State of Louisiana requested a modification of the requirement to submit SPAs related to the COVID-19 emergency by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 C.F.R. §430.20. CMS is approving this request pursuant to section 1135(b)(5) of the Act.

The State of Louisiana also requested a waiver of public notice requirements applicable to the state plan amendment (SPA) submission process. Public notice for SPAs is required under 42 C.F.R §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to ABPs. These requirements help to ensure that the affected public has reasonable opportunity to comment on these SPAs. CMS recognizes that during this public health emergency, Louisiana must act expeditiously to protect and serve the general public. Therefore, under section 1135(b)(1)(C) and 1135(b)(5) of the Act, CMS is approving the state’s request to waive these notice requirements applicable to this SPA. The State of Louisiana also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Under section 1135(b)(5) of the Act, CMS is also approving the State of Louisiana’s request for flexibility to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These approvals under section 1135 only apply with respect to SPAs that provide or increase beneficiary access to items and services related to COVID-19 (such as cost sharing waivers, payment rate increases, or amendments to ABPs to add services or providers) and that would not restrict or limit payment or services or otherwise burden beneficiaries and providers, and that are temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 emergency (or any extension thereof). Even though CMS is approving this waiver, we encourage the state to make all relevant information available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Louisiana’s Medicaid SPA Transmittal Number 20-0004 is approved effective March 1, 2020. Please note that the effective date for the new COVID-19 testing eligibility group described at section 1902(a)(10)(A)(ii)(XXIII) of the Act is March 18, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Tobias Griffin at 214-767-4425 or by email at tobias.griffin@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Louisiana and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.04 20 11 21:40 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF __ {1. TRANSMITTAL NUMBER 2. STATE STATE PLAN MATERIAL 20-0004 Louisiana

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

TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES March 1, 2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One) CO NEW STATE PLAN 1) AMENDMENT TO BE CONSIDERED ASNEW PLAN = @ AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THiS IS AN AMENDMENT (Separate transmittal for each amendment)

6, FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY 2020 $@ 14.147.120 Section 1135 of the Social Security Act b. FFY 2021 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable) Section 7 — General Provisions None — new pages 7.4 Medical Disaster Relief for the COVID-19 National Emergency

10. SUBJECT OF AMENDMENT The purpose of this SPA is to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse.

11. GOVERNOR'S REVIEW (Check One)

OO GoveRNor's OFFICE REPORTED NO COMMENT ® OTHER, AS SPECIFIED C1 comMENTS OF GOVERNOR'S OFFICE ENCLOSED The Govermor does not review State Plan material. (No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURE OF STATE AGENCY OFFICIAL 146. RETURN TO

Erin Campbell, Acting Medicaid Director State of Louisiana

13. TYPED

Cindy Rives, designee for Stephen R. Russo, JD Department of Health 414. TITLE 628 North 4" Street interim Secretary P.O. Box 91030 15. DATE SUBMITTED Baton Rouge, LA 70821-9030 April 3, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED March 27, 2020 April 20, 2020 PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20, SIGNATARBOMWREGIONSAOERICIAL March 1, 2020 Costello-S_ tw 21, TYPED NAME ; 22. TITLE | Deputy Director Anne Marie Costello Center for Medicaid & CHIP Services

23. REMARKS = The State requests a pen and ink change to box 7.

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

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ^ĞĐƚŝŽŶ ϳ ʹ 'ĞŶĞƌĂů WƌŽǀŝƐŝŽŶƐ ϳ͘ϰ͘ DĞĚŝĐĂŝĚ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ĨŽƌ ƚŚĞ Ks/Ͳϭϵ EĂƚŝŽŶĂů ŵĞƌŐĞŶĐLJ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƚŚĞ WƌĞƐŝĚĞŶƚ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ŝƐƐƵĞĚ Ă ƉƌŽĐůĂŵĂƚŝŽŶ ƚŚĂƚ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ŝŶ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĐŽŶƐƚŝƚƵƚĞƐ Ă ŶĂƚŝŽŶĂů ĞŵĞƌŐĞŶĐLJ ďLJ ƚŚĞ ĂƵƚŚŽƌŝƚŝĞƐ ǀĞƐƚĞĚ ŝŶ Śŝŵ ďLJ ƚŚĞ ŽŶƐƚŝƚƵƚŝŽŶ ĂŶĚ ƚŚĞ ůĂǁƐ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ͕ ŝŶĐůƵĚŝŶŐ ƐĞĐƚŝŽŶƐ ϮϬϭ ĂŶĚ ϯϬϭ ŽĨ ƚŚĞ EĂƚŝŽŶĂů

ŵĞƌŐĞŶĐŝĞƐ Đƚ ;ϱϬ h͘^͘͘ ϭϲϬϭ Ğƚ ƐĞƋ͘Ϳ͕ ĂŶĚ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ ;ĐƚͿ͘ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ ŽĨ ƚŚĞ Đƚ͕ ƚŚĞ ^ĞĐƌĞƚĂƌLJ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĞƉĂƌƚŵĞŶƚ ŽĨ ,ĞĂůƚŚ ĂŶĚ ,ƵŵĂŶ ^ĞƌǀŝĐĞƐ ŝŶǀŽŬĞĚ ŚŝƐ ĂƵƚŚŽƌŝƚLJ ƚŽ ǁĂŝǀĞ Žƌ ŵŽĚŝĨLJ ĐĞƌƚĂŝŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ŽĨ ƚŝƚůĞƐ ys///͕ y/y͕ ĂŶĚ yy/ ŽĨ ƚŚĞ Đƚ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ ĐŽŶƐĞƋƵĞŶĐĞƐ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ƚŽ ƚŚĞ ĞdžƚĞŶƚ ŶĞĐĞƐƐĂƌLJ͕ ĂƐ ĚĞƚĞƌŵŝŶĞĚ ďLJ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂƌĞ Θ DĞĚŝĐĂŝĚ ^ĞƌǀŝĐĞƐ ;D^Ϳ͕ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ƐƵĨĨŝĐŝĞŶƚ ŚĞĂůƚŚ ĐĂƌĞ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂƌĞ ĂǀĂŝůĂďůĞ ƚŽ ŵĞĞƚ ƚŚĞ ŶĞĞĚƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĞŶƌŽůůĞĚ ŝŶ ƚŚĞ ƌĞƐƉĞĐƚŝǀĞ ƉƌŽŐƌĂŵƐ ĂŶĚ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽǀŝĚĞƌƐ ƚŚĂƚ ĨƵƌŶŝƐŚ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ŝŶ ŐŽŽĚ ĨĂŝƚŚ͕ ďƵƚ ĂƌĞ ƵŶĂďůĞ ƚŽ ĐŽŵƉůLJ ǁŝƚŚ ŽŶĞ Žƌ ŵŽƌĞ ŽĨ ƐƵĐŚ ƌĞƋƵŝƌĞŵĞŶƚƐ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ŵĂLJ ďĞ ƌĞŝŵďƵƌƐĞĚ ĨŽƌ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂŶĚ ĞdžĞŵƉƚĞĚ ĨƌŽŵ ƐĂŶĐƚŝŽŶƐ ĨŽƌ ƐƵĐŚ ŶŽŶĐŽŵƉůŝĂŶĐĞ͕ ĂďƐĞŶƚ ĂŶLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ĨƌĂƵĚ Žƌ ĂďƵƐĞ͘ dŚŝƐ ĂƵƚŚŽƌŝƚLJ ƚŽŽŬ ĞĨĨĞĐƚ ĂƐ ŽĨ ϲWD

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

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ Đ͘ y dƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŝŵĞůŝŶĞƐ ƐƉĞĐŝĨŝĞĚ ŝŶ ΀>ŽƵŝƐŝĂŶĂ΁ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ŵŽĚŝĨLJ ƚŚĞ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƉƌŽĐĞƐƐ ďLJ ĞůŝŵŝŶĂƚŝŶŐ ƚŚĞ ŶƵŵďĞƌ ŽĨ ŶŽƚŝĨŝĐĂƚŝŽŶ ĚĂLJƐ ďĞĨŽƌĞ ƐƵďŵŝƐƐŝŽŶ ŽĨ ƚŚĞ ^W ĂŶĚͬŽƌ ĐŽŶĚƵĐƚŝŶŐ ĐŽŶƐƵůƚĂƚŝŽŶ ĂĨƚĞƌ ƐƵďŵŝƐƐŝŽŶ ŽĨ ƚŚĞ ^W͘ ^ĞĐƚŝŽŶ  ʹ ůŝŐŝďŝůŝƚLJ ϭ͘ y dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ Žƌ ϭϵϬϮ;ĂͿ;ϭϬͿ;ĐͿ ŽĨ ƚŚĞ Đƚ͘ dŚŝƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚĞ ŶĞǁ ŽƉƚŝŽŶĂů ŐƌŽƵƉ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƌŽǀŝĚŝŶŐ ĐŽǀĞƌĂŐĞ ĨŽƌ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ hŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͕ ĂƐ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ͘ /Ŷ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;ys///Ϳ͕ ƚŚĞ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ƚŽ ĂŶ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂů ;ĂƐ ĚĞĨŝŶĞĚ ŝŶ ƐƵďƐĞĐƚŝŽŶ ;ƐƐͿͿ ǁŚŽ ŝƐ ĞůŝŐŝďůĞ ĨŽƌ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ŽŶůLJ ďĞĐĂƵƐĞ ŽĨ ƐƵďƉĂƌĂŐƌĂƉŚ ;Ϳ;ŝŝͿ;yy///Ϳ ŝƐ ůŝŵŝƚĞĚ ƚŽ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ĨŽƌ ĂŶLJ ŝŶ ǀŝƚƌŽ ĚŝĂŐŶŽƐƚŝĐ ƉƌŽĚƵĐƚ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϯͿ;Ϳ ƚŚĂƚ ŝƐ ĂĚŵŝŶŝƐƚĞƌĞĚ ĚƵƌŝŶŐ ĂŶLJ ƉŽƌƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ĚĞƐĐƌŝďĞĚ ŝŶ ƐƵĐŚ ƐĞĐƚŝŽŶ ďĞŐŝŶŶŝŶŐ ŽŶ Žƌ ĂĨƚĞƌ DĂƌĐŚ ϭϴ͕ ϮϬϮϬ ;ĂŶĚ ƚŚĞ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ ŽĨ ƐƵĐŚ ƉƌŽĚƵĐƚͿ ĂŶĚ ĂŶLJ ǀŝƐŝƚ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϭϲ;ĂͿ;ϮͿ;'Ϳ ƚŚĂƚ ŝƐ ĨƵƌŶŝƐŚĞĚ ĚƵƌŝŶŐ ĂŶLJ ƐƵĐŚ ƉŽƌƚŝŽŶ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉŽƉƵůĂƚŝŽŶƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘Ϯϭϴ͗ Ă͘ ͺͺͺͺͺ ůů ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͲŽƌͲ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ ŽĨ ƚŚĞ Đƚ͗ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƉƉůŝĞƐ ůĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ďĂƐĞĚ ŽŶ ŵŽĚŝĨŝĞĚ ĂĚũƵƐƚĞĚ ŐƌŽƐƐ ŝŶĐŽŵĞ ;D'/Ϳ ĂƐ ĨŽůůŽǁƐ͘ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ŝŶĐŽŵĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ƌĞƐŽƵƌĐĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ϰ͘ y dŚĞ ĂŐĞŶĐLJ ĐŽŶƐŝĚĞƌƐ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĞǀĂĐƵĂƚĞĚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ůĞĂǀĞ ƚŚĞ ƐƚĂƚĞ ĨŽƌ ŵĞĚŝĐĂů ƌĞĂƐŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ Žƌ ǁŚŽ ĂƌĞ ŽƚŚĞƌǁŝƐĞ ĂďƐĞŶƚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĂŶĚ ǁŚŽ ŝŶƚĞŶĚ ƚŽ ƌĞƚƵƌŶ ƚŽ ƚŚĞ ƐƚĂƚĞ͕ ƚŽ ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ƌĞƐŝĚĞŶƚƐ ŽĨ ƚŚĞ ƐƚĂƚĞ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϰϬϯ;ũͿ;ϯͿ͘ ϱ͘ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ DĞĚŝĐĂŝĚ ĐŽǀĞƌĂŐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŝŶĚŝǀŝĚƵĂůƐ ůŝǀŝŶŐ ŝŶ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ĂƌĞ ŶŽŶͲƌĞƐŝĚĞŶƚƐ͗ ϲ͘ y dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ ĨŽƌ ĂŶ ĞdžƚĞŶƐŝŽŶ ŽĨ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĨŽƌ ŶŽŶͲĐŝƚŝnjĞŶƐ ĚĞĐůĂƌŝŶŐ ƚŽ ďĞ ŝŶ Ă ƐĂƚŝƐĨĂĐƚŽƌLJ ŝŵŵŝŐƌĂƚŝŽŶ ƐƚĂƚƵƐ͕ ŝĨ ƚŚĞ ŶŽŶͲĐŝƚŝnjĞŶ ŝƐ ŵĂŬŝŶŐ Ă ŐŽŽĚ ĨĂŝƚŚ ĞĨĨŽƌƚ ƚŽ ƌĞƐŽůǀĞ ĂŶLJ ŝŶĐŽŶƐŝƐƚĞŶĐĞƐ Žƌ ŽďƚĂŝŶ ĂŶLJ ŶĞĐĞƐƐĂƌLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ Žƌ ƚŚĞ ĂŐĞŶĐLJ ŝƐ ƵŶĂďůĞ ƚŽ ĐŽŵƉůĞƚĞ ƚŚĞ ǀĞƌŝĨŝĐĂƚŝŽŶ ƉƌŽĐĞƐƐ ǁŝƚŚŝŶ ƚŚĞ ϵϬͲĚĂLJ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ϳ͘ ^ĞĐƚŝŽŶ  ʹ ŶƌŽůůŵĞŶƚ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĞůĞĐƚƐ ƚŽ ĂůůŽǁ ŚŽƐƉŝƚĂůƐ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚĚŝƚŝŽŶĂů ƐƚĂƚĞ ƉůĂŶ ƉŽƉƵůĂƚŝŽŶƐ͕ Žƌ ĨŽƌ ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ĂŶ ĂƉƉƌŽǀĞĚ ƐĞĐƚŝŽŶ ϭϭϭϱ ĚĞŵŽŶƐƚƌĂƚŝŽŶ͕ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϰϳͿ;Ϳ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϭϭϭϬ͕ ƉƌŽǀŝĚĞĚ ƚŚĂƚ ƚŚĞ ĂŐĞŶĐLJ ŚĂƐ ĚĞƚĞƌŵŝŶĞĚ ƚŚĂƚ ƚŚĞ ŚŽƐƉŝƚĂů ŝƐ ĐĂƉĂďůĞ ŽĨ ŵĂŬŝŶŐ ƐƵĐŚ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ŝƚƐĞůĨ ĂƐ Ă ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚLJ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĞŶƚŝƚŝĞƐ ĂƐ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ Žƌ ĂĚĚƐ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ /ŶĚŝĐĂƚĞ ŝĨ ĂŶLJ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ ĂƌĞ ƉĞƌŵŝƚƚĞĚ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽŶůLJ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚŽƉƚƐ Ă ƚŽƚĂů ŽĨ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ĐŽŶƚŝŶƵŽƵƐ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ĐŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ĞŶƚĞƌ ĂŐĞ ͺͺͺͺͺ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ĂŐĞ ϭϵͿ ƌĞŐĂƌĚůĞƐƐ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĞͿ;ϭϮͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϵϮϲ͘ ϱ͘ ͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶĚƵĐƚƐ ƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽĨ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ D'/Ͳ ďĂƐĞĚ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϲϬϯ;ũͿ ŽŶĐĞ ĞǀĞƌLJ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ϰϮ &Z ϰϯϱ͘ϵϭϲ;ďͿ͘ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ƚŽ ƐƵƉƉŽƌƚ ĞŶƌŽůůŵĞŶƚ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ Žƌ ĨŽƌ ĂĨĨĞĐƚĞĚ ŝŶĚŝǀŝĚƵĂůƐ ;Ă ĐŽƉLJ ŽĨ ƚŚĞ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ŚĂƐ ďĞĞŶ ƐƵďŵŝƚƚĞĚ ƚŽ D^Ϳ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ ĂƉƉůŝĐĂƚŝŽŶ͘ ď͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ͘ Đ͘ ͺͺͺͺͺ dŚĞ ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ Žƌ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ ŝƐ ŵĂĚĞ ĂǀĂŝůĂďůĞ ĨŽƌ ƵƐĞ ŝŶ ĐĂůůͲĐĞŶƚĞƌƐ Žƌ ŽƚŚĞƌ ƚĞůĞƉŚŽŶĞ ĂƉƉůŝĐĂƚŝŽŶƐ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ͘ ^ĞĐƚŝŽŶ  ʹ WƌĞŵŝƵŵƐ ĂŶĚ ŽƐƚ ^ŚĂƌŝŶŐ ϭ͘ y dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ ĂŶĚ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĂƐ ĨŽůůŽǁƐ͗ dŚĞ ^ƚĂƚĞ ƐƵƐƉĞŶĚƐ Ăůů ĐŽƐƚ ƐŚĂƌŝŶŐ͘ Ϯ͘ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĞŶƌŽůůŵĞŶƚ ĨĞĞƐ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ͗ Ă͘ ůů ďĞŶĞĨŝĐŝĂƌŝĞƐ ď͘ ͺͺͺͺͺ dŚĞ ĨŽůůŽǁŝŶŐ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ͗ Eͬ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂůůŽǁƐ ǁĂŝǀĞƌ ŽĨ ƉĂLJŵĞŶƚ ŽĨ ƚŚĞ ĞŶƌŽůůŵĞŶƚ ĨĞĞ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ WůĞĂƐĞ ƐƉĞĐŝĨLJ ƚŚĞ ƐƚĂŶĚĂƌĚ;ƐͿ ĂŶĚͬŽƌ ĐƌŝƚĞƌŝĂ ƚŚĂƚ ƚŚĞ ƐƚĂƚĞ ǁŝůů ƵƐĞ ƚŽ ĚĞƚĞƌŵŝŶĞ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ^ĞĐƚŝŽŶ  ʹ ĞŶĞĨŝƚƐ ĞŶĞĨŝƚƐ͗ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚĚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ŝŶ ŝƚƐ ƐƚĂƚĞ ƉůĂŶ ;ŝŶĐůƵĚĞ ƐĞƌǀŝĐĞ ĚĞƐĐƌŝƉƚŝŽŶƐ͕ ƉƌŽǀŝĚĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ůŝŵŝƚĂƚŝŽŶƐ ŽŶ ĂŵŽƵŶƚ͕ ĚƵƌĂƚŝŽŶ Žƌ ƐĐŽƉĞ ŽĨ ƚŚĞ ďĞŶĞĨŝƚͿ͗ Ϯ͘ y dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐƵƌƌĞŶƚůLJ ĐŽǀĞƌĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ ƉůĂŶ͗ ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ĞdžƚĞŶĚ Ăůů ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ ŝ͘ ŶLJ ŵĞĚŝĐĂůůLJ ŶĞĐĞƐƐĂƌLJ ƐƵƌŐŝĐĂů ƉƌŽĐĞĚƵƌĞƐ ƚŚĂƚ ƌĞƋƵŝƌĞ ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĞŝƚŚĞƌ ďLJ ĨĞĞͲ ĨŽƌͲƐĞƌǀŝĐĞ͕ ŵĂŶĂŐĞĚ ĐĂƌĞ͕ Žƌ ďŽƚŚ͘ ŝŝ͘ WĞĚŝĂƚƌŝĐ ĂLJ ,ĞĂůƚŚ ĞŶƚĞƌ ;W,Ϳ ŝŝŝ͘ ƉŚLJƐŝĐŝĂŶ ĂĚŵŝŶŝƐƚĞƌĞĚ ĚƌƵŐƐ ŝǀ͘ ƵƌĂďůĞ ŵĞĚŝĐĂů ĞƋƵŝƉŵĞŶƚ ;D Ϳ ǀ͘ ,ŽŵĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ; ,,ͬW^Ϳ ǀŝ͘ ,ŽƐƉŝĐĞ ƐĞƌǀŝĐĞƐ ǀŝŝ͘ dŚĞƌĂƉŝĞƐ ;ƉŚLJƐŝĐĂů ƚŚĞƌĂƉLJ͕ ŽĐĐƵƉĂƚŝŽŶĂů ƚŚĞƌĂƉLJ͕ ƐƉĞĞĐŚ ƚŚĞƌĂƉLJͿ ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĨŽƌ >ŽŶŐ dĞƌŵ WĞƌƐŽŶĂů ĂƌĞ ^ĞƌǀŝĐĞƐ ;>dͲ W^Ϳ͕ ϰϮ &Z ϰϰϬ͘ϭϲϳ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͗ ŝ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ƚŚĂƚ ƐĞƌǀŝĐĞƐ ŵƵƐƚ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƚŚĞ ĂƉƉƌŽǀĞĚ ƉůĂŶ ŽĨ ĐĂƌĞ ĂŶĚ ƐƵƉƉŽƌƚŝŶŐ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ ƚŽ ĂƵƚŚŽƌŝnjĞ ŚŽƵƌƐ ƵƉ ƚŽ ϯϮ ŚŽƵƌƐ ƉĞƌ ǁĞĞŬ͕ ŝĨ ŶĞĞĚĞĚ͖ ŝŝ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ĨŽƌ ƚŚĞ ĂŐĞ͕ ĞĚƵĐĂƚŝŽŶ ĂŶĚ ĞdžƉĞƌŝĞŶĐĞ ĨŽƌ ƚŚĞ ƉĞƌƐŽŶĂů ĐĂƌĞ ƐĞƌǀŝĐĞƐ ǁŽƌŬĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ ĂŶĚ ĂůůŽǁ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌƐŽŶƐ ƚŽ ƐĞƌǀĞ ĂƐ ƚŚĞ ĚŝƌĞĐƚ ƐĞƌǀŝĐĞ ǁŽƌŬĞƌ ĨŽƌ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͗ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ĐƵƌĂƚŽƌ͖ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ƚƵƚŽƌ͖ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ƌĞƐƉŽŶƐŝďůĞ ƌĞƉƌĞƐĞŶƚĂƚŝǀĞ͖ Žƌ ƚŚĞ ƉĞƌƐŽŶ ƚŽ ǁŚŽŵ ƚŚĞ ƌĞĐŝƉŝĞŶƚ ŚĂƐ ŐŝǀĞŶ ZĞƉƌĞƐĞŶƚĂƚŝǀĞ ĂŶĚ DĂŶĚĂƚĞ ĂƵƚŚŽƌŝƚLJ ;WŽǁĞƌ ŽĨ ƚƚŽƌŶĞLJͿ ƵŶůĞƐƐ ƚŚĞLJ ĂƌĞ ůĞŐĂůůLJ ƌĞƐƉŽŶƐŝďůĞ ƌĞůĂƚŝǀĞƐ͖ ŝŝŝ͘ ůůŽǁ ƌĞĐŝƉŝĞŶƚƐ͛ ƌĞͲĂƐƐĞƐƐŵĞŶƚƐ ƚŽ ŐŽ ďĞLJŽŶĚ ƚŚĞ ϭϴͲŵŽŶƚŚ ƌĞƋƵŝƌĞŵĞŶƚ͘ dŚĞƐĞ ƌĞĐŝƉŝĞŶƚƐ ǁŝůů ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ŵŽŶŝƚŽƌĞĚ ƚŚƌŽƵŐŚ ŵŽŶƚŚůLJ ƚĞůĞƉŚŽŶĞ ĐŽŶƚĂĐƚƐ͖ ŝǀ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚ ƚŚĂƚ ƉůĂĐĞ;ƐͿ ŽĨ ƐĞƌǀŝĐĞ ŵƵƐƚ ďĞ ĚŽĐƵŵĞŶƚĞĚ ŝŶ ƚŚĞ ƉůĂŶ ŽĨ ĐĂƌĞ͖ ǀ͘ >dͲW^ ŵĂLJ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ ĂŶŽƚŚĞƌ ƐƚĂƚĞ ǁŝƚŚŽƵƚ ƉƌŝŽƌ ĂƉƉƌŽǀĂů ŽĨ ƚŚĞ KĨĨŝĐĞ ŽĨ ŐŝŶŐ ĂŶĚ ĚƵůƚ ^ĞƌǀŝĐĞƐ ;K^Ϳ Žƌ ŝƚƐ ĚĞƐŝŐŶĞĞ͖ ǀŝ͘  ƌĞĐŝƉŝĞŶƚ ŵĂLJ ƌĞĐĞŝǀĞ >dͲW^ ǁŚŝůĞ ůŝǀŝŶŐ ŝŶ Ă ŚŽŵĞ Žƌ ƉƌŽƉĞƌƚLJ ŽǁŶĞĚ͕ ŽƉĞƌĂƚĞĚ Žƌ ĐŽŶƚƌŽůůĞĚ ďLJ Ă ƉƌŽǀŝĚĞƌ ŽĨ ƐĞƌǀŝĐĞƐ ǁŚŽ ŝƐ ŶŽƚ ƌĞůĂƚĞĚ ďLJ ďůŽŽĚ Žƌ ŵĂƌƌŝĂŐĞ ƚŽ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͖ ǀŝŝ͘ dŚĞ ^ƚĂƚĞ ŵĂLJ ŝŶĐƌĞĂƐĞ ƚŚĞ ŵĂdžŝŵƵŵ ŶƵŵďĞƌ ŽĨ >dͲW^ ŚŽƵƌƐ ƌĞĐĞŝǀĞĚ ƉĞƌ ǁĞĞŬ͖ ĂŶĚ ǀŝŝŝ͘ dŚĞ ^ƚĂƚĞ ŵĂLJ ĂůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ͘ ͘ WĞĚŝĂƚƌŝĐ ĂLJ ,ĞĂůƚŚ ĂƌĞ ;W,Ϳ ƐŬŝůůĞĚ ƐĞƌǀŝĐĞƐ ŵĂLJ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ Ă ƌĞƐŝĚĞŶƚŝĂů ƐĞƚƚŝŶŐ ĚƵƌŝŶŐ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ƚŽ ƚŚŽƐĞ ĐŚŝůĚƌĞŶ ǁŚŽƐĞ ĨĂŵŝůŝĞƐ ĂƌĞ ŶŽƚ ĂďůĞ ƚŽ ƉƌŽǀŝĚĞ ƐƵĐŚ ĐĂƌĞ ŝĨ ƚŚĞ W, ŝƐ ĐůŽƐĞĚ ĚƵĞ ƚŽ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ϯ͘ y dŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ŶĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ Žƌ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐŽŵƉůLJ ǁŝƚŚ Ăůů ĂƉƉůŝĐĂďůĞ ƐƚĂƚƵƚŽƌLJ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƐƚĂƚĞǁŝĚĞŶĞƐƐ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭͿ͕ ĐŽŵƉĂƌĂďŝůŝƚLJ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ͕ ĂŶĚ ĨƌĞĞ ĐŚŽŝĐĞ ŽĨ ƉƌŽǀŝĚĞƌ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϮϯͿ͘ ϰ͘ y ƉƉůŝĐĂƚŝŽŶ ƚŽ ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐ ;WͿ͘ dŚĞ ƐƚĂƚĞ ĂĚŚĞƌĞƐ ƚŽ Ăůů W ƉƌŽǀŝƐŝŽŶƐ ŝŶ ϰϮ &Z WĂƌƚ ϰϰϬ͕ ^ƵďƉĂƌƚ ͘ dŚŝƐ ƐĞĐƚŝŽŶ ŽŶůLJ ĂƉƉůŝĞƐ ƚŽ ƐƚĂƚĞƐ ƚŚĂƚ ŚĂǀĞ ĂŶ ĂƉƉƌŽǀĞĚ W;ƐͿ͘ ƒǤ  Š‡ ƒ‰‡ › ƒ••—”‡• –Šƒ– –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–• ™‹ŽŽ „‡ ƒ†‡ ƒ˜ƒ‹Žƒ„Ž‡ –‘ ‹†‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” •Ǥ „Ǥ ̴̴̴̴̴ †‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” • ™‹ŽŽ ‘– ”‡ ‡‹˜‡ –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–•ǡ ‘” ™‹ŽŽ ‘Ž› ”‡ ‡‹˜‡ –Š‡ ˆ‘ŽŽ‘™‹‰ •—„•‡–ǣ dĞůĞŚĞĂůƚŚ͗ ϱ͘ y dŚĞ ĂŐĞŶĐLJ ƵƚŝůŝnjĞƐ ƚĞůĞŚĞĂůƚŚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĂŶŶĞƌ͕ ǁŚŝĐŚ ŵĂLJ ďĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ͛Ɛ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ƐƵƐƉĞŶĚ Ăůů ĨĂĐĞͲƚŽͲĨĂĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ĚĞƚĂŝůĞĚ ŝŶ ƚŚĞ >ŽƵŝƐŝĂŶĂ ^ƚĂƚĞ WůĂŶ ĨŽƌ Ăůů ƐĞƌǀŝĐĞƐ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͘ ƌƵŐ ĞŶĞĨŝƚ͗ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ƚŚĞ ĚĂLJ ƐƵƉƉůLJ Žƌ ƋƵĂŶƚŝƚLJ ůŝŵŝƚ ĨŽƌ ĐŽǀĞƌĞĚ ŽƵƚƉĂƚŝĞŶƚ ĚƌƵŐƐ͘ dŚĞ ĂŐĞŶĐLJ ƐŚŽƵůĚ ŽŶůLJ ŵĂŬĞ ƚŚŝƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŝĨ ŝƚƐ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉĂŐĞƐ ŚĂǀĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ĂŵŽƵŶƚ ŽĨ ŵĞĚŝĐĂƚŝŽŶ ĚŝƐƉĞŶƐĞĚ͘ ϳ͘ y WƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĨŽƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝƐ ĞdžƉĂŶĚĞĚ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ͕ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ͘ ϴ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĂLJŵĞŶƚ ĂĚũƵƐƚŵĞŶƚ ƚŽ ƚŚĞ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ǁŚĞŶ ĂĚĚŝƚŝŽŶĂů ĐŽƐƚƐ ĂƌĞ ŝŶĐƵƌƌĞĚ ďLJ ƚŚĞ ƉƌŽǀŝĚĞƌƐ ĨŽƌ ĚĞůŝǀĞƌLJ͘ ^ƚĂƚĞƐ ǁŝůů ŶĞĞĚ ƚŽ ƐƵƉƉůLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ƚŽ ũƵƐƚŝĨLJ ƚŚĞ ĂĚĚŝƚŝŽŶĂů ĨĞĞƐ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ϵ͘ y dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞŝƌ ƉƵďůŝƐŚĞĚ WƌĞĨĞƌƌĞĚ ƌƵŐ >ŝƐƚ ŝĨ ĚƌƵŐ ƐŚŽƌƚĂŐĞƐ ŽĐĐƵƌ͘ dŚŝƐ ǁŽƵůĚ ŝŶĐůƵĚĞ ŽƉƚŝŽŶƐ ĨŽƌ ĐŽǀĞƌŝŶŐ Ă ďƌĂŶĚ ŶĂŵĞ ĚƌƵŐ ƉƌŽĚƵĐƚ ƚŚĂƚ ŝƐ Ă ŵƵůƚŝͲƐŽƵƌĐĞ ĚƌƵŐ ŝĨ Ă ŐĞŶĞƌŝĐ ĚƌƵŐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĂǀĂŝůĂďůĞ͘ ^ĞĐƚŝŽŶ ʹ WĂLJŵĞŶƚƐ KƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ͗ ϭ͘ ͺͺ ͺͺͺ EĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ  ĂƌĞ ƉĂŝĚ ƵƐŝŶŐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĞƚŚŽĚŽůŽŐLJ͗ ƒǤ ̴̴̴ —„Ž‹•Š‡† ˆ‡‡ • Š‡†—Ž‡• Ȃ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ „Ǥ ̴̴̴̴̴ –Š‡”ǣ ĞƐĐƌŝďĞ ŵĞƚŚŽĚŽůŽŐLJ ŚĞƌĞ͘ /ŶĐƌĞĂƐĞƐ ƚŽ ƐƚĂƚĞ ƉůĂŶ ƉĂLJŵĞŶƚ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ Ϯ͘ y dŚĞ ĂŐĞŶĐLJ ŝŶĐƌĞĂƐĞƐ ƉĂLJŵĞŶƚ ƌĂƚĞƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ŝŶĐƌĞĂƐĞ ƚŚĞ ƉĂLJŵĞŶƚ ĨŽƌ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚLJ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJƐ ĨƌŽŵ ϭϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ ƚŽ ϭϬϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ͕ ĂŶĚ ŝŶĐůƵĚĞ Ă ΨϭϮ ŝŶĐƌĞĂƐĞ ƚŽ ƚŚĞ ĚĂŝůLJ ƉĞƌ ĚŝĞŵ ƌĂƚĞ ƉĂŝĚ ƚŽ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚŝĞƐ͘ ^ƚĂƚĞ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ĂŶĚ ŶŽŶͲƐƚĂƚĞ ŐŽǀĞƌŶŵĞŶƚ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ĨĂĐŝůŝƚŝĞƐ ĂƌĞ ŶŽƚ ĞůŝŐŝďůĞ ĨŽƌ͕ ĂŶĚ ǁŝůů ŶŽƚ ƌĞĐĞŝǀĞ͕ ƚŚĞ ƐƚĂƚĞ Žƌ ĨĞĚĞƌĂůůLJ ĚĞĐůĂƌĞĚ ĞŵĞƌŐĞŶĐLJ ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJ ƉĂLJŵĞŶƚƐ ĂŶĚ ǁŝůů ŶŽƚ ƌĞĐĞŝǀĞ ƚŚĞ ΨϭϮ ŝŶĐƌĞĂƐĞ ƚŽ ƚŚĞ ĚĂŝůLJ ƉĞƌ ĚŝĞŵ ƌĂƚĞ ĂƐ ĚĞƐĐƌŝďĞĚ ĂďŽǀĞ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ƉĂLJ /ŶƚĞƌŵĞĚŝĂƚĞ ĂƌĞ &ĂĐŝůŝƚŝĞƐ ĨŽƌ /ŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ /ŶƚĞůůĞĐƚƵĂů ŝƐĂďŝůŝƚŝĞƐ ;/&ƐͲ//Ϳ ďĞLJŽŶĚ ƚŚĞ ϰϱͲ ĚĂLJ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJƐ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ĂĚũƵƐƚ ƌĂƚĞƐ ŝŶ ƚŚĞ ƉŚLJƐŝĐŝĂŶ ďĞŶĞĨŝƚ ƚŽ ƌĞŝŵďƵƌƐĞ ĂŵďƵůĂŶĐĞ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞƌƐ ǁŚŽ ƉƌŽǀŝĚĞ ĂůůŽǁĂďůĞ ƐĞƌǀŝĐĞƐ ŽŶ ƐŝƚĞ͕ ǁŝƚŚŽƵƚ ƚƌĂŶƐƉŽƌƚ͕ ǁŚŝůĞ ƵŶĚĞƌ ƚŚĞ ƐƵƉĞƌǀŝƐŝŽŶ ŽĨ Ă ůŝĐĞŶƐĞĚ ƉŚLJƐŝĐŝĂŶ͘ Ă͘ ͺͺͺͺͺ WĂLJŵĞŶƚ ŝŶĐƌĞĂƐĞƐ ĂƌĞ ƚĂƌŐĞƚĞĚ ďĂƐĞĚ ŽŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐƌŝƚĞƌŝĂ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĐƌŝƚĞƌŝĂ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ď͘ WĂLJŵĞŶƚƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ ƚŚƌŽƵŐŚ͗ ‹Ǥ   •—’’Ž‡‡–ƒŽ ’ƒ›‡– ‘” ƒ††Ǧ‘ ™‹–Š‹ ƒ’’Ž‹ ƒ„Ž‡ —’’‡” ’ƒ›‡– Ž‹‹–•ǣ ΨϭϮ ƉĞƌ ĚĂLJ ĂĚĚͲŽŶ ƚŽ ƚŚĞ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚLJ ƌĂƚĞ͘ ‹‹Ǥ ̴̴̴̴̴  ‹ ”‡ƒ•‡ –‘ ”ƒ–‡• ƒ• †‡• ”‹„‡† „‡Ž‘™Ǥ ͺͺͺyͺͺ hŶŝĨŽƌŵůLJ ďLJ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌĐĞŶƚĂŐĞ͗ &Žƌ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ ĂŶĚ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚŝĞƐ͕ ŝŶĐƌĞĂƐĞ ƌĂƚĞ ĨƌŽŵ ϭϬ ƉĞƌĐĞŶƚ ƚŽ ϭϬϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ ĨŽƌ ŚŽŵĞ ĂŶĚ ŚŽƐƉŝƚĂů ůĞĂǀĞ ĚĂLJƐ͘ ͺͺͺͺͺ dŚƌŽƵŐŚ Ă ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ƉƵďůŝƐŚĞĚ ĨĞĞ ƐĐŚĞĚƵůĞƐ ʹ

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

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

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ •‡’ƒ”ƒ–‡Ž› ”‡‹„—”•‡† ƒ• ƒ ƒ†‹‹•–”ƒ–‹˜‡ ‘•– „› –Š‡ •–ƒ–‡ ™Š‡ ƒ ‡†‹ ƒ‹† •‡”˜‹ ‡ ‹• †‡Ž‹˜‡”‡†Ǥ KƚŚĞƌ͗ ϰ͘ KƚŚĞƌ ƉĂLJŵĞŶƚ ĐŚĂŶŐĞƐ͗ ^ĞĐƚŝŽŶ & ʹ WŽƐƚͲ ůŝŐŝďŝůŝƚLJ dƌĞĂƚŵĞŶƚ ŽĨ /ŶĐŽŵĞ ͳǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• –‘ ‘†‹ˆ› –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ˆ‘” ‹•–‹–—–‹‘ƒŽ‹œ‡† ‹†‹˜‹†—ƒŽ•Ǥ Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ‹• ‡“—ƒŽ –‘ ‘‡ ‘ˆ –Š‡ ˆ‘ŽŽ‘™‹‰ ƒ‘—–•ǣ ƒǤ ̴̴̴̴̴ Š‡ ‹†‹˜‹†—ƒŽǯ• –‘–ƒŽ ‹ ‘‡ „Ǥ ̴̴̴̴̴ ͵ͲͲ ’‡” ‡– ‘ˆ –Š‡  ˆ‡†‡”ƒŽ „‡‡ˆ‹– ”ƒ–‡

Ǥ ̴̴̴̴̴ –Š‡” ”‡ƒ•‘ƒ„Ž‡ ƒ‘—–ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• ƒ ‡™ ˜ƒ”‹ƒ ‡ –‘ –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡Ǥ ȋ‘–‡ǣ Ž‡ –‹‘ ‘ˆ –Š‹• ‘’–‹‘ ‹• ‘– †‡’‡†‡– ‘ ƒ •–ƒ–‡ ‡Ž‡ –‹‰ –Š‡ ‘’–‹‘ †‡• ”‹„‡† –Š‡ ‘’–‹‘ ‹ ǤͳǤ ƒ„‘˜‡ǤȌ dŚĞ ƐƚĂƚĞ ƉƌŽƚĞĐƚƐ ĂŵŽƵŶƚƐ ĞdžĐĞĞĚŝŶŐ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ŚĂǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ŐƌĞĂƚĞƌ ƉĞƌƐŽŶĂů ŶĞĞĚƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ ŐƌĞĂƚĞƌ ŶĞĞĚƐ ĂŶĚ ƚŚĞ ĂŵŽƵŶƚ;ƐͿ ƉƌŽƚĞĐƚĞĚ ĨŽƌ ĞĂĐŚ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ͘ ^ĞĐƚŝŽŶ ' ʹ KƚŚĞƌ WŽůŝĐŝĞƐ ĂŶĚ WƌŽĐĞĚƵƌĞƐ ŝĨĨĞƌŝŶŐ ĨƌŽŵ ƉƉƌŽǀĞĚ DĞĚŝĐĂŝĚ ^ƚĂƚĞ WůĂŶ ͬĚĚŝƚŝŽŶĂů /ŶĨŽƌŵĂƚŝŽŶ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ WZ ŝƐĐůŽƐƵƌĞ ^ƚĂƚĞŵĞŶƚ ĐĐŽƌĚŝŶŐ ƚŽ ƚŚĞ WĂƉĞƌǁŽƌŬ ZĞĚƵĐƚŝŽŶ Đƚ ŽĨ ϭϵϵϱ͕ ŶŽ ƉĞƌƐŽŶƐ ĂƌĞ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞƐƉŽŶĚ ƚŽ Ă ĐŽůůĞĐƚŝŽŶ ŽĨ ŝŶĨŽƌŵĂƚŝŽŶ ƵŶůĞƐƐ ŝƚ ĚŝƐƉůĂLJƐ Ă ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ͘ dŚĞ ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ĨŽƌ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ϬϵϯϴͲϭϭϰϴ ; džƉŝƌĞƐ ϬϯͬϯϭͬϮϬϮϭͿ͘ dŚĞ ƚŝŵĞ ƌĞƋƵŝƌĞĚ ƚŽ ĐŽŵƉůĞƚĞ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ĞƐƚŝŵĂƚĞĚ ƚŽ ĂǀĞƌĂŐĞ ϭ ƚŽ Ϯ ŚŽƵƌƐ ƉĞƌ ƌĞƐƉŽŶƐĞ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƚŝŵĞ ƚŽ ƌĞǀŝĞǁ ŝŶƐƚƌƵĐƚŝŽŶƐ͕ ƐĞĂƌĐŚ ĞdžŝƐƚŝŶŐ ĚĂƚĂ ƌĞƐŽƵƌĐĞƐ͕ ŐĂƚŚĞƌ ƚŚĞ ĚĂƚĂ ŶĞĞĚĞĚ͕ ĂŶĚ ĐŽŵƉůĞƚĞ ĂŶĚ ƌĞǀŝĞǁ ƚŚĞ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ͘ zŽƵƌ ƌĞƐƉŽŶƐĞ ŝƐ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞĐĞŝǀĞ Ă ǁĂŝǀĞƌ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ͘ ůů ƌĞƐƉŽŶƐĞƐ ĂƌĞ ƉƵďůŝĐ ĂŶĚ ǁŝůů ďĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ŽŶ ƚŚĞ D^ ǁĞď ƐŝƚĞ͘ /Ĩ LJŽƵ ŚĂǀĞ ĐŽŵŵĞŶƚƐ ĐŽŶĐĞƌŶŝŶŐ ƚŚĞ ĂĐĐƵƌĂĐLJ ŽĨ ƚŚĞ ƚŝŵĞ ĞƐƚŝŵĂƚĞ;ƐͿ Žƌ ƐƵŐŐĞƐƚŝŽŶƐ ĨŽƌ ŝŵƉƌŽǀŝŶŐ ƚŚŝƐ ĨŽƌŵ͕ ƉůĞĂƐĞ ǁƌŝƚĞ ƚŽ͗ D^͕ ϳϱϬϬ ^ĞĐƵƌŝƚLJ ŽƵůĞǀĂƌĚ͕ ƚƚŶ͗ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞƌ͕ DĂŝů ^ƚŽƉ ϰͲϮϲͲϬϱ͕ ĂůƚŝŵŽƌĞ͕ DĂƌLJůĂŶĚ ϮϭϮϰϰͲϭϴϱϬ͘ ΎΎΎD^ ŝƐĐůŽƐƵƌĞΎΎΎ WůĞĂƐĞ ĚŽ ŶŽƚ ƐĞŶĚ ĂƉƉůŝĐĂƚŝŽŶƐ͕ ĐůĂŝŵƐ͕ ƉĂLJŵĞŶƚƐ͕ ŵĞĚŝĐĂů ƌĞĐŽƌĚƐ Žƌ ĂŶLJ ĚŽĐƵŵĞŶƚƐ ĐŽŶƚĂŝŶŝŶŐ ƐĞŶƐŝƚŝǀĞ ŝŶĨŽƌŵĂƚŝŽŶ ƚŽ ƚŚĞ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞ͘ WůĞĂƐĞ ŶŽƚĞ ƚŚĂƚ ĂŶLJ ĐŽƌƌĞƐƉŽŶĚĞŶĐĞ ŶŽƚ ƉĞƌƚĂŝŶŝŶŐ ƚŽ ƚŚĞ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ďƵƌĚĞŶ ĂƉƉƌŽǀĞĚ ƵŶĚĞƌ ƚŚĞ ĂƐƐŽĐŝĂƚĞĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ůŝƐƚĞĚ ŽŶ ƚŚŝƐ ĨŽƌŵ ǁŝůů ŶŽƚ ďĞ ƌĞǀŝĞǁĞĚ͕ ĨŽƌǁĂƌĚĞĚ͕ Žƌ ƌĞƚĂŝŶĞĚ͘ /Ĩ LJŽƵ ŚĂǀĞ ƋƵĞƐƚŝŽŶƐ Žƌ ĐŽŶĐĞƌŶƐ ƌĞŐĂƌĚŝŶŐ ǁŚĞƌĞ ƚŽ ƐƵďŵŝƚ LJŽƵƌ ĚŽĐƵŵĞŶƚƐ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂŝĚ Θ ,/W ^ĞƌǀŝĐĞƐ Ăƚ ϰϭϬͲϳϴϲͲϯϴϳϬ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 20-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

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

June 26, 2020

Ms. Ruth Johnson

Medicaid Director

State of Louisiana Department of Health

628 N 4th St.

P.O. Box 91030

Baton Rouge, LA 70821-9030

Re: Louisiana State Plan Amendment (SPA) 20-0006 Dear Ms. Johnson:

We have reviewed the proposed amendment to add section 7.4.1 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0006. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan,

during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof).

On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 ef seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency,

including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of Louisiana requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of Louisiana also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Louisiana’s Medicaid SPA Transmittal Number 20-0006 is approved effective March 1, 2020. Please note that the effective date for the new COVID-19 testing eligibility group described at section 1902(a)(10)(A)(ii)(XXIII) of the Act is March 18, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures 3OHDVH FRQWDFW 7RELDV *ULIILQ DW  RU E\ HPDLO DW WRELDVJULIILQ#FPVKKVJRY LI \RX KDYH DQ\ TXHVWLRQV DERXW WKLV DSSURYDO :H DSSUHFLDWH WKH HIIRUWV RI \RX DQG \RXU VWDII LQ UHVSRQGLQJ WR WKH QHHGV RI WKH UHVLGHQWV RI WKH 6WDWH RI /RXLVLDQD DQG WKH KHDOWK FDUH FRPPXQLW\ Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.06 26 08 05:22 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF __|1. TRANSMITTAL NUMBER 2. STATE

STATE PLAN MATERIAL 20-0006 Louisiana

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

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES March 1, 2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One) C1 NEW STATE PLAN 1 AMENDMENT TO BE CONSIDERED AS NEW PLAN & AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY 2020 $0 Section 1135 of the Social Security Act b. FFY 2021 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable) Section 7 — General Provisions Same (TN 20-0004) 7.4.1 Medical Disaster Relief for the COVID-19 National Emergency

10. SUBJECT OF AMENDMENT The purpose of this SPA is to waive or modify certain requirements of titles SH, XIX;#nd St of the Act as a result of the consequences COVID-19 pandemic, in order to remove language that requires Pediatric Day Healthcare Center (PDHC) closure in order for families to receive services in a residential setting, to change the section number of the Disaster Relief SPA template from 7.4 to 7.4.1 and to add pagination to the Disaster Relief SPA template.

11. GOVERNOR'S REVIEW (Check One)

C0 Governor's OFFICE REPORTED NO COMMENT & OTHER, AS SPECIFIED OJ comments OF GOVERNOR'S OFFICE ENCLOSED The Governor does not review State Plan material. (1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SI NCY OFFICIAL 16. RETURN TO a Ruth Johnson, Medicaid Executive Director 13. TYPED NAME State of Louisiana Cindy Rives, designee for Dr. Courtney N. Phillips Department of Health 14. TITLE 628 North 4" Street Secretary P.O. Box 91030 15. DATE SUBMITTED Baton Rouge, LA 70821-9030 May 19, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED May 19, 2020 pune 2672020) PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURENEE REGIONAL GREIRIA L ° March 1, 2020 Costello -S jae. z70men° 21. TYPED NAME 22. TITLE Deputy Director Anne Marie Costello Center for Medicaid & CHIP Services

23. REMARKS The State requests a pen and ink change to box 10.

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

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

—‡ ʹ6ǡ ʹͲʹͲ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ Ϯ dE͗ ϮϬͲϬϬϬϲ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ Đ͘ y dƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŝŵĞůŝŶĞƐ ƐƉĞĐŝĨŝĞĚ ŝŶ ΀>ŽƵŝƐŝĂŶĂ΁ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ŵŽĚŝĨLJ ƚŚĞ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƉƌŽĐĞƐƐ ďLJ ĞůŝŵŝŶĂƚŝŶŐ ƚŚĞ ŶƵŵďĞƌ ŽĨ ŶŽƚŝĨŝĐĂƚŝŽŶ ĚĂLJƐ ďĞĨŽƌĞ ƐƵďŵŝƐƐŝŽŶ ŽĨ ƚŚĞ ^W ĂŶĚͬŽƌ ĐŽŶĚƵĐƚŝŶŐ ĐŽŶƐƵůƚĂƚŝŽŶ ĂĨƚĞƌ ƐƵďŵŝƐƐŝŽŶ ŽĨ ƚŚĞ ^W͘ ^ĞĐƚŝŽŶ  ʹ ůŝŐŝďŝůŝƚLJ ϭ͘ y dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ Žƌ ϭϵϬϮ;ĂͿ;ϭϬͿ;ĐͿ ŽĨ ƚŚĞ Đƚ͘ dŚŝƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚĞ ŶĞǁ ŽƉƚŝŽŶĂů ŐƌŽƵƉ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƌŽǀŝĚŝŶŐ ĐŽǀĞƌĂŐĞ ĨŽƌ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ dŚĞ ^ƚĂƚĞ ĞůĞĐƚƐ ƚŽ ĐŽǀĞƌ Ăůů ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ ĂƐ ĚĞĨŝŶĞĚ ƵŶĚĞƌ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƵƌƐƵĂŶƚ ƚŽ ^ĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ŽĨ ƚŚĞ Đƚ͕ ĞĨĨĞĐƚŝǀĞ DĂƌĐŚ ϭϴ͕ ϮϬϮϬ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉŽƉƵůĂƚŝŽŶƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘Ϯϭϴ͗ Ă͘ ͺͺͺͺͺ ůů ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͲŽƌͲ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ ŽĨ ƚŚĞ Đƚ͗ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƉƉůŝĞƐ ůĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ďĂƐĞĚ ŽŶ ŵŽĚŝĨŝĞĚ ĂĚũƵƐƚĞĚ ŐƌŽƐƐ ŝŶĐŽŵĞ ;D'/Ϳ ĂƐ ĨŽůůŽǁƐ͘ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ŝŶĐŽŵĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ƌĞƐŽƵƌĐĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ

—‡ ʹ6ǡ ʹͲʹͲ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ ϯ dE͗ ϮϬͲϬϬϬϲ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ ϰ͘ y dŚĞ ĂŐĞŶĐLJ ĐŽŶƐŝĚĞƌƐ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĞǀĂĐƵĂƚĞĚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ůĞĂǀĞ ƚŚĞ ƐƚĂƚĞ ĨŽƌ ŵĞĚŝĐĂů ƌĞĂƐŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ Žƌ ǁŚŽ ĂƌĞ ŽƚŚĞƌǁŝƐĞ ĂďƐĞŶƚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĂŶĚ ǁŚŽ ŝŶƚĞŶĚ ƚŽ ƌĞƚƵƌŶ ƚŽ ƚŚĞ ƐƚĂƚĞ͕ ƚŽ ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ƌĞƐŝĚĞŶƚƐ ŽĨ ƚŚĞ ƐƚĂƚĞ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϰϬϯ;ũͿ;ϯͿ͘ ϱ͘ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ DĞĚŝĐĂŝĚ ĐŽǀĞƌĂŐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŝŶĚŝǀŝĚƵĂůƐ ůŝǀŝŶŐ ŝŶ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ĂƌĞ ŶŽŶͲƌĞƐŝĚĞŶƚƐ͗ ϲ͘ y dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ ĨŽƌ ĂŶ ĞdžƚĞŶƐŝŽŶ ŽĨ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĨŽƌ ŶŽŶͲĐŝƚŝnjĞŶƐ ĚĞĐůĂƌŝŶŐ ƚŽ ďĞ ŝŶ Ă ƐĂƚŝƐĨĂĐƚŽƌLJ ŝŵŵŝŐƌĂƚŝŽŶ ƐƚĂƚƵƐ͕ ŝĨ ƚŚĞ ŶŽŶͲĐŝƚŝnjĞŶ ŝƐ ŵĂŬŝŶŐ Ă ŐŽŽĚ ĨĂŝƚŚ ĞĨĨŽƌƚ ƚŽ ƌĞƐŽůǀĞ ĂŶLJ ŝŶĐŽŶƐŝƐƚĞŶĐĞƐ Žƌ ŽďƚĂŝŶ ĂŶLJ ŶĞĐĞƐƐĂƌLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ Žƌ ƚŚĞ ĂŐĞŶĐLJ ŝƐ ƵŶĂďůĞ ƚŽ ĐŽŵƉůĞƚĞ ƚŚĞ ǀĞƌŝĨŝĐĂƚŝŽŶ ƉƌŽĐĞƐƐ ǁŝƚŚŝŶ ƚŚĞ ϵϬͲĚĂLJ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ϳ͘ ^ĞĐƚŝŽŶ  ʹ ŶƌŽůůŵĞŶƚ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĞůĞĐƚƐ ƚŽ ĂůůŽǁ ŚŽƐƉŝƚĂůƐ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚĚŝƚŝŽŶĂů ƐƚĂƚĞ ƉůĂŶ ƉŽƉƵůĂƚŝŽŶƐ͕ Žƌ ĨŽƌ ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ĂŶ ĂƉƉƌŽǀĞĚ ƐĞĐƚŝŽŶ ϭϭϭϱ ĚĞŵŽŶƐƚƌĂƚŝŽŶ͕ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϰϳͿ;Ϳ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϭϭϭϬ͕ ƉƌŽǀŝĚĞĚ ƚŚĂƚ ƚŚĞ ĂŐĞŶĐLJ ŚĂƐ ĚĞƚĞƌŵŝŶĞĚ ƚŚĂƚ ƚŚĞ ŚŽƐƉŝƚĂů ŝƐ ĐĂƉĂďůĞ ŽĨ ŵĂŬŝŶŐ ƐƵĐŚ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ŝƚƐĞůĨ ĂƐ Ă ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚLJ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĞŶƚŝƚŝĞƐ ĂƐ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ Žƌ ĂĚĚƐ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ /ŶĚŝĐĂƚĞ ŝĨ ĂŶLJ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ ĂƌĞ ƉĞƌŵŝƚƚĞĚ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽŶůLJ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ͘ ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚŽƉƚƐ Ă ƚŽƚĂů ŽĨ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ĐŽŶƚŝŶƵŽƵƐ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ĐŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ĞŶƚĞƌ ĂŐĞ ͺͺͺͺͺ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ĂŐĞ ϭϵͿ ƌĞŐĂƌĚůĞƐƐ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĞͿ;ϭϮͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϵϮϲ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ

—‡ ʹ6ǡ ʹͲʹͲ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ ϰ dE͗ ϮϬͲϬϬϬϲ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ ϱ͘ ͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶĚƵĐƚƐ ƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽĨ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ D'/Ͳ ďĂƐĞĚ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϲϬϯ;ũͿ ŽŶĐĞ ĞǀĞƌLJ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ϰϮ &Z ϰϯϱ͘ϵϭϲ;ďͿ͘ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ƚŽ ƐƵƉƉŽƌƚ ĞŶƌŽůůŵĞŶƚ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ Žƌ ĨŽƌ ĂĨĨĞĐƚĞĚ ŝŶĚŝǀŝĚƵĂůƐ ;Ă ĐŽƉLJ ŽĨ ƚŚĞ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ŚĂƐ ďĞĞŶ ƐƵďŵŝƚƚĞĚ ƚŽ D^Ϳ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ ĂƉƉůŝĐĂƚŝŽŶ͘ ď͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ͘ Đ͘ ͺͺͺͺͺ dŚĞ ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ Žƌ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ ŝƐ ŵĂĚĞ ĂǀĂŝůĂďůĞ ĨŽƌ ƵƐĞ ŝŶ ĐĂůůͲĐĞŶƚĞƌƐ Žƌ ŽƚŚĞƌ ƚĞůĞƉŚŽŶĞ ĂƉƉůŝĐĂƚŝŽŶƐ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ͘ ^ĞĐƚŝŽŶ  ʹ WƌĞŵŝƵŵƐ ĂŶĚ ŽƐƚ ^ŚĂƌŝŶŐ ϭ͘ y dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ ĂŶĚ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĂƐ ĨŽůůŽǁƐ͗ dŚĞ ^ƚĂƚĞ ƐƵƐƉĞŶĚƐ Ăůů ĐŽƐƚ ƐŚĂƌŝŶŐ͘ Ϯ͘ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĞŶƌŽůůŵĞŶƚ ĨĞĞƐ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ͗ Ă͘ ůů ďĞŶĞĨŝĐŝĂƌŝĞƐ ď͘ ͺͺͺͺͺ dŚĞ ĨŽůůŽǁŝŶŐ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ͗ Eͬ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂůůŽǁƐ ǁĂŝǀĞƌ ŽĨ ƉĂLJŵĞŶƚ ŽĨ ƚŚĞ ĞŶƌŽůůŵĞŶƚ ĨĞĞ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ WůĞĂƐĞ ƐƉĞĐŝĨLJ ƚŚĞ ƐƚĂŶĚĂƌĚ;ƐͿ ĂŶĚͬŽƌ ĐƌŝƚĞƌŝĂ ƚŚĂƚ ƚŚĞ ƐƚĂƚĞ ǁŝůů ƵƐĞ ƚŽ ĚĞƚĞƌŵŝŶĞ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ ^ĞĐƚŝŽŶ  ʹ ĞŶĞĨŝƚƐ ĞŶĞĨŝƚƐ͗ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚĚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ŝŶ ŝƚƐ ƐƚĂƚĞ ƉůĂŶ ;ŝŶĐůƵĚĞ ƐĞƌǀŝĐĞ ĚĞƐĐƌŝƉƚŝŽŶƐ͕ ƉƌŽǀŝĚĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ůŝŵŝƚĂƚŝŽŶƐ ŽŶ ĂŵŽƵŶƚ͕ ĚƵƌĂƚŝŽŶ Žƌ ƐĐŽƉĞ ŽĨ ƚŚĞ ďĞŶĞĨŝƚͿ͗ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ

—‡ ʹ6ǡ ʹͲʹͲ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ ϱ dE͗ ϮϬͲϬϬϬϲ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ Ϯ͘ y dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐƵƌƌĞŶƚůLJ ĐŽǀĞƌĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ ƉůĂŶ͗ ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ĞdžƚĞŶĚ Ăůů ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ ŝ͘ ŶLJ ŵĞĚŝĐĂůůLJ ŶĞĐĞƐƐĂƌLJ ƐƵƌŐŝĐĂů ƉƌŽĐĞĚƵƌĞƐ ƚŚĂƚ ƌĞƋƵŝƌĞ ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĞŝƚŚĞƌ ďLJ ĨĞĞͲ ĨŽƌͲƐĞƌǀŝĐĞ͕ ŵĂŶĂŐĞĚ ĐĂƌĞ͕ Žƌ ďŽƚŚ͘ ŝŝ͘ WĞĚŝĂƚƌŝĐ ĂLJ ,ĞĂůƚŚ ĞŶƚĞƌ ;W,Ϳ ŝŝŝ͘ ƉŚLJƐŝĐŝĂŶ ĂĚŵŝŶŝƐƚĞƌĞĚ ĚƌƵŐƐ ŝǀ͘ ƵƌĂďůĞ ŵĞĚŝĐĂů ĞƋƵŝƉŵĞŶƚ ;D Ϳ ǀ͘ ,ŽŵĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ; ,,ͬW^Ϳ ǀŝ͘ ,ŽƐƉŝĐĞ ƐĞƌǀŝĐĞƐ ǀŝŝ͘ dŚĞƌĂƉŝĞƐ ;ƉŚLJƐŝĐĂů ƚŚĞƌĂƉLJ͕ ŽĐĐƵƉĂƚŝŽŶĂů ƚŚĞƌĂƉLJ͕ ƐƉĞĞĐŚ ƚŚĞƌĂƉLJͿ ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĨŽƌ >ŽŶŐ dĞƌŵ WĞƌƐŽŶĂů ĂƌĞ ^ĞƌǀŝĐĞƐ ;>dͲ W^Ϳ͕ ϰϮ &Z ϰϰϬ͘ϭϲϳ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͗ ŝ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ƚŚĂƚ ƐĞƌǀŝĐĞƐ ŵƵƐƚ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƚŚĞ ĂƉƉƌŽǀĞĚ ƉůĂŶ ŽĨ ĐĂƌĞ ĂŶĚ ƐƵƉƉŽƌƚŝŶŐ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ ƚŽ ĂƵƚŚŽƌŝnjĞ ŚŽƵƌƐ ƵƉ ƚŽ ϯϮ ŚŽƵƌƐ ƉĞƌ ǁĞĞŬ͕ ŝĨ ŶĞĞĚĞĚ͖ ŝŝ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ĨŽƌ ƚŚĞ ĂŐĞ͕ ĞĚƵĐĂƚŝŽŶ ĂŶĚ ĞdžƉĞƌŝĞŶĐĞ ĨŽƌ ƚŚĞ ƉĞƌƐŽŶĂů ĐĂƌĞ ƐĞƌǀŝĐĞƐ ǁŽƌŬĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ ĂŶĚ ĂůůŽǁ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌƐŽŶƐ ƚŽ ƐĞƌǀĞ ĂƐ ƚŚĞ ĚŝƌĞĐƚ ƐĞƌǀŝĐĞ ǁŽƌŬĞƌ ĨŽƌ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͗ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ĐƵƌĂƚŽƌ͖ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ƚƵƚŽƌ͖ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ƌĞƐƉŽŶƐŝďůĞ ƌĞƉƌĞƐĞŶƚĂƚŝǀĞ͖ Žƌ ƚŚĞ ƉĞƌƐŽŶ ƚŽ ǁŚŽŵ ƚŚĞ ƌĞĐŝƉŝĞŶƚ ŚĂƐ ŐŝǀĞŶ ZĞƉƌĞƐĞŶƚĂƚŝǀĞ ĂŶĚ DĂŶĚĂƚĞ ĂƵƚŚŽƌŝƚLJ ;WŽǁĞƌ ŽĨ ƚƚŽƌŶĞLJͿ ƵŶůĞƐƐ ƚŚĞLJ ĂƌĞ ůĞŐĂůůLJ ƌĞƐƉŽŶƐŝďůĞ ƌĞůĂƚŝǀĞƐ͖ ŝŝŝ͘ ůůŽǁ ƌĞĐŝƉŝĞŶƚƐ͛ ƌĞͲĂƐƐĞƐƐŵĞŶƚƐ ƚŽ ŐŽ ďĞLJŽŶĚ ƚŚĞ ϭϴͲŵŽŶƚŚ ƌĞƋƵŝƌĞŵĞŶƚ͘ dŚĞƐĞ ƌĞĐŝƉŝĞŶƚƐ ǁŝůů ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ŵŽŶŝƚŽƌĞĚ ƚŚƌŽƵŐŚ ŵŽŶƚŚůLJ ƚĞůĞƉŚŽŶĞ ĐŽŶƚĂĐƚƐ͖ ŝǀ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚ ƚŚĂƚ ƉůĂĐĞ;ƐͿ ŽĨ ƐĞƌǀŝĐĞ ŵƵƐƚ ďĞ ĚŽĐƵŵĞŶƚĞĚ ŝŶ ƚŚĞ ƉůĂŶ ŽĨ ĐĂƌĞ͖ ǀ͘ >dͲW^ ŵĂLJ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ ĂŶŽƚŚĞƌ ƐƚĂƚĞ ǁŝƚŚŽƵƚ ƉƌŝŽƌ ĂƉƉƌŽǀĂů ŽĨ ƚŚĞ KĨĨŝĐĞ ŽĨ ŐŝŶŐ ĂŶĚ ĚƵůƚ ^ĞƌǀŝĐĞƐ ;K^Ϳ Žƌ ŝƚƐ ĚĞƐŝŐŶĞĞ͖ ǀŝ͘  ƌĞĐŝƉŝĞŶƚ ŵĂLJ ƌĞĐĞŝǀĞ >dͲW^ ǁŚŝůĞ ůŝǀŝŶŐ ŝŶ Ă ŚŽŵĞ Žƌ ƉƌŽƉĞƌƚLJ ŽǁŶĞĚ͕ ŽƉĞƌĂƚĞĚ Žƌ ĐŽŶƚƌŽůůĞĚ ďLJ Ă ƉƌŽǀŝĚĞƌ ŽĨ ƐĞƌǀŝĐĞƐ ǁŚŽ ŝƐ ŶŽƚ ƌĞůĂƚĞĚ ďLJ ďůŽŽĚ Žƌ ŵĂƌƌŝĂŐĞ ƚŽ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͖ ǀŝŝ͘ dŚĞ ^ƚĂƚĞ ŵĂLJ ŝŶĐƌĞĂƐĞ ƚŚĞ ŵĂdžŝŵƵŵ ŶƵŵďĞƌ ŽĨ >dͲW^ ŚŽƵƌƐ ƌĞĐĞŝǀĞĚ ƉĞƌ ǁĞĞŬ͖ ĂŶĚ ǀŝŝŝ͘ dŚĞ ^ƚĂƚĞ ŵĂLJ ĂůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ͘ ͘ WĞĚŝĂƚƌŝĐ ĂLJ ,ĞĂůƚŚ ĂƌĞ ;W,Ϳ ƐŬŝůůĞĚ ƐĞƌǀŝĐĞƐ ŵĂLJ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ Ă ƌĞƐŝĚĞŶƚŝĂů ƐĞƚƚŝŶŐ ĚƵƌŝŶŐ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ƚŽ ƚŚŽƐĞ ĐŚŝůĚƌĞŶ ǁŚŽƐĞ ĨĂŵŝůŝĞƐ ĂƌĞ ŶŽƚ ĂďůĞ ƚŽ ƉƌŽǀŝĚĞ ƐƵĐŚ ĐĂƌĞ ĚƵĞ ƚŽ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ϯ͘ y dŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ŶĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ Žƌ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐŽŵƉůLJ ǁŝƚŚ Ăůů ĂƉƉůŝĐĂďůĞ ƐƚĂƚƵƚŽƌLJ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƐƚĂƚĞǁŝĚĞŶĞƐƐ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭͿ͕ ĐŽŵƉĂƌĂďŝůŝƚLJ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ͕ ĂŶĚ ĨƌĞĞ ĐŚŽŝĐĞ ŽĨ ƉƌŽǀŝĚĞƌ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϮϯͿ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ

—‡ ʹ6ǡ ʹͲʹͲ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ ϲ dE͗ ϮϬͲϬϬϬϲ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ ϰ͘ y ƉƉůŝĐĂƚŝŽŶ ƚŽ ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐ ;WͿ͘ dŚĞ ƐƚĂƚĞ ĂĚŚĞƌĞƐ ƚŽ Ăůů W ƉƌŽǀŝƐŝŽŶƐ ŝŶ ϰϮ &Z WĂƌƚ ϰϰϬ͕ ^ƵďƉĂƌƚ ͘ dŚŝƐ ƐĞĐƚŝŽŶ ŽŶůLJ ĂƉƉůŝĞƐ ƚŽ ƐƚĂƚĞƐ ƚŚĂƚ ŚĂǀĞ ĂŶ ĂƉƉƌŽǀĞĚ W;ƐͿ͘ ƒǤ  Š‡ ƒ‰‡ › ƒ••—”‡• –Šƒ– –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–• ™‹ŽŽ „‡ ƒ†‡ ƒ˜ƒ‹Žƒ„Ž‡ –‘ ‹†‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” •Ǥ „Ǥ ̴̴̴̴̴ †‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” • ™‹ŽŽ ‘– ”‡ ‡‹˜‡ –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–•ǡ ‘” ™‹ŽŽ ‘Ž› ”‡ ‡‹˜‡ –Š‡ ˆ‘ŽŽ‘™‹‰ •—„•‡–ǣ dĞůĞŚĞĂůƚŚ͗ ϱ͘ y dŚĞ ĂŐĞŶĐLJ ƵƚŝůŝnjĞƐ ƚĞůĞŚĞĂůƚŚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĂŶŶĞƌ͕ ǁŚŝĐŚ ŵĂLJ ďĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ͛Ɛ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ŵĞĞƚ ĨĂĐĞͲ ƚŽͲĨĂĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ĚĞƚĂŝůĞĚ ŝŶ ƚŚĞ >ŽƵŝƐŝĂŶĂ ^ƚĂƚĞ WůĂŶ ĨŽƌ Ăůů ƐĞƌǀŝĐĞƐ ǀŝĂ ƚĞůĞŚĞĂůƚŚ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͘ ƌƵŐ ĞŶĞĨŝƚ͗ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ƚŚĞ ĚĂLJ ƐƵƉƉůLJ Žƌ ƋƵĂŶƚŝƚLJ ůŝŵŝƚ ĨŽƌ ĐŽǀĞƌĞĚ ŽƵƚƉĂƚŝĞŶƚ ĚƌƵŐƐ͘ dŚĞ ĂŐĞŶĐLJ ƐŚŽƵůĚ ŽŶůLJ ŵĂŬĞ ƚŚŝƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŝĨ ŝƚƐ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉĂŐĞƐ ŚĂǀĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ĂŵŽƵŶƚ ŽĨ ŵĞĚŝĐĂƚŝŽŶ ĚŝƐƉĞŶƐĞĚ͘ ϳ͘ y WƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĨŽƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝƐ ĞdžƉĂŶĚĞĚ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ͕ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ͘ ϴ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĂLJŵĞŶƚ ĂĚũƵƐƚŵĞŶƚ ƚŽ ƚŚĞ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ǁŚĞŶ ĂĚĚŝƚŝŽŶĂů ĐŽƐƚƐ ĂƌĞ ŝŶĐƵƌƌĞĚ ďLJ ƚŚĞ ƉƌŽǀŝĚĞƌƐ ĨŽƌ ĚĞůŝǀĞƌLJ͘ ^ƚĂƚĞƐ ǁŝůů ŶĞĞĚ ƚŽ ƐƵƉƉůLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ƚŽ ũƵƐƚŝĨLJ ƚŚĞ ĂĚĚŝƚŝŽŶĂů ĨĞĞƐ͘ ϵ͘ y dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞŝƌ ƉƵďůŝƐŚĞĚ WƌĞĨĞƌƌĞĚ ƌƵŐ >ŝƐƚ ŝĨ ĚƌƵŐ ƐŚŽƌƚĂŐĞƐ ŽĐĐƵƌ͘ dŚŝƐ ǁŽƵůĚ ŝŶĐůƵĚĞ ŽƉƚŝŽŶƐ ĨŽƌ ĐŽǀĞƌŝŶŐ Ă ďƌĂŶĚ ŶĂŵĞ ĚƌƵŐ ƉƌŽĚƵĐƚ ƚŚĂƚ ŝƐ Ă ŵƵůƚŝͲƐŽƵƌĐĞ ĚƌƵŐ ŝĨ Ă ŐĞŶĞƌŝĐ ĚƌƵŐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĂǀĂŝůĂďůĞ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ

—‡ ʹ6ǡ ʹͲʹͲ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ ϳ dE͗ ϮϬͲϬϬϬϲ ƉƉƌŽǀĂů ĂƚĞ͗ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ ^ĞĐƚŝŽŶ ʹ WĂLJŵĞŶƚƐ KƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ͗ ϭ͘ ͺͺ ͺͺͺ EĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ  ĂƌĞ ƉĂŝĚ ƵƐŝŶŐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĞƚŚŽĚŽůŽŐLJ͗ ƒǤ ̴̴̴ —„Ž‹•Š‡† ˆ‡‡ • Š‡†—Ž‡• Ȃ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ „Ǥ ̴̴̴̴̴ –Š‡”ǣ ĞƐĐƌŝďĞ ŵĞƚŚŽĚŽůŽŐLJ ŚĞƌĞ͘ /ŶĐƌĞĂƐĞƐ ƚŽ ƐƚĂƚĞ ƉůĂŶ ƉĂLJŵĞŶƚ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ Ϯ͘ y dŚĞ ĂŐĞŶĐLJ ŝŶĐƌĞĂƐĞƐ ƉĂLJŵĞŶƚ ƌĂƚĞƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ŝŶĐƌĞĂƐĞ ƚŚĞ ƉĂLJŵĞŶƚ ĨŽƌ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚLJ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJƐ ĨƌŽŵ ϭϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ ƚŽ ϭϬϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ͕ ĂŶĚ ŝŶĐůƵĚĞ Ă ΨϭϮ ŝŶĐƌĞĂƐĞ ƚŽ ƚŚĞ ĚĂŝůLJ ƉĞƌ ĚŝĞŵ ƌĂƚĞ ƉĂŝĚ ƚŽ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚŝĞƐ͘ ^ƚĂƚĞ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ĂŶĚ ŶŽŶͲƐƚĂƚĞ ŐŽǀĞƌŶŵĞŶƚ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ĨĂĐŝůŝƚŝĞƐ ĂƌĞ ŶŽƚ ĞůŝŐŝďůĞ ĨŽƌ͕ ĂŶĚ ǁŝůů ŶŽƚ ƌĞĐĞŝǀĞ͕ ƚŚĞ ƐƚĂƚĞ Žƌ ĨĞĚĞƌĂůůLJ ĚĞĐůĂƌĞĚ ĞŵĞƌŐĞŶĐLJ ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJ ƉĂLJŵĞŶƚƐ ĂŶĚ ǁŝůů ŶŽƚ ƌĞĐĞŝǀĞ ƚŚĞ ΨϭϮ ŝŶĐƌĞĂƐĞ ƚŽ ƚŚĞ ĚĂŝůLJ ƉĞƌ ĚŝĞŵ ƌĂƚĞ ĂƐ ĚĞƐĐƌŝďĞĚ ĂďŽǀĞ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ƉĂLJ /ŶƚĞƌŵĞĚŝĂƚĞ ĂƌĞ &ĂĐŝůŝƚŝĞƐ ĨŽƌ /ŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ /ŶƚĞůůĞĐƚƵĂů ŝƐĂďŝůŝƚŝĞƐ ;/&ƐͲ//Ϳ ďĞLJŽŶĚ ƚŚĞ ϰϱͲ ĚĂLJ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJƐ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ĂĚũƵƐƚ ƌĂƚĞƐ ŝŶ ƚŚĞ ƉŚLJƐŝĐŝĂŶ ďĞŶĞĨŝƚ ƚŽ ƌĞŝŵďƵƌƐĞ ĂŵďƵůĂŶĐĞ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞƌƐ ǁŚŽ ƉƌŽǀŝĚĞ ĂůůŽǁĂďůĞ ƐĞƌǀŝĐĞƐ ŽŶ ƐŝƚĞ͕ ǁŝƚŚŽƵƚ ƚƌĂŶƐƉŽƌƚ͕ ǁŚŝůĞ ƵŶĚĞƌ ƚŚĞ ƐƵƉĞƌǀŝƐŝŽŶ ŽĨ Ă ůŝĐĞŶƐĞĚ ƉŚLJƐŝĐŝĂŶ͘ Ă͘ ͺͺͺͺͺ WĂLJŵĞŶƚ ŝŶĐƌĞĂƐĞƐ ĂƌĞ ƚĂƌŐĞƚĞĚ ďĂƐĞĚ ŽŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐƌŝƚĞƌŝĂ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĐƌŝƚĞƌŝĂ͘ ď͘ WĂLJŵĞŶƚƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ ƚŚƌŽƵŐŚ͗ ‹Ǥ   •—’’Ž‡‡–ƒŽ ’ƒ›‡– ‘” ƒ††Ǧ‘ ™‹–Š‹ ƒ’’Ž‹ ƒ„Ž‡ —’’‡” ’ƒ›‡– Ž‹‹–•ǣ ͺͺͺͺͺͺͺͺͺͺ

—‡ ʹ6ǡ ʹͲʹͲ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ ϴ dE͗ ϮϬͲϬϬϬϲ ƉƉƌŽǀĂů ĂƚĞ͗ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ ΨϭϮ ƉĞƌ ĚĂLJ ĂĚĚͲŽŶ ƚŽ ƚŚĞ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚLJ ƌĂƚĞ͘ ‹‹Ǥ ̴̴̴̴̴  ‹ ”‡ƒ•‡ –‘ ”ƒ–‡• ƒ• †‡• ”‹„‡† „‡Ž‘™Ǥ ͺͺͺyͺͺ hŶŝĨŽƌŵůLJ ďLJ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌĐĞŶƚĂŐĞ͗ &Žƌ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ ĂŶĚ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚŝĞƐ͕ ŝŶĐƌĞĂƐĞ ƌĂƚĞ ĨƌŽŵ ϭϬ ƉĞƌĐĞŶƚ ƚŽ ϭϬϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ ĨŽƌ ŚŽŵĞ ĂŶĚ ŚŽƐƉŝƚĂů ůĞĂǀĞ ĚĂLJƐ͘ ͺͺͺͺͺ dŚƌŽƵŐŚ Ă ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ƉƵďůŝƐŚĞĚ ĨĞĞ ƐĐŚĞĚƵůĞƐ ʹ

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

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

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^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ ϵ dE͗ ϮϬͲϬϬϬϲ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ ^ĞĐƚŝŽŶ & ʹ WŽƐƚͲ ůŝŐŝďŝůŝƚLJ dƌĞĂƚŵĞŶƚ ŽĨ /ŶĐŽŵĞ ͳǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• –‘ ‘†‹ˆ› –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ˆ‘” ‹•–‹–—–‹‘ƒŽ‹œ‡† ‹†‹˜‹†—ƒŽ•Ǥ Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ‹• ‡“—ƒŽ –‘ ‘‡ ‘ˆ –Š‡ ˆ‘ŽŽ‘™‹‰ ƒ‘—–•ǣ ƒǤ ̴̴̴̴̴ Š‡ ‹†‹˜‹†—ƒŽǯ• –‘–ƒŽ ‹ ‘‡ „Ǥ ̴̴̴̴̴ ͵ͲͲ ’‡” ‡– ‘ˆ –Š‡  ˆ‡†‡”ƒŽ „‡‡ˆ‹– ”ƒ–‡

Ǥ ̴̴̴̴̴ –Š‡” ”‡ƒ•‘ƒ„Ž‡ ƒ‘—–ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• ƒ ‡™ ˜ƒ”‹ƒ ‡ –‘ –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡Ǥ ȋ‘–‡ǣ Ž‡ –‹‘ ‘ˆ –Š‹• ‘’–‹‘ ‹• ‘– †‡’‡†‡– ‘ ƒ •–ƒ–‡ ‡Ž‡ –‹‰ –Š‡ ‘’–‹‘ †‡• ”‹„‡† –Š‡ ‘’–‹‘ ‹ ǤͳǤ ƒ„‘˜‡ǤȌ dŚĞ ƐƚĂƚĞ ƉƌŽƚĞĐƚƐ ĂŵŽƵŶƚƐ ĞdžĐĞĞĚŝŶŐ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ŚĂǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ŐƌĞĂƚĞƌ ƉĞƌƐŽŶĂů ŶĞĞĚƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ ŐƌĞĂƚĞƌ ŶĞĞĚƐ ĂŶĚ ƚŚĞ ĂŵŽƵŶƚ;ƐͿ ƉƌŽƚĞĐƚĞĚ ĨŽƌ ĞĂĐŚ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ͘ ^ĞĐƚŝŽŶ ' ʹ KƚŚĞƌ WŽůŝĐŝĞƐ ĂŶĚ WƌŽĐĞĚƵƌĞƐ ŝĨĨĞƌŝŶŐ ĨƌŽŵ ƉƉƌŽǀĞĚ DĞĚŝĐĂŝĚ ^ƚĂƚĞ WůĂŶ ͬĚĚŝƚŝŽŶĂů /ŶĨŽƌŵĂƚŝŽŶ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ

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ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E WĂŐĞ ϭϬ dE͗ ϮϬͲϬϬϬϲ ^ƵƉĞƌƐĞĚĞƐ dE͗ ϮϬͲϬϬϬϰ WZ ŝƐĐůŽƐƵƌĞ ^ƚĂƚĞŵĞŶƚ ĐĐŽƌĚŝŶŐ ƚŽ ƚŚĞ WĂƉĞƌǁŽƌŬ ZĞĚƵĐƚŝŽŶ Đƚ ŽĨ ϭϵϵϱ͕ ŶŽ ƉĞƌƐŽŶƐ ĂƌĞ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞƐƉŽŶĚ ƚŽ Ă ĐŽůůĞĐƚŝŽŶ ŽĨ ŝŶĨŽƌŵĂƚŝŽŶ ƵŶůĞƐƐ ŝƚ ĚŝƐƉůĂLJƐ Ă ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ͘ dŚĞ ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ĨŽƌ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ϬϵϯϴͲϭϭϰϴ ; džƉŝƌĞƐ ϬϯͬϯϭͬϮϬϮϭͿ͘ dŚĞ ƚŝŵĞ ƌĞƋƵŝƌĞĚ ƚŽ ĐŽŵƉůĞƚĞ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ĞƐƚŝŵĂƚĞĚ ƚŽ ĂǀĞƌĂŐĞ ϭ ƚŽ Ϯ ŚŽƵƌƐ ƉĞƌ ƌĞƐƉŽŶƐĞ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƚŝŵĞ ƚŽ ƌĞǀŝĞǁ ŝŶƐƚƌƵĐƚŝŽŶƐ͕ ƐĞĂƌĐŚ ĞdžŝƐƚŝŶŐ ĚĂƚĂ ƌĞƐŽƵƌĐĞƐ͕ ŐĂƚŚĞƌ ƚŚĞ ĚĂƚĂ ŶĞĞĚĞĚ͕ ĂŶĚ ĐŽŵƉůĞƚĞ ĂŶĚ ƌĞǀŝĞǁ ƚŚĞ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ͘ zŽƵƌ ƌĞƐƉŽŶƐĞ ŝƐ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞĐĞŝǀĞ Ă ǁĂŝǀĞƌ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ͘ ůů ƌĞƐƉŽŶƐĞƐ ĂƌĞ ƉƵďůŝĐ ĂŶĚ ǁŝůů ďĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ŽŶ ƚŚĞ D^ ǁĞď ƐŝƚĞ͘ /Ĩ LJŽƵ ŚĂǀĞ ĐŽŵŵĞŶƚƐ ĐŽŶĐĞƌŶŝŶŐ ƚŚĞ ĂĐĐƵƌĂĐLJ ŽĨ ƚŚĞ ƚŝŵĞ ĞƐƚŝŵĂƚĞ;ƐͿ Žƌ ƐƵŐŐĞƐƚŝŽŶƐ ĨŽƌ ŝŵƉƌŽǀŝŶŐ ƚŚŝƐ ĨŽƌŵ͕ ƉůĞĂƐĞ ǁƌŝƚĞ ƚŽ͗ D^͕ ϳϱϬϬ ^ĞĐƵƌŝƚLJ ŽƵůĞǀĂƌĚ͕ ƚƚŶ͗ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞƌ͕ DĂŝů ^ƚŽƉ ϰͲϮϲͲϬϱ͕ ĂůƚŝŵŽƌĞ͕ DĂƌLJůĂŶĚ ϮϭϮϰϰͲϭϴϱϬ͘ ΎΎΎD^ ŝƐĐůŽƐƵƌĞΎΎΎ WůĞĂƐĞ ĚŽ ŶŽƚ ƐĞŶĚ ĂƉƉůŝĐĂƚŝŽŶƐ͕ ĐůĂŝŵƐ͕ ƉĂLJŵĞŶƚƐ͕ ŵĞĚŝĐĂů ƌĞĐŽƌĚƐ Žƌ ĂŶLJ ĚŽĐƵŵĞŶƚƐ ĐŽŶƚĂŝŶŝŶŐ ƐĞŶƐŝƚŝǀĞ ŝŶĨŽƌŵĂƚŝŽŶ ƚŽ ƚŚĞ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞ͘ WůĞĂƐĞ ŶŽƚĞ ƚŚĂƚ ĂŶLJ ĐŽƌƌĞƐƉŽŶĚĞŶĐĞ ŶŽƚ ƉĞƌƚĂŝŶŝŶŐ ƚŽ ƚŚĞ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ďƵƌĚĞŶ ĂƉƉƌŽǀĞĚ ƵŶĚĞƌ ƚŚĞ ĂƐƐŽĐŝĂƚĞĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ůŝƐƚĞĚ ŽŶ ƚŚŝƐ ĨŽƌŵ ǁŝůů ŶŽƚ ďĞ ƌĞǀŝĞǁĞĚ͕ ĨŽƌǁĂƌĚĞĚ͕ Žƌ ƌĞƚĂŝŶĞĚ͘ /Ĩ LJŽƵ ŚĂǀĞ ƋƵĞƐƚŝŽŶƐ Žƌ ĐŽŶĐĞƌŶƐ ƌĞŐĂƌĚŝŶŐ ǁŚĞƌĞ ƚŽ ƐƵďŵŝƚ LJŽƵƌ ĚŽĐƵŵĞŶƚƐ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂŝĚ Θ ,/W ^ĞƌǀŝĐĞƐ Ăƚ ϰϭϬͲϳϴϲͲϯϴϳϬ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ

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ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 20-013 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 0300 Kansas City, Missouri 64106-2898 Medicaid and CHIP Operations Group January 12, 2021 Ms. Tara LeBlanc, Interim Medicaid Director State of Louisiana Department of Health 628 N 4th Street P.O. Box 91030 Baton Rouge, LA 70821-9030 RE: TN LA 20-0013 Dear Ms. LeBlanc: We have reviewed the State’s proposed amendment to the Louisiana State Plan submitted under Transmittal Number (TN) 20-0013 dated October 27, 2020. This state plan amendment is to amend the provisions governing hospice services provided concurrently with life-prolonging treatments to individuals under age 21 in order to update existing terminology and reflect current practices, and to comply with federal requirements which allow for pediatric concurrent care. Based on the information submitted, we approved the amendment on January 12, 2021, for incorporation into the official Louisiana State Plan with an effective date of November 20, 2020. A copy of the CMS-179 and approved plan page is enclosed with this letter. If you have any questions regarding this matter, you may contact Tobias Griffin at (214) 767-4425, or by email at tobias.griffin@cms.hhs.gov. Sincerely, Division of Program Operations Enclosures cc: Billy Bob Farrell, Branch Manager Karen Barnes, LA Department of Health

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 20-0013 2. STATE Louisiana 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE November 20, 2020 5. TYPE OF PLAN MATERIAL (Check One) ܆NEW STATE PLAN ܆AMENDMENT TO BE CONSIDERED AS NEW PLAN ܈AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 1905(o) of the Social Security Act 42 CFR Part 418 7. FEDERAL BUDGET IMPACT a. FFY 2021 $ 0 b. FFY 2022 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 3.1-A, Item 18, Page 8 Attachment 4.19-B, Item 18, Page 2 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Same (TN 13-47) None (New Page) 10. SUBJECT OF AMENDMENT The purpose of this SPA is to amend the provisions governing hospice services provided concurrently with life-prolonging treatments to individuals under age 21 in order to update existing terminology and reflect current practices, and to comply with federal requirements which allow for pediatric concurrent care. 12. SIGNATURE OF STATE AGENCY OFFICIAL 16. RETURN TO Tara A. LeBlanc Interim Medicaid Executive Director State of Louisiana Department of Health 628 North 4th Street P.O. Box 91030 Baton Rouge, LA 70821-9030 13. TYPED NAME Ruth Johnson, designee for Dr. Courtney N. Phillips 14. TITLE Secretary 15. DATE SUBMITTED October 27, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS The State requests a pen and ink change to boxes 8 and 9. 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT ܈OTHER, AS SPECIFIED The Governor does not review State Plan material. COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL -DQXDU\ -DPHV*6FRWW 'LUHFWRU'LYLVLRQRI3URJUDP2SHUDWLRQV 1RYHPEHU 2FWREHU

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT ATTACHMENT 3.1-A MEDICAL ASSISTANCE PROGRAM Item 18, Page 8 STATE OF LOUISIANA AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATION ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED AS FOLLOWS: TN 20-0013_____ Approval Date _____________ Effective Date 11/20/2020_____ Supersedes TN 13-47 IV. Waiver of Payment for Other Services Hospice providers must provide services to beneficiaries that are comparable to the Medicaid covered services that could have been received prior to the election of hospice. This requirement refers to all Medicaid-covered services including, but not limited to, durable medical equipment, prescription drugs, and physician-administered drugs. Upon the election of hospice, beneficiaries waive all rights to payment of services related to the treatment of the terminal condition for which hospice services were elected or related conditions. Beneficiaries under age 21 who are approved for hospice may continue to receive life-prolonging treatments. Life-prolonging treatments are defined as Medicaid-covered services provided to a beneficiary with the purpose of treating, modifying, or curing a medical condition to allow the beneficiary to live as long as possible, even if that medical condition is also the hospice qualifying diagnosis. The hospice provider and other providers must coordinate life-prolonging treatments and incorporate them into the plan of care. For beneficiaries under the age of 21, the hospice provider is responsible for making a daily visit, unless specifically declined by the beneficiary or family, to coordinate care and ensure that there is no duplication of services. The daily visit is not required if the beneficiary is not in the home due to hospitalization or inpatient respite or inpatient hospice stays. -DQXDU\

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 21-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 0300 Kansas City, Missouri 64106-2898 Medicaid and CHIP Operations Group August 26, 2021

Mr. Michael Boutte, Interim Medicaid Director State of Louisiana Department of Health 628 N 4th Street P.O. Box 91030 Baton Rouge, LA 70821-9030 RE: TN LA 21-0010 Dear Mr. Boutte:

We have reviewed the State’s proposed amendment to the Louisiana State Plan submitted under Transmittal Number (TN) 20-0010 dated June 28, 2021. This state plan amendment is to amend the provisions governing third party liability in order to clarify language around the wait and see period for child support enforcement and around third-party recovery for accident and health claims.

Based on the information submitted, we approved the amendment on August 26, 2021, for incorporation into the official Louisiana State Plan with an effective date of April 1, 2021. A copy of the CMS-179 and approved plan pages are enclosed with this letter.

If you have any questions regarding this matter, you may contact Tobias Griffin at (214) 767-4425, or by email at tobias.griffin@cms.hhs.gov.

Sincerely,

James G. Scott, Director Division of Program Operations

Enclosures cc: Billy Bob Farrell, Branch Manager Karen Barnes, LA Department of Health Digitally signed by James ott -S : 2021.08.26 15:13:45 0'

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Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 20-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 April 20, 2020 Ms. Ruth Johnson Medicaid Director State of Louisiana, Department of Health 628 N 4th St. P.O. Box 91030 Baton Rouge, LA 70821-9030 Re: Louisiana State Plan Amendment (SPA) 20-0004 Dear Ms. Johnson: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID- 19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20- 0004. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. The State of Louisiana requested a modification of the requirement to submit SPAs related to the COVID-19 emergency by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 C.F.R. §430.20. CMS is approving this request pursuant to section 1135(b)(5) of the Act.

The State of Louisiana also requested a waiver of public notice requirements applicable to the state plan amendment (SPA) submission process. Public notice for SPAs is required under 42 C.F.R §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to ABPs. These requirements help to ensure that the affected public has reasonable opportunity to comment on these SPAs. CMS recognizes that during this public health emergency, Louisiana must act expeditiously to protect and serve the general public. Therefore, under section 1135(b)(1)(C) and 1135(b)(5) of the Act, CMS is approving the state’s request to waive these notice requirements applicable to this SPA. The State of Louisiana also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Under section 1135(b)(5) of the Act, CMS is also approving the State of Louisiana’s request for flexibility to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These approvals under section 1135 only apply with respect to SPAs that provide or increase beneficiary access to items and services related to COVID-19 (such as cost sharing waivers, payment rate increases, or amendments to ABPs to add services or providers) and that would not restrict or limit payment or services or otherwise burden beneficiaries and providers, and that are temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 emergency (or any extension thereof). Even though CMS is approving this waiver, we encourage the state to make all relevant information available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Louisiana’s Medicaid SPA Transmittal Number 20-0004 is approved effective March 1, 2020. Please note that the effective date for the new COVID-19 testing eligibility group described at section 1902(a)(10)(A)(ii)(XXIII) of the Act is March 18, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Tobias Griffin at 214-767-4425 or by email at tobias.griffin@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Louisiana and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF __ {1. TRANSMITTAL NUMBER 2. STATE STATE PLAN MATERIAL 20-0004 Louisiana

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

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

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

4, PROPOSED EFFECTIVE DATE March 1, 2020

5. TYPE OF PLAN MATERIAL (Check One) Cl NEW STATE PLAN

O AMENDMENT TO BE CONSIDERED AS NEW PLAN

@ AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THiS IS AN AMENDMENT (Separate transmittal for each amendment)

6, FEDERAL STATUTE/REGULATION CITATION

Section 1135 of the Social Security Act

7. FEDERAL BUDGET IMPACT

a. FFY 2020 $8 14,147,120 b. FFY 2021 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Section 7 — General Provisions 7.4 Medical Disaster Relief for the COVID-19 National Emergency

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

None — new pages

10. SUBJECT OF AMENDMENT The purpose of this SPA is to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse.

11. GOVERNOR'S REVIEW (Check One)

Oo GOVERNOR'S OFFICE REPORTED NO COMMENT C1 comMMENTS OF GOVERNOR'S OFFICE ENCLOSED (1 No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

& OTHER, AS SPECIFIED The Govermor does not review State Plan material.

12. SIGNATURE OF STATE AGENCY OFFICIAL

~~

13. TYPED NAME" Cindy Rives, designee for Stephen R. Russo, JD

14. TITLE

16. RETURN TO Erin Campbell, Acting Medicaid Director State of Louisiana Department of Health 628 North 4" Street

Interim Secretary P.O. Box 91030 45, DATE SUBMITTED Baton Rouge, LA 70821-9030 April 3, 2020

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED March 27,2020

18. DATE APPROVED April 20, 2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL March 1, 2020

20, SIGNATAREB ONREGIONA OFFICIAL

21, TYPED NAME Anne Marie Costello

22. TITLE | Deputy Director Center for Medicaid & CHIP Services

23. REMARKS = The State requests a pen and ink change to box 7.

FORM CMS-179 (07/92)

Instructions on Back

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ^ĞĐƚŝŽŶ ϳ ʹ 'ĞŶĞƌĂů WƌŽǀŝƐŝŽŶƐ ϳ͘ϰ͘ DĞĚŝĐĂŝĚ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ĨŽƌ ƚŚĞ Ks/Ͳϭϵ EĂƚŝŽŶĂů ŵĞƌŐĞŶĐLJ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƚŚĞ WƌĞƐŝĚĞŶƚ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ŝƐƐƵĞĚ Ă ƉƌŽĐůĂŵĂƚŝŽŶ ƚŚĂƚ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ŝŶ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĐŽŶƐƚŝƚƵƚĞƐ Ă ŶĂƚŝŽŶĂů ĞŵĞƌŐĞŶĐLJ ďLJ ƚŚĞ ĂƵƚŚŽƌŝƚŝĞƐ ǀĞƐƚĞĚ ŝŶ Śŝŵ ďLJ ƚŚĞ ŽŶƐƚŝƚƵƚŝŽŶ ĂŶĚ ƚŚĞ ůĂǁƐ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ͕ ŝŶĐůƵĚŝŶŐ ƐĞĐƚŝŽŶƐ ϮϬϭ ĂŶĚ ϯϬϭ ŽĨ ƚŚĞ EĂƚŝŽŶĂů

ŵĞƌŐĞŶĐŝĞƐ Đƚ ;ϱϬ h͘^͘͘ ϭϲϬϭ Ğƚ ƐĞƋ͘Ϳ͕ ĂŶĚ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ ;ĐƚͿ͘ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ ŽĨ ƚŚĞ Đƚ͕ ƚŚĞ ^ĞĐƌĞƚĂƌLJ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĞƉĂƌƚŵĞŶƚ ŽĨ ,ĞĂůƚŚ ĂŶĚ ,ƵŵĂŶ ^ĞƌǀŝĐĞƐ ŝŶǀŽŬĞĚ ŚŝƐ ĂƵƚŚŽƌŝƚLJ ƚŽ ǁĂŝǀĞ Žƌ ŵŽĚŝĨLJ ĐĞƌƚĂŝŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ŽĨ ƚŝƚůĞƐ ys///͕ y/y͕ ĂŶĚ yy/ ŽĨ ƚŚĞ Đƚ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ ĐŽŶƐĞƋƵĞŶĐĞƐ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ƚŽ ƚŚĞ ĞdžƚĞŶƚ ŶĞĐĞƐƐĂƌLJ͕ ĂƐ ĚĞƚĞƌŵŝŶĞĚ ďLJ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂƌĞ Θ DĞĚŝĐĂŝĚ ^ĞƌǀŝĐĞƐ ;D^Ϳ͕ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ƐƵĨĨŝĐŝĞŶƚ ŚĞĂůƚŚ ĐĂƌĞ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂƌĞ ĂǀĂŝůĂďůĞ ƚŽ ŵĞĞƚ ƚŚĞ ŶĞĞĚƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĞŶƌŽůůĞĚ ŝŶ ƚŚĞ ƌĞƐƉĞĐƚŝǀĞ ƉƌŽŐƌĂŵƐ ĂŶĚ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽǀŝĚĞƌƐ ƚŚĂƚ ĨƵƌŶŝƐŚ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ŝŶ ŐŽŽĚ ĨĂŝƚŚ͕ ďƵƚ ĂƌĞ ƵŶĂďůĞ ƚŽ ĐŽŵƉůLJ ǁŝƚŚ ŽŶĞ Žƌ ŵŽƌĞ ŽĨ ƐƵĐŚ ƌĞƋƵŝƌĞŵĞŶƚƐ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ŵĂLJ ďĞ ƌĞŝŵďƵƌƐĞĚ ĨŽƌ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂŶĚ ĞdžĞŵƉƚĞĚ ĨƌŽŵ ƐĂŶĐƚŝŽŶƐ ĨŽƌ ƐƵĐŚ ŶŽŶĐŽŵƉůŝĂŶĐĞ͕ ĂďƐĞŶƚ ĂŶLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ĨƌĂƵĚ Žƌ ĂďƵƐĞ͘ dŚŝƐ ĂƵƚŚŽƌŝƚLJ ƚŽŽŬ ĞĨĨĞĐƚ ĂƐ ŽĨ ϲWD

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

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ Đ͘ y dƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŝŵĞůŝŶĞƐ ƐƉĞĐŝĨŝĞĚ ŝŶ ΀>ŽƵŝƐŝĂŶĂ΁ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ŵŽĚŝĨLJ ƚŚĞ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƉƌŽĐĞƐƐ ďLJ ĞůŝŵŝŶĂƚŝŶŐ ƚŚĞ ŶƵŵďĞƌ ŽĨ ŶŽƚŝĨŝĐĂƚŝŽŶ ĚĂLJƐ ďĞĨŽƌĞ ƐƵďŵŝƐƐŝŽŶ ŽĨ ƚŚĞ ^W ĂŶĚͬŽƌ ĐŽŶĚƵĐƚŝŶŐ ĐŽŶƐƵůƚĂƚŝŽŶ ĂĨƚĞƌ ƐƵďŵŝƐƐŝŽŶ ŽĨ ƚŚĞ ^W͘ ^ĞĐƚŝŽŶ  ʹ ůŝŐŝďŝůŝƚLJ ϭ͘ y dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ Žƌ ϭϵϬϮ;ĂͿ;ϭϬͿ;ĐͿ ŽĨ ƚŚĞ Đƚ͘ dŚŝƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚĞ ŶĞǁ ŽƉƚŝŽŶĂů ŐƌŽƵƉ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƌŽǀŝĚŝŶŐ ĐŽǀĞƌĂŐĞ ĨŽƌ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ hŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͕ ĂƐ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ͘ /Ŷ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;ys///Ϳ͕ ƚŚĞ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ƚŽ ĂŶ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂů ;ĂƐ ĚĞĨŝŶĞĚ ŝŶ ƐƵďƐĞĐƚŝŽŶ ;ƐƐͿͿ ǁŚŽ ŝƐ ĞůŝŐŝďůĞ ĨŽƌ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ŽŶůLJ ďĞĐĂƵƐĞ ŽĨ ƐƵďƉĂƌĂŐƌĂƉŚ ;Ϳ;ŝŝͿ;yy///Ϳ ŝƐ ůŝŵŝƚĞĚ ƚŽ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ĨŽƌ ĂŶLJ ŝŶ ǀŝƚƌŽ ĚŝĂŐŶŽƐƚŝĐ ƉƌŽĚƵĐƚ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϯͿ;Ϳ ƚŚĂƚ ŝƐ ĂĚŵŝŶŝƐƚĞƌĞĚ ĚƵƌŝŶŐ ĂŶLJ ƉŽƌƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ĚĞƐĐƌŝďĞĚ ŝŶ ƐƵĐŚ ƐĞĐƚŝŽŶ ďĞŐŝŶŶŝŶŐ ŽŶ Žƌ ĂĨƚĞƌ DĂƌĐŚ ϭϴ͕ ϮϬϮϬ ;ĂŶĚ ƚŚĞ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ ŽĨ ƐƵĐŚ ƉƌŽĚƵĐƚͿ ĂŶĚ ĂŶLJ ǀŝƐŝƚ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϭϲ;ĂͿ;ϮͿ;'Ϳ ƚŚĂƚ ŝƐ ĨƵƌŶŝƐŚĞĚ ĚƵƌŝŶŐ ĂŶLJ ƐƵĐŚ ƉŽƌƚŝŽŶ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉŽƉƵůĂƚŝŽŶƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘Ϯϭϴ͗ Ă͘ ͺͺͺͺͺ ůů ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͲŽƌͲ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ ŽĨ ƚŚĞ Đƚ͗ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƉƉůŝĞƐ ůĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ďĂƐĞĚ ŽŶ ŵŽĚŝĨŝĞĚ ĂĚũƵƐƚĞĚ ŐƌŽƐƐ ŝŶĐŽŵĞ ;D'/Ϳ ĂƐ ĨŽůůŽǁƐ͘ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ŝŶĐŽŵĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ƌĞƐŽƵƌĐĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ϰ͘ y dŚĞ ĂŐĞŶĐLJ ĐŽŶƐŝĚĞƌƐ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĞǀĂĐƵĂƚĞĚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ůĞĂǀĞ ƚŚĞ ƐƚĂƚĞ ĨŽƌ ŵĞĚŝĐĂů ƌĞĂƐŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ Žƌ ǁŚŽ ĂƌĞ ŽƚŚĞƌǁŝƐĞ ĂďƐĞŶƚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĂŶĚ ǁŚŽ ŝŶƚĞŶĚ ƚŽ ƌĞƚƵƌŶ ƚŽ ƚŚĞ ƐƚĂƚĞ͕ ƚŽ ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ƌĞƐŝĚĞŶƚƐ ŽĨ ƚŚĞ ƐƚĂƚĞ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϰϬϯ;ũͿ;ϯͿ͘ ϱ͘ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ DĞĚŝĐĂŝĚ ĐŽǀĞƌĂŐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŝŶĚŝǀŝĚƵĂůƐ ůŝǀŝŶŐ ŝŶ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ĂƌĞ ŶŽŶͲƌĞƐŝĚĞŶƚƐ͗ ϲ͘ y dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ ĨŽƌ ĂŶ ĞdžƚĞŶƐŝŽŶ ŽĨ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĨŽƌ ŶŽŶͲĐŝƚŝnjĞŶƐ ĚĞĐůĂƌŝŶŐ ƚŽ ďĞ ŝŶ Ă ƐĂƚŝƐĨĂĐƚŽƌLJ ŝŵŵŝŐƌĂƚŝŽŶ ƐƚĂƚƵƐ͕ ŝĨ ƚŚĞ ŶŽŶͲĐŝƚŝnjĞŶ ŝƐ ŵĂŬŝŶŐ Ă ŐŽŽĚ ĨĂŝƚŚ ĞĨĨŽƌƚ ƚŽ ƌĞƐŽůǀĞ ĂŶLJ ŝŶĐŽŶƐŝƐƚĞŶĐĞƐ Žƌ ŽďƚĂŝŶ ĂŶLJ ŶĞĐĞƐƐĂƌLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ Žƌ ƚŚĞ ĂŐĞŶĐLJ ŝƐ ƵŶĂďůĞ ƚŽ ĐŽŵƉůĞƚĞ ƚŚĞ ǀĞƌŝĨŝĐĂƚŝŽŶ ƉƌŽĐĞƐƐ ǁŝƚŚŝŶ ƚŚĞ ϵϬͲĚĂLJ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ϳ͘ ^ĞĐƚŝŽŶ  ʹ ŶƌŽůůŵĞŶƚ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĞůĞĐƚƐ ƚŽ ĂůůŽǁ ŚŽƐƉŝƚĂůƐ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚĚŝƚŝŽŶĂů ƐƚĂƚĞ ƉůĂŶ ƉŽƉƵůĂƚŝŽŶƐ͕ Žƌ ĨŽƌ ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ĂŶ ĂƉƉƌŽǀĞĚ ƐĞĐƚŝŽŶ ϭϭϭϱ ĚĞŵŽŶƐƚƌĂƚŝŽŶ͕ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϰϳͿ;Ϳ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϭϭϭϬ͕ ƉƌŽǀŝĚĞĚ ƚŚĂƚ ƚŚĞ ĂŐĞŶĐLJ ŚĂƐ ĚĞƚĞƌŵŝŶĞĚ ƚŚĂƚ ƚŚĞ ŚŽƐƉŝƚĂů ŝƐ ĐĂƉĂďůĞ ŽĨ ŵĂŬŝŶŐ ƐƵĐŚ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ŝƚƐĞůĨ ĂƐ Ă ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚLJ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĞŶƚŝƚŝĞƐ ĂƐ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ Žƌ ĂĚĚƐ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ /ŶĚŝĐĂƚĞ ŝĨ ĂŶLJ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ ĂƌĞ ƉĞƌŵŝƚƚĞĚ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽŶůLJ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚŽƉƚƐ Ă ƚŽƚĂů ŽĨ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ĐŽŶƚŝŶƵŽƵƐ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ĐŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ĞŶƚĞƌ ĂŐĞ ͺͺͺͺͺ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ĂŐĞ ϭϵͿ ƌĞŐĂƌĚůĞƐƐ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĞͿ;ϭϮͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϵϮϲ͘ ϱ͘ ͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶĚƵĐƚƐ ƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽĨ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ D'/Ͳ ďĂƐĞĚ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϲϬϯ;ũͿ ŽŶĐĞ ĞǀĞƌLJ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ϰϮ &Z ϰϯϱ͘ϵϭϲ;ďͿ͘ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ƚŽ ƐƵƉƉŽƌƚ ĞŶƌŽůůŵĞŶƚ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ Žƌ ĨŽƌ ĂĨĨĞĐƚĞĚ ŝŶĚŝǀŝĚƵĂůƐ ;Ă ĐŽƉLJ ŽĨ ƚŚĞ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ŚĂƐ ďĞĞŶ ƐƵďŵŝƚƚĞĚ ƚŽ D^Ϳ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ ĂƉƉůŝĐĂƚŝŽŶ͘ ď͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ͘ Đ͘ ͺͺͺͺͺ dŚĞ ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ Žƌ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ ŝƐ ŵĂĚĞ ĂǀĂŝůĂďůĞ ĨŽƌ ƵƐĞ ŝŶ ĐĂůůͲĐĞŶƚĞƌƐ Žƌ ŽƚŚĞƌ ƚĞůĞƉŚŽŶĞ ĂƉƉůŝĐĂƚŝŽŶƐ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ͘ ^ĞĐƚŝŽŶ  ʹ WƌĞŵŝƵŵƐ ĂŶĚ ŽƐƚ ^ŚĂƌŝŶŐ ϭ͘ y dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ ĂŶĚ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĂƐ ĨŽůůŽǁƐ͗ dŚĞ ^ƚĂƚĞ ƐƵƐƉĞŶĚƐ Ăůů ĐŽƐƚ ƐŚĂƌŝŶŐ͘ Ϯ͘ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĞŶƌŽůůŵĞŶƚ ĨĞĞƐ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ͗ Ă͘ ůů ďĞŶĞĨŝĐŝĂƌŝĞƐ ď͘ ͺͺͺͺͺ dŚĞ ĨŽůůŽǁŝŶŐ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ͗ Eͬ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂůůŽǁƐ ǁĂŝǀĞƌ ŽĨ ƉĂLJŵĞŶƚ ŽĨ ƚŚĞ ĞŶƌŽůůŵĞŶƚ ĨĞĞ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ WůĞĂƐĞ ƐƉĞĐŝĨLJ ƚŚĞ ƐƚĂŶĚĂƌĚ;ƐͿ ĂŶĚͬŽƌ ĐƌŝƚĞƌŝĂ ƚŚĂƚ ƚŚĞ ƐƚĂƚĞ ǁŝůů ƵƐĞ ƚŽ ĚĞƚĞƌŵŝŶĞ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ^ĞĐƚŝŽŶ  ʹ ĞŶĞĨŝƚƐ ĞŶĞĨŝƚƐ͗ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚĚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ŝŶ ŝƚƐ ƐƚĂƚĞ ƉůĂŶ ;ŝŶĐůƵĚĞ ƐĞƌǀŝĐĞ ĚĞƐĐƌŝƉƚŝŽŶƐ͕ ƉƌŽǀŝĚĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ůŝŵŝƚĂƚŝŽŶƐ ŽŶ ĂŵŽƵŶƚ͕ ĚƵƌĂƚŝŽŶ Žƌ ƐĐŽƉĞ ŽĨ ƚŚĞ ďĞŶĞĨŝƚͿ͗ Ϯ͘ y dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐƵƌƌĞŶƚůLJ ĐŽǀĞƌĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ ƉůĂŶ͗ ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ĞdžƚĞŶĚ Ăůů ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ ŝ͘ ŶLJ ŵĞĚŝĐĂůůLJ ŶĞĐĞƐƐĂƌLJ ƐƵƌŐŝĐĂů ƉƌŽĐĞĚƵƌĞƐ ƚŚĂƚ ƌĞƋƵŝƌĞ ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĞŝƚŚĞƌ ďLJ ĨĞĞͲ ĨŽƌͲƐĞƌǀŝĐĞ͕ ŵĂŶĂŐĞĚ ĐĂƌĞ͕ Žƌ ďŽƚŚ͘ ŝŝ͘ WĞĚŝĂƚƌŝĐ ĂLJ ,ĞĂůƚŚ ĞŶƚĞƌ ;W,Ϳ ŝŝŝ͘ ƉŚLJƐŝĐŝĂŶ ĂĚŵŝŶŝƐƚĞƌĞĚ ĚƌƵŐƐ ŝǀ͘ ƵƌĂďůĞ ŵĞĚŝĐĂů ĞƋƵŝƉŵĞŶƚ ;D Ϳ ǀ͘ ,ŽŵĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ; ,,ͬW^Ϳ ǀŝ͘ ,ŽƐƉŝĐĞ ƐĞƌǀŝĐĞƐ ǀŝŝ͘ dŚĞƌĂƉŝĞƐ ;ƉŚLJƐŝĐĂů ƚŚĞƌĂƉLJ͕ ŽĐĐƵƉĂƚŝŽŶĂů ƚŚĞƌĂƉLJ͕ ƐƉĞĞĐŚ ƚŚĞƌĂƉLJͿ ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĨŽƌ >ŽŶŐ dĞƌŵ WĞƌƐŽŶĂů ĂƌĞ ^ĞƌǀŝĐĞƐ ;>dͲ W^Ϳ͕ ϰϮ &Z ϰϰϬ͘ϭϲϳ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͗ ŝ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ƚŚĂƚ ƐĞƌǀŝĐĞƐ ŵƵƐƚ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƚŚĞ ĂƉƉƌŽǀĞĚ ƉůĂŶ ŽĨ ĐĂƌĞ ĂŶĚ ƐƵƉƉŽƌƚŝŶŐ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ ƚŽ ĂƵƚŚŽƌŝnjĞ ŚŽƵƌƐ ƵƉ ƚŽ ϯϮ ŚŽƵƌƐ ƉĞƌ ǁĞĞŬ͕ ŝĨ ŶĞĞĚĞĚ͖ ŝŝ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ĨŽƌ ƚŚĞ ĂŐĞ͕ ĞĚƵĐĂƚŝŽŶ ĂŶĚ ĞdžƉĞƌŝĞŶĐĞ ĨŽƌ ƚŚĞ ƉĞƌƐŽŶĂů ĐĂƌĞ ƐĞƌǀŝĐĞƐ ǁŽƌŬĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ ĂŶĚ ĂůůŽǁ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌƐŽŶƐ ƚŽ ƐĞƌǀĞ ĂƐ ƚŚĞ ĚŝƌĞĐƚ ƐĞƌǀŝĐĞ ǁŽƌŬĞƌ ĨŽƌ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͗ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ĐƵƌĂƚŽƌ͖ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ƚƵƚŽƌ͖ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͛Ɛ ƌĞƐƉŽŶƐŝďůĞ ƌĞƉƌĞƐĞŶƚĂƚŝǀĞ͖ Žƌ ƚŚĞ ƉĞƌƐŽŶ ƚŽ ǁŚŽŵ ƚŚĞ ƌĞĐŝƉŝĞŶƚ ŚĂƐ ŐŝǀĞŶ ZĞƉƌĞƐĞŶƚĂƚŝǀĞ ĂŶĚ DĂŶĚĂƚĞ ĂƵƚŚŽƌŝƚLJ ;WŽǁĞƌ ŽĨ ƚƚŽƌŶĞLJͿ ƵŶůĞƐƐ ƚŚĞLJ ĂƌĞ ůĞŐĂůůLJ ƌĞƐƉŽŶƐŝďůĞ ƌĞůĂƚŝǀĞƐ͖ ŝŝŝ͘ ůůŽǁ ƌĞĐŝƉŝĞŶƚƐ͛ ƌĞͲĂƐƐĞƐƐŵĞŶƚƐ ƚŽ ŐŽ ďĞLJŽŶĚ ƚŚĞ ϭϴͲŵŽŶƚŚ ƌĞƋƵŝƌĞŵĞŶƚ͘ dŚĞƐĞ ƌĞĐŝƉŝĞŶƚƐ ǁŝůů ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ŵŽŶŝƚŽƌĞĚ ƚŚƌŽƵŐŚ ŵŽŶƚŚůLJ ƚĞůĞƉŚŽŶĞ ĐŽŶƚĂĐƚƐ͖ ŝǀ͘ ůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚ ƚŚĂƚ ƉůĂĐĞ;ƐͿ ŽĨ ƐĞƌǀŝĐĞ ŵƵƐƚ ďĞ ĚŽĐƵŵĞŶƚĞĚ ŝŶ ƚŚĞ ƉůĂŶ ŽĨ ĐĂƌĞ͖ ǀ͘ >dͲW^ ŵĂLJ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ ĂŶŽƚŚĞƌ ƐƚĂƚĞ ǁŝƚŚŽƵƚ ƉƌŝŽƌ ĂƉƉƌŽǀĂů ŽĨ ƚŚĞ KĨĨŝĐĞ ŽĨ ŐŝŶŐ ĂŶĚ ĚƵůƚ ^ĞƌǀŝĐĞƐ ;K^Ϳ Žƌ ŝƚƐ ĚĞƐŝŐŶĞĞ͖ ǀŝ͘  ƌĞĐŝƉŝĞŶƚ ŵĂLJ ƌĞĐĞŝǀĞ >dͲW^ ǁŚŝůĞ ůŝǀŝŶŐ ŝŶ Ă ŚŽŵĞ Žƌ ƉƌŽƉĞƌƚLJ ŽǁŶĞĚ͕ ŽƉĞƌĂƚĞĚ Žƌ ĐŽŶƚƌŽůůĞĚ ďLJ Ă ƉƌŽǀŝĚĞƌ ŽĨ ƐĞƌǀŝĐĞƐ ǁŚŽ ŝƐ ŶŽƚ ƌĞůĂƚĞĚ ďLJ ďůŽŽĚ Žƌ ŵĂƌƌŝĂŐĞ ƚŽ ƚŚĞ ƌĞĐŝƉŝĞŶƚ͖ ǀŝŝ͘ dŚĞ ^ƚĂƚĞ ŵĂLJ ŝŶĐƌĞĂƐĞ ƚŚĞ ŵĂdžŝŵƵŵ ŶƵŵďĞƌ ŽĨ >dͲW^ ŚŽƵƌƐ ƌĞĐĞŝǀĞĚ ƉĞƌ ǁĞĞŬ͖ ĂŶĚ ǀŝŝŝ͘ dŚĞ ^ƚĂƚĞ ŵĂLJ ĂůůŽǁ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞ ƉƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ͘ ͘ WĞĚŝĂƚƌŝĐ ĂLJ ,ĞĂůƚŚ ĂƌĞ ;W,Ϳ ƐŬŝůůĞĚ ƐĞƌǀŝĐĞƐ ŵĂLJ ďĞ ƉƌŽǀŝĚĞĚ ŝŶ Ă ƌĞƐŝĚĞŶƚŝĂů ƐĞƚƚŝŶŐ ĚƵƌŝŶŐ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ƚŽ ƚŚŽƐĞ ĐŚŝůĚƌĞŶ ǁŚŽƐĞ ĨĂŵŝůŝĞƐ ĂƌĞ ŶŽƚ ĂďůĞ ƚŽ ƉƌŽǀŝĚĞ ƐƵĐŚ ĐĂƌĞ ŝĨ ƚŚĞ W, ŝƐ ĐůŽƐĞĚ ĚƵĞ ƚŽ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ϯ͘ y dŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ŶĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ Žƌ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐŽŵƉůLJ ǁŝƚŚ Ăůů ĂƉƉůŝĐĂďůĞ ƐƚĂƚƵƚŽƌLJ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƐƚĂƚĞǁŝĚĞŶĞƐƐ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭͿ͕ ĐŽŵƉĂƌĂďŝůŝƚLJ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ͕ ĂŶĚ ĨƌĞĞ ĐŚŽŝĐĞ ŽĨ ƉƌŽǀŝĚĞƌ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϮϯͿ͘ ϰ͘ y ƉƉůŝĐĂƚŝŽŶ ƚŽ ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐ ;WͿ͘ dŚĞ ƐƚĂƚĞ ĂĚŚĞƌĞƐ ƚŽ Ăůů W ƉƌŽǀŝƐŝŽŶƐ ŝŶ ϰϮ &Z WĂƌƚ ϰϰϬ͕ ^ƵďƉĂƌƚ ͘ dŚŝƐ ƐĞĐƚŝŽŶ ŽŶůLJ ĂƉƉůŝĞƐ ƚŽ ƐƚĂƚĞƐ ƚŚĂƚ ŚĂǀĞ ĂŶ ĂƉƉƌŽǀĞĚ W;ƐͿ͘ ƒǤ  Š‡ ƒ‰‡ › ƒ••—”‡• –Šƒ– –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–• ™‹ŽŽ „‡ ƒ†‡ ƒ˜ƒ‹Žƒ„Ž‡ –‘ ‹†‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” •Ǥ „Ǥ ̴̴̴̴̴ †‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” • ™‹ŽŽ ‘– ”‡ ‡‹˜‡ –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–•ǡ ‘” ™‹ŽŽ ‘Ž› ”‡ ‡‹˜‡ –Š‡ ˆ‘ŽŽ‘™‹‰ •—„•‡–ǣ dĞůĞŚĞĂůƚŚ͗ ϱ͘ y dŚĞ ĂŐĞŶĐLJ ƵƚŝůŝnjĞƐ ƚĞůĞŚĞĂůƚŚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĂŶŶĞƌ͕ ǁŚŝĐŚ ŵĂLJ ďĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ͛Ɛ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ƐƵƐƉĞŶĚ Ăůů ĨĂĐĞͲƚŽͲĨĂĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ĚĞƚĂŝůĞĚ ŝŶ ƚŚĞ >ŽƵŝƐŝĂŶĂ ^ƚĂƚĞ WůĂŶ ĨŽƌ Ăůů ƐĞƌǀŝĐĞƐ ĨŽƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͘ ƌƵŐ ĞŶĞĨŝƚ͗ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ƚŚĞ ĚĂLJ ƐƵƉƉůLJ Žƌ ƋƵĂŶƚŝƚLJ ůŝŵŝƚ ĨŽƌ ĐŽǀĞƌĞĚ ŽƵƚƉĂƚŝĞŶƚ ĚƌƵŐƐ͘ dŚĞ ĂŐĞŶĐLJ ƐŚŽƵůĚ ŽŶůLJ ŵĂŬĞ ƚŚŝƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŝĨ ŝƚƐ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉĂŐĞƐ ŚĂǀĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ĂŵŽƵŶƚ ŽĨ ŵĞĚŝĐĂƚŝŽŶ ĚŝƐƉĞŶƐĞĚ͘ ϳ͘ y WƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĨŽƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝƐ ĞdžƉĂŶĚĞĚ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ͕ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ͘ ϴ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĂLJŵĞŶƚ ĂĚũƵƐƚŵĞŶƚ ƚŽ ƚŚĞ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ǁŚĞŶ ĂĚĚŝƚŝŽŶĂů ĐŽƐƚƐ ĂƌĞ ŝŶĐƵƌƌĞĚ ďLJ ƚŚĞ ƉƌŽǀŝĚĞƌƐ ĨŽƌ ĚĞůŝǀĞƌLJ͘ ^ƚĂƚĞƐ ǁŝůů ŶĞĞĚ ƚŽ ƐƵƉƉůLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ƚŽ ũƵƐƚŝĨLJ ƚŚĞ ĂĚĚŝƚŝŽŶĂů ĨĞĞƐ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ϵ͘ y dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞŝƌ ƉƵďůŝƐŚĞĚ WƌĞĨĞƌƌĞĚ ƌƵŐ >ŝƐƚ ŝĨ ĚƌƵŐ ƐŚŽƌƚĂŐĞƐ ŽĐĐƵƌ͘ dŚŝƐ ǁŽƵůĚ ŝŶĐůƵĚĞ ŽƉƚŝŽŶƐ ĨŽƌ ĐŽǀĞƌŝŶŐ Ă ďƌĂŶĚ ŶĂŵĞ ĚƌƵŐ ƉƌŽĚƵĐƚ ƚŚĂƚ ŝƐ Ă ŵƵůƚŝͲƐŽƵƌĐĞ ĚƌƵŐ ŝĨ Ă ŐĞŶĞƌŝĐ ĚƌƵŐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĂǀĂŝůĂďůĞ͘ ^ĞĐƚŝŽŶ ʹ WĂLJŵĞŶƚƐ KƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ͗ ϭ͘ ͺͺ ͺͺͺ EĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ  ĂƌĞ ƉĂŝĚ ƵƐŝŶŐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĞƚŚŽĚŽůŽŐLJ͗ ƒǤ ̴̴̴ —„Ž‹•Š‡† ˆ‡‡ • Š‡†—Ž‡• Ȃ

ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ „Ǥ ̴̴̴̴̴ –Š‡”ǣ ĞƐĐƌŝďĞ ŵĞƚŚŽĚŽůŽŐLJ ŚĞƌĞ͘ /ŶĐƌĞĂƐĞƐ ƚŽ ƐƚĂƚĞ ƉůĂŶ ƉĂLJŵĞŶƚ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ Ϯ͘ y dŚĞ ĂŐĞŶĐLJ ŝŶĐƌĞĂƐĞƐ ƉĂLJŵĞŶƚ ƌĂƚĞƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ŝŶĐƌĞĂƐĞ ƚŚĞ ƉĂLJŵĞŶƚ ĨŽƌ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚLJ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJƐ ĨƌŽŵ ϭϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ ƚŽ ϭϬϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ͕ ĂŶĚ ŝŶĐůƵĚĞ Ă ΨϭϮ ŝŶĐƌĞĂƐĞ ƚŽ ƚŚĞ ĚĂŝůLJ ƉĞƌ ĚŝĞŵ ƌĂƚĞ ƉĂŝĚ ƚŽ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚŝĞƐ͘ ^ƚĂƚĞ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ĂŶĚ ŶŽŶͲƐƚĂƚĞ ŐŽǀĞƌŶŵĞŶƚ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ĨĂĐŝůŝƚŝĞƐ ĂƌĞ ŶŽƚ ĞůŝŐŝďůĞ ĨŽƌ͕ ĂŶĚ ǁŝůů ŶŽƚ ƌĞĐĞŝǀĞ͕ ƚŚĞ ƐƚĂƚĞ Žƌ ĨĞĚĞƌĂůůLJ ĚĞĐůĂƌĞĚ ĞŵĞƌŐĞŶĐLJ ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJ ƉĂLJŵĞŶƚƐ ĂŶĚ ǁŝůů ŶŽƚ ƌĞĐĞŝǀĞ ƚŚĞ ΨϭϮ ŝŶĐƌĞĂƐĞ ƚŽ ƚŚĞ ĚĂŝůLJ ƉĞƌ ĚŝĞŵ ƌĂƚĞ ĂƐ ĚĞƐĐƌŝďĞĚ ĂďŽǀĞ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ƉĂLJ /ŶƚĞƌŵĞĚŝĂƚĞ ĂƌĞ &ĂĐŝůŝƚŝĞƐ ĨŽƌ /ŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ /ŶƚĞůůĞĐƚƵĂů ŝƐĂďŝůŝƚŝĞƐ ;/&ƐͲ//Ϳ ďĞLJŽŶĚ ƚŚĞ ϰϱͲ ĚĂLJ ůĞĂǀĞ ŽĨ ĂďƐĞŶĐĞ ĚĂLJƐ͘ dŽ ĂĚĚƌĞƐƐ ƚŚĞ Ks/Ͳϭϵ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ^ƚĂƚĞ ƌĞƐƉĞĐƚĨƵůůLJ ƌĞƋƵĞƐƚƐ ƚŽ ĂĚũƵƐƚ ƌĂƚĞƐ ŝŶ ƚŚĞ ƉŚLJƐŝĐŝĂŶ ďĞŶĞĨŝƚ ƚŽ ƌĞŝŵďƵƌƐĞ ĂŵďƵůĂŶĐĞ ƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞƌƐ ǁŚŽ ƉƌŽǀŝĚĞ ĂůůŽǁĂďůĞ ƐĞƌǀŝĐĞƐ ŽŶ ƐŝƚĞ͕ ǁŝƚŚŽƵƚ ƚƌĂŶƐƉŽƌƚ͕ ǁŚŝůĞ ƵŶĚĞƌ ƚŚĞ ƐƵƉĞƌǀŝƐŝŽŶ ŽĨ Ă ůŝĐĞŶƐĞĚ ƉŚLJƐŝĐŝĂŶ͘ Ă͘ ͺͺͺͺͺ WĂLJŵĞŶƚ ŝŶĐƌĞĂƐĞƐ ĂƌĞ ƚĂƌŐĞƚĞĚ ďĂƐĞĚ ŽŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐƌŝƚĞƌŝĂ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĐƌŝƚĞƌŝĂ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ ď͘ WĂLJŵĞŶƚƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ ƚŚƌŽƵŐŚ͗ ‹Ǥ   •—’’Ž‡‡–ƒŽ ’ƒ›‡– ‘” ƒ††Ǧ‘ ™‹–Š‹ ƒ’’Ž‹ ƒ„Ž‡ —’’‡” ’ƒ›‡– Ž‹‹–•ǣ ΨϭϮ ƉĞƌ ĚĂLJ ĂĚĚͲŽŶ ƚŽ ƚŚĞ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ Žƌ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚLJ ƌĂƚĞ͘ ‹‹Ǥ ̴̴̴̴̴  ‹ ”‡ƒ•‡ –‘ ”ƒ–‡• ƒ• †‡• ”‹„‡† „‡Ž‘™Ǥ ͺͺͺyͺͺ hŶŝĨŽƌŵůLJ ďLJ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌĐĞŶƚĂŐĞ͗ &Žƌ ƉƌŝǀĂƚĞůLJ ŽǁŶĞĚ ĂŶĚ ŽƉĞƌĂƚĞĚ ŶƵƌƐŝŶŐ ĨĂĐŝůŝƚŝĞƐ͕ ŝŶĐƌĞĂƐĞ ƌĂƚĞ ĨƌŽŵ ϭϬ ƉĞƌĐĞŶƚ ƚŽ ϭϬϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ƉĞƌ ĚŝĞŵ ĨŽƌ ŚŽŵĞ ĂŶĚ ŚŽƐƉŝƚĂů ůĞĂǀĞ ĚĂLJƐ͘ ͺͺͺͺͺ dŚƌŽƵŐŚ Ă ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ƉƵďůŝƐŚĞĚ ĨĞĞ ƐĐŚĞĚƵůĞƐ ʹ

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

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

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ •‡’ƒ”ƒ–‡Ž› ”‡‹„—”•‡† ƒ• ƒ ƒ†‹‹•–”ƒ–‹˜‡ ‘•– „› –Š‡ •–ƒ–‡ ™Š‡ ƒ ‡†‹ ƒ‹† •‡”˜‹ ‡ ‹• †‡Ž‹˜‡”‡†Ǥ KƚŚĞƌ͗ ϰ͘ KƚŚĞƌ ƉĂLJŵĞŶƚ ĐŚĂŶŐĞƐ͗ ^ĞĐƚŝŽŶ & ʹ WŽƐƚͲ ůŝŐŝďŝůŝƚLJ dƌĞĂƚŵĞŶƚ ŽĨ /ŶĐŽŵĞ ͳǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• –‘ ‘†‹ˆ› –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ˆ‘” ‹•–‹–—–‹‘ƒŽ‹œ‡† ‹†‹˜‹†—ƒŽ•Ǥ Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ‹• ‡“—ƒŽ –‘ ‘‡ ‘ˆ –Š‡ ˆ‘ŽŽ‘™‹‰ ƒ‘—–•ǣ ƒǤ ̴̴̴̴̴ Š‡ ‹†‹˜‹†—ƒŽǯ• –‘–ƒŽ ‹ ‘‡ „Ǥ ̴̴̴̴̴ ͵ͲͲ ’‡” ‡– ‘ˆ –Š‡  ˆ‡†‡”ƒŽ „‡‡ˆ‹– ”ƒ–‡

Ǥ ̴̴̴̴̴ –Š‡” ”‡ƒ•‘ƒ„Ž‡ ƒ‘—–ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• ƒ ‡™ ˜ƒ”‹ƒ ‡ –‘ –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡Ǥ ȋ‘–‡ǣ Ž‡ –‹‘ ‘ˆ –Š‹• ‘’–‹‘ ‹• ‘– †‡’‡†‡– ‘ ƒ •–ƒ–‡ ‡Ž‡ –‹‰ –Š‡ ‘’–‹‘ †‡• ”‹„‡† –Š‡ ‘’–‹‘ ‹ ǤͳǤ ƒ„‘˜‡ǤȌ dŚĞ ƐƚĂƚĞ ƉƌŽƚĞĐƚƐ ĂŵŽƵŶƚƐ ĞdžĐĞĞĚŝŶŐ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ŚĂǀĞ ƚŚĞ ĨŽůůŽǁŝŶŐ ŐƌĞĂƚĞƌ ƉĞƌƐŽŶĂů ŶĞĞĚƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ǁŝƚŚ ŐƌĞĂƚĞƌ ŶĞĞĚƐ ĂŶĚ ƚŚĞ ĂŵŽƵŶƚ;ƐͿ ƉƌŽƚĞĐƚĞĚ ĨŽƌ ĞĂĐŚ ŐƌŽƵƉ Žƌ ŐƌŽƵƉƐ͘ ^ĞĐƚŝŽŶ ' ʹ KƚŚĞƌ WŽůŝĐŝĞƐ ĂŶĚ WƌŽĐĞĚƵƌĞƐ ŝĨĨĞƌŝŶŐ ĨƌŽŵ ƉƉƌŽǀĞĚ DĞĚŝĐĂŝĚ ^ƚĂƚĞ WůĂŶ ͬĚĚŝƚŝŽŶĂů /ŶĨŽƌŵĂƚŝŽŶ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ >Kh/^/E dE͗ ϮϬͲϬϬϬϰ ^ƵƉĞƌƐĞĚĞƐ dE͗ EĞǁ WĂŐĞƐ WZ ŝƐĐůŽƐƵƌĞ ^ƚĂƚĞŵĞŶƚ ĐĐŽƌĚŝŶŐ ƚŽ ƚŚĞ WĂƉĞƌǁŽƌŬ ZĞĚƵĐƚŝŽŶ Đƚ ŽĨ ϭϵϵϱ͕ ŶŽ ƉĞƌƐŽŶƐ ĂƌĞ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞƐƉŽŶĚ ƚŽ Ă ĐŽůůĞĐƚŝŽŶ ŽĨ ŝŶĨŽƌŵĂƚŝŽŶ ƵŶůĞƐƐ ŝƚ ĚŝƐƉůĂLJƐ Ă ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ͘ dŚĞ ǀĂůŝĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ĨŽƌ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ϬϵϯϴͲϭϭϰϴ ; džƉŝƌĞƐ ϬϯͬϯϭͬϮϬϮϭͿ͘ dŚĞ ƚŝŵĞ ƌĞƋƵŝƌĞĚ ƚŽ ĐŽŵƉůĞƚĞ ƚŚŝƐ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ŝƐ ĞƐƚŝŵĂƚĞĚ ƚŽ ĂǀĞƌĂŐĞ ϭ ƚŽ Ϯ ŚŽƵƌƐ ƉĞƌ ƌĞƐƉŽŶƐĞ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƚŝŵĞ ƚŽ ƌĞǀŝĞǁ ŝŶƐƚƌƵĐƚŝŽŶƐ͕ ƐĞĂƌĐŚ ĞdžŝƐƚŝŶŐ ĚĂƚĂ ƌĞƐŽƵƌĐĞƐ͕ ŐĂƚŚĞƌ ƚŚĞ ĚĂƚĂ ŶĞĞĚĞĚ͕ ĂŶĚ ĐŽŵƉůĞƚĞ ĂŶĚ ƌĞǀŝĞǁ ƚŚĞ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ͘ zŽƵƌ ƌĞƐƉŽŶƐĞ ŝƐ ƌĞƋƵŝƌĞĚ ƚŽ ƌĞĐĞŝǀĞ Ă ǁĂŝǀĞƌ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ͘ ůů ƌĞƐƉŽŶƐĞƐ ĂƌĞ ƉƵďůŝĐ ĂŶĚ ǁŝůů ďĞ ŵĂĚĞ ĂǀĂŝůĂďůĞ ŽŶ ƚŚĞ D^ ǁĞď ƐŝƚĞ͘ /Ĩ LJŽƵ ŚĂǀĞ ĐŽŵŵĞŶƚƐ ĐŽŶĐĞƌŶŝŶŐ ƚŚĞ ĂĐĐƵƌĂĐLJ ŽĨ ƚŚĞ ƚŝŵĞ ĞƐƚŝŵĂƚĞ;ƐͿ Žƌ ƐƵŐŐĞƐƚŝŽŶƐ ĨŽƌ ŝŵƉƌŽǀŝŶŐ ƚŚŝƐ ĨŽƌŵ͕ ƉůĞĂƐĞ ǁƌŝƚĞ ƚŽ͗ D^͕ ϳϱϬϬ ^ĞĐƵƌŝƚLJ ŽƵůĞǀĂƌĚ͕ ƚƚŶ͗ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞƌ͕ DĂŝů ^ƚŽƉ ϰͲϮϲͲϬϱ͕ ĂůƚŝŵŽƌĞ͕ DĂƌLJůĂŶĚ ϮϭϮϰϰͲϭϴϱϬ͘ ΎΎΎD^ ŝƐĐůŽƐƵƌĞΎΎΎ WůĞĂƐĞ ĚŽ ŶŽƚ ƐĞŶĚ ĂƉƉůŝĐĂƚŝŽŶƐ͕ ĐůĂŝŵƐ͕ ƉĂLJŵĞŶƚƐ͕ ŵĞĚŝĐĂů ƌĞĐŽƌĚƐ Žƌ ĂŶLJ ĚŽĐƵŵĞŶƚƐ ĐŽŶƚĂŝŶŝŶŐ ƐĞŶƐŝƚŝǀĞ ŝŶĨŽƌŵĂƚŝŽŶ ƚŽ ƚŚĞ WZ ZĞƉŽƌƚƐ ůĞĂƌĂŶĐĞ KĨĨŝĐĞ͘ WůĞĂƐĞ ŶŽƚĞ ƚŚĂƚ ĂŶLJ ĐŽƌƌĞƐƉŽŶĚĞŶĐĞ ŶŽƚ ƉĞƌƚĂŝŶŝŶŐ ƚŽ ƚŚĞ ŝŶĨŽƌŵĂƚŝŽŶ ĐŽůůĞĐƚŝŽŶ ďƵƌĚĞŶ ĂƉƉƌŽǀĞĚ ƵŶĚĞƌ ƚŚĞ ĂƐƐŽĐŝĂƚĞĚ KD ĐŽŶƚƌŽů ŶƵŵďĞƌ ůŝƐƚĞĚ ŽŶ ƚŚŝƐ ĨŽƌŵ ǁŝůů ŶŽƚ ďĞ ƌĞǀŝĞǁĞĚ͕ ĨŽƌǁĂƌĚĞĚ͕ Žƌ ƌĞƚĂŝŶĞĚ͘ /Ĩ LJŽƵ ŚĂǀĞ ƋƵĞƐƚŝŽŶƐ Žƌ ĐŽŶĐĞƌŶƐ ƌĞŐĂƌĚŝŶŐ ǁŚĞƌĞ ƚŽ ƐƵďŵŝƚ LJŽƵƌ ĚŽĐƵŵĞŶƚƐ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂŝĚ Θ ,/W ^ĞƌǀŝĐĞƐ Ăƚ ϰϭϬͲϳϴϲͲϯϴϳϬ͘ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ɖƌŝů ϮϬ͕ ϮϬϮϬ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ DĂƌĐŚ ϭ͕ ϮϬϮϬ

Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 23-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All LA - Submission Package - LA2023MS0001O - (LA-23-0002) - Eligibility Summary Reviewable Units Versions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, KS 641 06 Correspondence Log 1 Center for Medicaid & CHIP Services June 27, 2023 Stephen Russo Secretary Louisiana Department of Health 628 North 4th Street Kansas City, KS 641 06 Baton Rouge, LA, LA 70802 Re: Approval of State Plan Amendment LA-23-0002 Dear Stephen Russo, Analyst Notes Approval Letter .., Transaction Logs News Related Actions MS I ct1"1US FO~ MEDICARE & MEDICAID SEJMCES On March 30, 2023, the Centers for Medicare and Medicaid Services (CMS) received Louisiana State Plan Amendment (SPA) LA-23-0002, in which the state proposed to adopt additional resource disregards under the authority of section 1902(r)(2) of the Social Security Act. We approve Louisiana State Plan Amendment (SPA) LA-23-0002 with an effective date(s) of January 01, 2023. If you have any questions regarding this amendment, please contact Tobias Griffin at 214-767-4425 or via email at tobias.griffin@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services _J

Records / Submission Packages - View All LA - Submission Package - LA2023MS0001O - (LA-23-0002) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID N/A State Information State/Territory Name: Louisiana Submission Component 0 State Plan Amendment SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date N/ A ... Medicaid Agency Name: Louisiana Department of Health 0 Medicaid Q CHIP

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID N/A SPA ID and Effective Date SPA ID LA-23-0002 Reviewable Unit Medically Needy Income Level Handling of Excess Income (Spenddown) Medically Needy Resource Level Optional Eligibility Groups Individuals Eligible for Cash Except for Institutionalization Individuals in Institutions Eligible under a Special Income Level PACE Participants Age and Disability-Related Poverty Level Ticket to Work Basic Medically Needy Populations Based on Age, Blindness or Disability Proposed Effective Date 1/1/2023 1/1/2023 1/1/2023 1/1/2023 1/1/2023 1/1/2023 1/1/2023 1/1/2023 1/1/2023 1/1/2023 Page Number of the Superseded Plan Section or Attachment (If Applicable): SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date N/ A Superseded SPA ID LA-97-16 LA-97-16 LA-01-16 LA-21-0024 LA-96-15 LA-94-20, LA-09-40 LA-04-06 LA-91-23, 14-04 LA-04-01, 14-03 LA03-30,09-40,97-12, 14-03

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID N/A Executive Summary SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date N/ A Summary Description lncludlng The purpose of this SPA is to amend the provisions governing financial eligibility in the Medical Assistance program in order Goals and Objectives to adopt additional resource disregards under Section 1902(r)(2) of the Social Security Act. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact First Second Federal Fiscal Year 2023 2024 Federal Statute / Regulation Citation 1902(r)2 of the Social Security Act Amount $3418555 $0 Supporting documentation of budget impact is uploaded {optional). Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID N/A Governor's Office Review Q Nocomment 0 Comments received 0 No response within 45 days O other SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date N/ A Describe The Governor does not review State Plan material.

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 6/28/2023 12:22 PM EDT

Records I Submission Packages - View All LA - Submission Package - LA2023MS0001O - (LA-23-0002) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered A. Income Level Used 1. The state employs a single income level for the medically needy. SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 ... 2. The income level varies based on differences between shelter costs in urban and rural areas. O ves Q No 3. The level used is: Urban Household size 2 3 4 5 6 7 8 9 The areas in which the level varies are: Standard $100.00 $192.00 $258.00 $317.00 $375.00 $425.00 $475.00 $525.00 $575.00 Name of area: Urban Rural Description: Within a metropolitan statistical area. Outside of a metropolitan statistical area. The state uses an additional incremental amount for larger household sizes. Q Yes 0 No The dollar amounts increase automatically each year Q Yes 0 No

Household size 10 Rural Household size 2 3 4 5 6 7 8 9 10 Standard $617.00 Standard $92.00 $167.00 $233.00 $292.00 $350.00 $400.00 $450.00 $500.00 $550.00 $600.00 The state uses an additional incremental amount for larger household sizes. Q ves 0 No The dollar amounts increase automatically each year Q Yes 0 No

Medically Needy Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered B. Basis for Income Level 1. Minimum Income Level SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The minimum income level for this eligibility group is the lower of the state's July 1996 AFDC payment standard or the state's income standard for the Parents and Other Caretaker Relatives eligibility group. 2. Maximum Income Level The maximum income level for this eligibility group is 133 1 /3 percent of the higher of the state's 1996 AFDC payment standard or the state's income standard for the Parents and Other Caretaker Relatives eligibility group.

Medically Needy Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered C. Additional Information (optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medicaid State Plan Eligibility Income/Resource Standards Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 If countable income exceeds the income standard, the state must deduct from income medical expenses incurred by the individual or family or financially responsible relatives that are not subject to payment by a third party, in accordance with 42 CFR 435.831 and 42 CFR 435.121. A. Budget Periods Income in excess of the appropriate income standard is considered available for payment of medical or remedial care expenses in budget periods that do not exceed six months. 1. In determining income eligibility, countable income is reduced by the amount of incurred medical or remedial care expenses during the budget period specified below: 0 a. One budget period of: 0 b. More than one budget period, as described below: D i. Community budget period C: ii. Institutional budget period C: iii. Other budget period Name of other budget period: Non-institutionalized 2. The state includes part or all of the retroactive period in the budget period. 0 Yes Q No Length of budget period: 0 (1) 6 months 0 (2) 5 months 0 (3) 4 months 0 (4) 3 months 0 (5) 2 months 0 (6)1 month Length of budget period: (4)3 months Description: The State uses a 3-month budget period for non-institutionalized individuals.

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 B. Types of Eligible Expenses 1. In determining incurred expenses to be deducted from income, the state includes: a. Medicare, Medicaid, and other health insurance premiums and enrollment fees. b. Cost sharing, including copayments, coinsurance, and deductibles, imposed by Medicare, Medicaid or other health insurance. c. Expenses for necessary medical and remedial services recognized by state law but not included in the state plan. d. Expenses for necessary medical and remedial services included in the state plan, including those that exceed limitations on the amount, duration, and scope of services. 2. The state also includes medical institutional expenses projected to the end of the budget period at the Medicaid reimbursement rate. Q Yes 0 No 3. Incurred expenses subject to payment by a third party are not deducted unless the third party is a public program (other than Medicaid) of a state and the program is financed by the state.

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered C. Timeframe of Deduction of Expenses In determining incurred expenses to be deducted from income, the state deducts: SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 1. For retroactive budget periods and a budget period that includes both retroactive and prospective budget, the state deducts: a. Eligible expenses incurred during the budget period, whether paid or unpaid. b. Payments made during the budget period on eligible expenses incurred at any time prior to the budget period, if not previously deducted in establishing eligibility. c. Unpaid eligible expenses, which have not been deducted previously in establishing eligibility, and were incurred: 0 i. At any time prior to the budget period. 2. For prospective budget period(s), the state deducts: 0 ii. Prior to the third month before the month of application, but no earlier than: O iii. No earlier than the third month before the month of application. a. Eligible expenses incurred during the budget period, whether paid or unpaid. b. Payments made during the budget period on eligible expenses incurred at any time prior to the budget period, if not previously deducted in establishing eligibility. c. Unpaid eligible expenses that are carried over from the prior budget period and have not been deducted previously in establishing eligibility.

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered D. Order of Deduction of Expenses Incurred medical or remedial care expenses are deducted in the following order: 0 1. By the type of service, in the following order: SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 a. Premiums, deductibles, coinsurance and co-payments. b. Expenses for necessary medical or remedial care services that are recognized under state law but not included in the State Plan. c. Expenses for necessary medical or remedial care services that are included in the state Plan that exceed agency limitations on amount, duration, or scope of services. d. Expenses for necessary medical or remedial care services that are included in the state Plan that are within the agency limitations on amount, duration, or scope of services. 0 2. In chronological order by the date of the service, or the date cost sharing payments are due. 0 3. In chronological order by the date the bill is submitted to the state by the individual.

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered E. Reasonable Limitations The state sets reasonable limits on the amount to be deducted for expenses. Q Yes 0 No SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered F. Spenddown Payments Made by Individuals The state permits individuals to pay-in their spenddown liability. Q Yes 0 No SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Handling of Excess Income (Spenddown) MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-97-16 User-Entered G. Additional Information {optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Resource Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-01-16 User-Entered A. Medically Needy Resource Level Structure 1. The state employs a single resource level for the medically needy. SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 2. The resource level is equal to or higher than the lowest resource standard used under the most closely related cash assistance program.

Medically Needy Resource Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-01-16 User-Entered B. Resource Level Used The level used is: Household size 2 Standard $2000.00 $3000.00 SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state uses an additional incremental amount for larger household sizes. 0 Yes Q No Incremental Amount: $25.00

Medically Needy Resource Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-01-16 User-Entered C. Additional Information (optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-21-0024 System-Derived A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. 0 Yes Q No SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Optional Coverage of Parents and Other Caretaker Relatives Reasonable Classifications of Individuals under Age 21 Children with Non-lV-E Adoption Assistance Independent Foster Care Adolescents Optional Targeted Low Income Children Individuals above 133% FPL under Age 65 Individuals Needing Treatment for Breast or Cervical Cancer Individuals Eligible for Family Planning Services Individuals with Tuberculosis Individuals Electing COBRA Continuation Coverage Aged, Blind and Disabled Eligibility Group Name Individuals Eligible for but Not Receiving Cash Assistance Covered In State Plan □ C C C □ □ Covered In State Plan □ Include RU In Package 0 □ □ □ □ □ □ □ □ □ □ Include RU In Package 0 □ Included in Another Submission Package 0 0 0 0 0 0 0 0 0 0 Included in Another Submission Package 0 Source Type 0 NEW CONVERTED CONVERTED CONVERTED CONVERTED NEW NEW CONVERTED CONVERTED NEW Source Type 0 NEW

Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Source Type 9 9 Submission Package Individuals Eligible for [!] 0 Cash Except for C APPROVED Institutionalization Individuals Receiving Home and Community- [!] 0 Based Waiver Services □ NEW under Institutional Rules Optional State [!] 0 Supplement □ □ NEW Beneficiaries Individuals in Institutions Eligible [!] C 0 APPROVED under a Special Income Level PACE Participants [!] C C 0 APPROVED Individuals Receiving [!] □ □ 0 NEW Hospice Children under Age 19 [!] C □ 0 APPROVED with a Disability Age and Disability- [!] C C 0 APPROVED Related Poverty Level Work Incentives [!] □ □ 0 NEW Ticket to Work Basic [!] C C 0 APPROVED Ticket to Work Medical [!] □ Improvements □ 0 NEW Family Opportunity Act [!] 0 Children with a □ NEW Disability Individuals Receiving State Plan Home and [!] □ □ 0 NEW Community-Based Services Individuals Receiving State Plan Home and Community-Based [!] □ □ 0 NEW Services Who Are Otherwise Eligible for HCBS Waivers

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-21-0024 System-Derived B. Medically Needy Options for Coverage SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state provides Medicaid to specified groups of individuals who are medically needy. 0 Yes Q No The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Medically Needy Pregnant Women Medically Needy Children under Age 18 Aged, Blind and Disabled Eligibility Group Name Protected Medically Needy Individuals Who Were Eligible in 1973 [!] [!] 2. Optional Medically Needy: Families and Adults Eligibility Group Name Medically Needy Reasonable Classifications of Individuals under Age 21 Medically Needy Parents and Other Caretaker Relatives Aged, Blind and Disabled Eligibility Group Name Medically Needy Populations Based on Age, Blindness or Disability Covered In State Plan C C Covered In State Plan Covered In State Plan C Covered In State Plan Include RU In Package 0 □ □ Include RU In Package 0 □ Include RU In Package 0 □ □ Include RU In Package 0 Included in Another Submission Package 0 0 Included in Another Submission Package 0 Included in Another Submission Package 0 0 Included in Another Submission Package 0 Source Type 0 NEW NEW Source Type 0 NEW Source Type 0 NEW NEW Source Type 0 APPROVED

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-21-0024 System-Derived C. Additional Information (optional) Eligibility Groups Deselected from Coverage SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Cash Except for Institutionalization MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Individuals who would be eligible for federal cash assistance or an optional state supplement, except for institutionalization. Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-96-15 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state covers the optional Individuals Eligible for Cash Except for Institutionalization eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are in a medical institution. 2. Would meet the eligibility requirements for at least one of the following cash assistance programs, but for the lower income standards used to determine eligibility for institutionalized individuals: [: a. SSI C: b. Optional State Supplement C c.AFDC

Individuals Eligible for Cash Except for Institutionalization MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-96-15 User-Entered B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 0 Yes Q No SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Individuals Eligible for Cash Except for Institutionalization MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-96-15 User-Entered C. Financial Methodologies SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, 5SI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. In calculating household income and resources for populations for which AFDC is the most closely related program, the following methodology(ies) are used: 0 a. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 0 b. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. 0 Yes 0 No 4. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: C: Lump sums are disregarded as a resource. C: Proceeds from a settlement C: Specified type of lump sum: Name of lump sum type: Unspent settlement funds received in class action lawsuit, Nancy Anderson, et al. v. Bob Dean Jr., et al., 24th Judicial District Court, Parish of Jefferson, No. 820-839. Description: Unspent funds received as a class member, pursuant to the class settlement in the case of Nancy Anderson, et al. v. Bob Dean Jr., et al., 24th Judicial District Court, Parish of Jefferson, No. 820-839, shall be excluded from resources.

Individuals Eligible for Cash Except for Institutionalization MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-96-15 User-Entered D. Income Standard Used SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for Cash Except for Institutionalization MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-96-15 User-Entered F. Additional Information (optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Individuals who are in medical institutions for at least 30 consecutive days who are eligible under a special income level. Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-94-20, LA-09-40 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state covers Individuals in Institutions Eligible under a Special Income Level in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Have been in a medical institution for at least 30 consecutive days. 2. Have income at or below a standard described in section D.

Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-94-20, LA-09-40 User-Entered B.lndividuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 0 Yes Q No SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-94-20, LA-09-40 User-Entered C. Financial Methodologies SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 1. In calculating household income, the methodologies of the most closely related cash assistance program are used, except that disregards are not applied. 2. In calculating household resources, the methodologies of the most closely related cash assistance program are used Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: C: The state uses a less restrictive methodology with respect to resources set aside for burial. C: A higher amount is disregarded: C: The value of a countable life insurance policy is disregarded. C: Lump sums are disregarded as a resource. C: Proceeds from a settlement C: Specified type of lump sum: Amount: $10000.00 Description of disregard: The cash surrender value of life insurance and burial policies with a combined face value up to $10,000 will be disregarded. Name of lump sum type: Unspent settlement funds received in class action lawsuit, Nancy Anderson, et al. v. Bob Dean Jr., et al., 24th Judicial District Court, Parish of Jefferson, No. 820-839. Description: Unspent funds received as a class member, pursuant to the class settlement in the case of Nancy Anderson, et al. v. Bob Dean Jr., et al., 24th Judicial District Court, Parish of Jefferson, No. 820-839, shall be excluded from resources.

Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-94-20, LA-09-40 User-Entered D. Income Standard Used The income standard for this group is: 0 1. 300% of the SSI Federal Benefit Rate (FBR) for an individual 0 2. Other lower income level SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O SPA ID LA-23-0002 Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-94-20, LA-09-40 User-Entered Initial Submission Date 3/30/2023 Effective Date 1/1/2023 E.Resource Standard Used The resource standard for this group is the one used for the most closely-related cash assistance program.

Individuals in Institutions Eligible under a Special Income Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-94-20, LA-09-40 User-Entered F.Additional Information (optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage PACE Participants MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Individuals who would be eligible for Medicaid under institutional rules and who participate in the PACE program. Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-06 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state operates the PACE Participants eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would be eligible for one or more of the following Medicaid eligibility groups if in a medical institution: C: a. Individuals in Institutions Eligible under a Special Income Level C: b. Age and Disability-related Poverty Level D c. Medically Needy Individuals D d. Individuals Eligible for but Not Receiving Cash Assistance D e. Other eligibility group(s): 2. Are enrolled in a Program of All-Inclusive Care for the Elderly (PACE) program under a PACE program agreement. 3. Require, or will require in the absence of the continued provision of PACE services, the level of care furnished by a nursing facility.

PACE Participants MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-06 User-Entered B. Financial Methodologies SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The income and resource methodologies used for this group are those used to determine eligibility for a state plan group under which the individual would be eligible if in an institution.

PACE Participants MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-06 User-Entered C. Income and Resource Standards SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 1. The income and resource standards used for this group are those used to determine eligibility for a state plan group under which the individual would be eligible if in an institution. 2. An individual's gross income may not exceed 300% of the SSI federal benefit rate.

PACE Participants MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-06 User-Entered D. Additional Information (optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Age and Disability- Related Poverty Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Individuals who are age 65 or older or who have a disability, with income no higher than 100% FPL. Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-91-23, 14-04 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state covers the optional Age and Disability-Related Poverty Level eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Meet at least one of the following condition(s): a. Are age 65 or older; or b. Have a disability. 2. Have income and resources at or below the standard for this group.

Age and Disability- Related Poverty Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-91-23, 14-04 User-Entered B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 0 Yes Q No SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Age and Disability- Related Poverty Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-91-23, 14-04 User-Entered C. Financial Methodologies SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 1. SSI methodologies are used in calculating household income and resources. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. Q ves 0 No 3. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No a. The state uses the same less restrictive resource methodologies for all individuals covered. 0 Yes Q No The less restrictive resource methodologies are: C Lump sums are disregarded as a resource. C Specified type of lump sum: Name of lump sum type: Unspent settlement funds received in class action lawsuit, Nancy Anderson, et al. v. Bob Dean Jr., et al., 24th Judicial District Court, Parish of Jefferson, No. 820- 839. Description: Unspent funds received as a class member, pursuant to the class settlement in the case of Nancy Anderson, et al. v. Bob Dean Jr., et al., 24th Judicial District Court, Parish of Jefferson, No. 820- 839, shall be excluded from resources.

Age and Disability- Related Poverty Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-91-23, 14-04 User-Entered D. Income Standard Used The income standard for this eligibility group is: Q 1. 100% FPL 0 2. A lower percent of the FPL: SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 75.00% FPL

Age and Disability- Related Poverty Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-91-23, 14-04 User-Entered E. Resource Standard Used The resource standard used is: 0 1. The resource limit for the SSI program; or SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 0 2. The resource limit used in the state's medically needy program, if higher.

Age and Disability- Related Poverty Level MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-91-23, 14-04 User-Entered F. Additional Information (optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 Notwithstanding the indication above that Louisiana uses 75 percent of Federal Poverty Level (FPL) as the income standard, the state uses an income standard of 100 percent of the Supplemental Security Income (SSI) Federal Benefit Rate (FBR) for this group.

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Ticket to Work Basic MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Individuals between ages 16 and 64 with a disability, who have earned income. Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-01, 14-03 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state covers the optional Ticket to Work basic eligibility group in accordance with the following provisions:

Ticket to Work Basic MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-01 , 14-03 User-Entered A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are at least age 16 but less than 65 years of age. 2. Have earned income. 3. But for earned income, meet the SSI definition of disability. 4. Have income and resources that do not exceed the standards established by the state. SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Ticket to Work Basic MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-01 , 14-03 User-Entered B. Financial Methodologies SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 1. SSI methodologies are used in calculating household income and resources. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. Q Yes 0 No 3. Less restrictive methodologies are used in calculating countable resources. O ves Q No The less restrictive resource methodologies are: C The state uses a less restrictive methodology with respect to resources set aside for burial. C A higher amount is disregarded: C The value of a countable life insurance policy is disregarded. Amount: $10000.00 Description of disregard: The cash surrender value of life insurance and burial policies with a combined face value up to $10,000 shall be disregarded.

Ticket to Work Basic MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-01 , 14-03 User-Entered C. Income Standard Used The income standard for this group is: 0 1. No income standard 0 2. A percentage of the federal poverty level: O 3. A percentage of the SSI Federal Benefit Rate: 0 4. A dollar amount Q s. Other SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 FPL 100.00%

Ticket to Work Basic MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023M50001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-01, 14-03 User-Entered D. Resource Standard Used The resource standard for this group is: 0 1. No resource standard 0 2. 5SI resource standard SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 0 4. A dollar amount higher than the 551 resource standard Single Individual $10000.00 Couple $10000.00

Ticket to Work Basic MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-01 , 14-03 User-Entered E. Premiums and Cost Sharing SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan.

Ticket to Work Basic MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA-04-01 , 14-03 User-Entered F. Additional Information (optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Populations Based on Age, Blindness or Disability MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Individuals who are age 65 or older or who have blindness or a disability who do not qualify as categorically needy. Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA03-30,09-40,97-12, 14-03 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state covers the optional Medically Needy Populations Based on Age, Blindness or Disability eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1.Meet at least one of the following: a. Are age 65 or older; b. Have blindness; or c. Have a disability. 2. Are not otherwise eligible for categorically needy coverage under the state plan. 3. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA03-30,09-40,97-12, 14-03 User-Entered B. Individuals Covered The state covers the following populations: C 1. Individuals age 65 or older C 2. Individuals with blindness C 3. Individuals who have a disability SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA03-30,09-40,97-12, 14-03 User-Entered SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 C. Financial Methodologies 1. The state uses the same financial methodology for all individuals covered. 0 Yes Q No 2. The financial methodology used is: a. SSI methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. Less restrictive methodologies are used in calculating countable income. 0 Yes Q No The less restrictive income methodologies are: C A specified type of income is disregarded: Name of income type: In-kind Support and Maintenance Income Description: In-kind Support and Maintenance income is disregarded. c. Less restrictive methodologies are used in calculating countable resources. 0 Yes Q No The less restrictive resource methodologies are: C The state uses a less restrictive methodology with respect to resources set aside for burial. C A higher amount is disregar ded: C The value of a countable life insurance policy is disregarded. Amount: $10000.00 Description of disregard: The cash surrender value of life insurance and burial policies with a combined face value up to $10,000 shall be disregarde d. C A beneficiary of a "qualified state long-term care insurance partnership" policy (partnership policy), as defined in section 1917(b)(1 )(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance benefit payments made to or on behalf of the individual from the partnership policy.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA03-30,09-40,97-12, 14-03 User-Entered D. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O SPA ID LA-23-0002 Submission Type Official Approval Date 06/27/2023 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 Superseded SPA ID LA03-30,09-40,97-12, 14-03 User-Entered E. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA03-30,09-40,97-12, 14-03 User-Entered F. Spenddown SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023 The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is defined in the Handling of Excess Income (Spenddown) RU.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID I Medicaid State Plan I Eligibility I LA2023MS0001O I LA-23-0002 Package Header Package ID LA2023MS0001O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID LA03-30,09-40,97-12, 14-03 User-Entered G. Additional Information {optional) SPA ID LA-23-0002 Initial Submission Date 3/30/2023 Effective Date 1/1/2023

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Table of Contents State/Territory Name: Louisiana State Plan Amendment (SPA) #: 23-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages