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us-ma/policy/cms/medicaid-state-plan/spa · Axiom

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Attachment 4.19-B (3) Page 2 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Private Psychiatric Hospital Outpatient Services

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections

1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-B(3) of this State plan, where applicable:

fE:3| Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

oO Additional Other Provider-Preventable Conditions identified below: - None.

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

Reduction in provider payment may be limited to the extent that the following apply: (i) the identified provider preventable conditions would otherwise result in an increase in payment; (ii) the State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non- Payment for provider-preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) listed above

When a hospital reports a PCC, MassHealth will not pay for services which the hospital indicates are PPC-related and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

TN: 011-012 Approval Date: JUN 13 2012 Effective Date: 07/01/12 Supersedes: New

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Attachment 4.19-B (2) Page § State Plan under Title XIX of the Social Security Act State: Massachusetts

Methods Used to Determine Rates of Payment for Chronic Disease

and Rehabilitation Hospital Outpatient Services

e Inaddition, the following:

11.

Intraoperative or immediately postoperative death in a ASA class 1 patient Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended. Patient death or serious disability associated with patient elopement (disappearance)

. Patient suicide or attempted suicide resulting in serious disability, while being

cared for in a healthcare facility

Patient death or serious disability associated with a medication error (¢.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

Maternal death or serious disability associated with labor or delivery in a low- risk pregnancy while being cared for in a healthcare facility.

Death or serious disability (kernicterus) associated with failure to identify and: treat hyperbilirubinemia in neonates.

Patient death or serious disability due to spinal manipulative therapy

. Patient death or serious disability associated with the use of restraints or bedrails

while being cared for in a health care facility Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

Reductions in provider payment may be limited to the extent that the following apply: (i) The identified provider preventable conditions would otherwise result in an increase in payment; (ii) The State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider-preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as

TN: 011-012 Supersedes: New

Approval Date: SUN 12 2012 Effective Date: 07/01/12

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Attachment 4.19-B (2) Page 6 State Plan under Title XIX of the Social Security Act . State: Massachusetts Methods Used to Determine Rates of Payment for Chronic Disease and Rehabilitation Hospital Outpatient Services

Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above

When a hospital reports a PCC, MassHealth will reduce payments to the Hospital as follows:

1. Payments for Outpatient Services: MassHealth will not pay for services which the hospital indicates are PPC-related and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

2. Follow-Up Care in Same Hospital: If a hospital reports that it provided follow-up outpatient services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license. MassHealth will not pay for the reported follow-up services. If the hospital reports that non-PPC-related services were provided during the follow-up visit, payment will be made, but MassHealth will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth

Charges for services, including co-payments or deductions, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursements according to the methodology above.

D. Serious Reportable Events

The non-payment provisions set forth in this Section IID. apply to the following serious reportable events (SREs), where applicable: 1. Infant discharged to the wrong person. 2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. 3. Any instance of care ordered by or provided by someone impersonating a physician, nurse,

TN: 011-012 Approval Date: JN 1.9 2012 Effective Date: 07/01/12 Supersedes: New .

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Attachment 4.19-B (2) . Page 7 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Chronic Disease and Rehabilitation Hospital Outpatient Services

pharmacist, or other licensed health care provider. 4. Abduction of a patient of any age. 5. Sexual assault on a patient within or on the grounds of the healthcare facility.

Hospitals are prohibited from charging or seeking payment from MassHealth or the Member for Hospital services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the Hospital license that was preventable, within the Hospital’s control, and unambiguously the result of a system failure, as described in DPH regulations at 105 CMR 130.332 as in effect on the date of service. Non-reimbursable Hospital services include:

1. All services provided during the outpatient visit during which a preventable SRE occurred;

and

2. All services provided during readmissions and follow-up outpatient visits as a result of a non-billable SRE provided:

a. at a facility under the same license as the Hospital at which a non-billable SRE occurred; or

b. on the premises of a separately licensed hospital with common ownership or a common corporate parent of the Hospital at which a non-billable SRE occurred.

3. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the Member.

Non-payment provisions also apply to third-party liability and crossover payments by MassHealth.

A Hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria in number 2 above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE may bill MassHealth for all medically necessary Hospital services provided to the patient following a preventable SRE.

TN: 011-012 Approval Date: ‘JUN 12 2012 xstective Date: 07/01/12 Supersedes: New

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Attachment 4.19-A (2b) Page 7

State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Privately-Owned Psychiatric Hospital Services

C. Provider Preventable Conditions

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions ; The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart “A, and sections 1902(a)(4), 1902(a\(6), and 1903 with respect to non-payment for provider-preventable conditions.

Health Care-Acquired Conditions

The State identifies the following Health Care-Acquired Conditions for non-payment under Attachment 4.19-A(2b) (Privately-Owned Psychiatric Hospital Services) of this State plan, where applicable.

[El Hospital-Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

Other Provider-Preventable Conditions The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-A(2b) (Privately-Owned Psychiatric Hospital Services)of this State plan, where applicable.

_@ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure

performed on the wrong patient. Additional Other Provider-Preventable Conditions identified below: None.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

TN: 011-012 Approval Date: JUN 12 2012 — rettective Date: 07/01/12 Supersedes: New

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Attachment 4.19-A (2b) Page 8

State Plan under Title XIX of the Social Security Act State: Massachusetts

Methods Used to Determine Rates of Payment for Privately-Owned Psychiatric Hospital Services

Payment Method

EOHHS will pay participating psychiatric hospitals and substance abuse and treatment hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider-preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (‘OPPCs”) above. The OPPCs consist of the three National Coverage Determinations (the “NCDs”) that are listed above.

When a hospital reports a PPC that the hospital indicates was not present on admission, MassHealth will reduce payments to the hospital as follows:

Inpatient Per Diem Rate: a. MassHealth will not pay the Inpatient Per Diem Rate if the hospital reports

that only PPC-related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

. MassHealth will pay the Inpatient Per Diem Rate if the hospital reports that

non-PPC related services were also delivered on that day, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

2. Administrative Day Per-Diem Rate:

a. MassHealth will not pay the per diem if the hospital reports that only PPC-

related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

. MassHealth will pay the per diem if the hospital reports that non-PPC-related

services were also delivered on that day, but will exclude all reported PPC- related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by

MassHealth.

TN: 011-012 Supersedes: New

Approval Date: JUN 122012 Effective Date: 07/01/12

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Attachment 4.19-B Page 8 State Plan under Title XIX of the Social Security Act State: Massachusetts

Methods and Standards for Establishing Payment Rates - Other Types of Care

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections

1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-B (Other Types of Care) of this State plan, for these services, where applicable:

X-ray services

Physician services

Optometric services

Clinic services** -

Dental services

Podiatry services

FQHC /RHC services

Licensed Freestanding Birth Center services

X__ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

Additional Other Provider-Preventable Conditions identified below: - None.

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method: Effective for dates of service on or after July 1, 2012, MassHealth will not pay for OPPC-related services if the provider reports an Other Provider Preventable Condition (OPPC). Ifa provider’s future year payment rate is calculated using a data source that would otherwise include the OPPC, all reported OPPC-related costs/services will be excluded from the calculation.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

TN 011-012 Approval Date: JUN 1 2 2012 Effective Date: 07/01/12 Supersedes: New

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Attachment 4.19-B Page 10 State Plan under Title XIX of the Social Security Act State: Massachusetts

Methods and Standards for Establishing Payment Rates — Other Types of Care

Citation

42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions — Freestanding Ambulatory Surgery Center (FASC) Services

The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable

conditions.

Other Provider-Preventable Conditions The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-B of this State Plan (Other Types of Care), for Freestanding Ambulatory Surgery Center (FASC) services, where applicable:

X__ Additional Other Provider-Preventable Conditions identified below:

e The following Hospital Acquired Conditions as identified by Medicare, as they may be updated by CMS:

Foreign object retained after surgery Air Embolism Blood incompatibility Stage II and IV Pressure Ulcers Falls and Trauma, related to: y fractures

dislocations intracranial injuries crushing injuries burns

e other injuries 6. Manifestations of poor glycemic control, including: e diabetic ketoacidosis e nonketotic hyperosmolar coma e hypoglycemic coma e secondary diabetes with hyperosmolarity

wPrwndr

e Inaddition, the following:

1. 2.

Intraoperative or immediately postoperative death in a ASA class 1 patient

Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.

TN 011-012 Supersedes: New

Approval Date: JUN i 2 2012 . Effective Date: 07/01/12

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Attachment 4.19-B Page 11 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods and Standards for Establishing Payment Rates — Other Types of Care

Patient death or serious disability associated with patient elopement (disappearance)

Patient suicide or attempted suicide resulting in serious disability, while being cared

for in a healthcare facility

6. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

7. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

8. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates.

9. Patient death or serious disability due to spinal manipulative therapy

10. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility

11. Death or significant injury of a patient or staff member resulting from a physical

assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

Effective for dates of service on or after July 1, 2012, MassHealth will not pay the FASC for OPPC- related services if the FASC reports an Other Provider Preventable Condition (OPPC). Ifa future year FASC payment rate is calculated using a data source that would otherwise include the OPPC, all reported OPPC-related costs/services will be excluded from the calculation.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

Charges for services, including co-payments or deductibles deemed non-billable to MassHelath are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursement according to the methodology above.

TN 011-012 Approval Date: JUN 1.2 2012 Effective Date: 07/01/12 Supersedes: New

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Attachment 4.19-B (1)

Page 14 State Plan Under Title XIX of the Social Security Act State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Outpatient Hospital Services

LL.

In addition, the following:

Intraoperative or immediately postoperative death in a ASA class 1 patient

Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.

Patient death or serious disability associated with patient elopement (disappearance) Patient suicide or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

Death or serious disability (kemicterus) associated with failure to identify and treat hyperbilirubinemia in neonates. ~ :

Patient death or serious disability due to spinal manipulative therapy

. Patient death or serious disability associated with the use of restraints or bedrails

No reduction in payment for a provider preventable condition will be imposed ona provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment, ‘for that patient by that provider. :

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider- preventable conditions, effective for dates of service on or after July 1, 2012.

TN: 011-012 Supersedes: New

Approval Date: JUN 12 2012 Effective Date: 07/01/12

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Attachment 4.19-B (1)

Page 15 State Plan Under Title XIX of the Social Security Act

State: Massachusetts Methods Used to Determine Rates of Payment for Acute Outpatient Hospital Services

When a Hospital reports a PCC, MassHealth will reduce payments to the Hospital as follows:

1. PAPE:

a. MassHealth will not pay the PAPE if the Hospital reports that only-PPC- related services were delivered during the episode of care, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. MassHealth will pay the PAPE if the Hospital reports that non-PPC related services were also delivered during the same episode of care, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

2. Outpatient Hospital Payments for Hospital-Based Physician Services: MassHealth will not pay for outpatient Hospital-based physician services reported as PPC-related services.

3. Follow-Care in Same Hospital: If a Hospital reports that it provided follow-up outpatient hospital services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license., MassHealth will not pay for the reported follow-up services. If the hospital reports that non—PPC-related services were provided during the follow-up episode of care, payment will be made, but MassHealth will exclude all PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third party liability and crossover payments by MassHealth.

Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member. 7

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursement according to the methodology above.

TN: 011-012 Supersedes: New Approval Date: JUN 12 2012 Effective Date: 07/01/12

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Attachment 4.19-B (1) Page 16 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Outpatient Hospital Services

B. Serious Reportable Events

The non-payment provisions set forth in this Section VI.B. apply to the following serious reportable events (SREs), where applicable:

1. Infant discharged to the wrong person

2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances

3. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

4. Abduction of a patient of any age.

5. Sexual assault on a patient within or on the grounds of the healthcare re facility

Hospitals are prohibited from charging or seeking payment from MassHealth or the Member for Hospital and Hospital-Based Physician services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the Hospital license that was preventable, within the Hospital’s control, and unambiguously the result of a system failure, as described in DPH regulations at 105 CMR 130.332 as in effect on the date of service. Non- reimbursable Hospital and Hospital-Based Physician services include:

1. All services provided during the outpatient visit during which a preventable SRE occurred; and

2. All services provided during readmissions and follow-up outpatient visits as a result of a non-billable SRE provided:

a ata facility under the same license as the Hospital at which a non-billable SRE occurred; or

b. on the premises of a separately licensed hospital with common ownership or a common corporate parent of the Hospital at which a non-billable SRE occurred.

3. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the Member.

The non-payment provision also applies to third-party liability and crossover payments by MassHealth.

A Hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria in number 2 above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE may bill MassHealth for all medically necessary Hospital and Hospital-Based Physician services provided to the patient following a preventable SRE.

TN: 011-012 Supersedes: New Approval Date: JUN 12 2012 Effective Date: 07/01/12

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Attachment 4.19-A(2a) . Page 14 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods for Establishing Payment Rates — Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services

Vv. Provider Preventable Conditions

Citation 42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

Payment Adjustment for Provider Preventable Conditions The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections

1902(a)(4),1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions.

Health Care-Acquired Conditions

The State identifies the following Health Care-Acquired Conditions for non-payment under Attachment 4.19-A(2a) (Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services) of this State plan where applicable.

{& Hospital-Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-A(2a) (Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services) of this State plan where applicable.

@& Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

Additional Other Provider-Preventable Conditions identified below:

Intraoperative or immediately postoperative death in a ASA class 1 patient . Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

3. Patient death or serious disability associated with the use or function of a device in patient

care, in which the device is used or functions other than as intended.

Patient death or serious disability associated with patient elopement (disappearance)

Patient suicide or attempted suicide resulting in serious disability, while being cared for in a

healthcare facility

6. Patient death of serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

7. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

8. Death or serious disability (kernicterus) associated with failure to identify and treat

hyperbilirubinemia in neonates.

TN: 011-012 Approval Date: JUN 1.2 2012 Extective Date: 07/01/12 Supersedes: New

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Attachment 4.19-A(2a) Page 15 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods for Establishing Payment Rates — Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services

9. Patient death or serious disability due to spinal manipulative therapy

10. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility ,

11. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for provider- preventable conditions, effective for dates of service on or after July 1, 2012.

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

When a hospital reports a PPC that the hospital indicates was not present on admission, MassHealth will reduce payments to the hospital as follows: 1. Inpatient Per Diem Rate:

a. MassHealth will not pay the Inpatient Per Diem Rate if the hospital reports that only PPC-related services were delivered on that day and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC. .

b. MassHealth will pay the Inpatient Per Diem Rate if the hospital reports that non-PPC related services were also delivered on that day but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

2. Administrative Per-Diem (AD) Rate:

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Attachment 4.19-A(2a) Page 16 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods for Establishing Payment Rates — Privately-Owned Chronic Disease and Rehabilitation Inpatient Hospital Services

a. MassHealth will not pay the per diem if the hospital reports that only PPC- related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. MassHealth will pay the per diem if the hospital reports that non-PPC-related services were also delivered on that day but will exclude all reported PPC- related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

3. Follow-Up Care in Same Hospital: If a hospital reports that it provided follow-up inpatient hospital services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license, MassHealth will not pay for the reported follow-up services. If the hospital reports that non-PPC-related services were provided on any day during the follow-up stay, payment will be made for that day, but MassHealth will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

Charges for service, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursements according to the methodology above.

VI. Serious Reportable Events (SREs)

The non-payment provisions set forth in this Section VI apply to the following serious reportable events (SREs), where applicable:

1. Infant discharged to the wrong person. 2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. 3. Any Instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed health care provider. 4. Abduction of a patient of any age. | 5. Sexual assault on a patient within or on the grounds of a health care facility. |

Hospitals are prohibited from charging or seeking payment from MassHealth or the Member for hospital services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the hospital license that was preventable, within the hospital’s control, and unambiguously the result of a system failure, as described in DPH regulations at 105 CMR 130.332 as in effect on the date of service. Non-reimbursable hospital services include:

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Attachment 4.19-A(3) Page 28 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Services in State-Owned Non-Acute Hospitals

¢ crushing injuries e burns e — other injuries 6. Manifestations of poor glycemic control, including: e diabetic ketoacidosis e nonketotic hyperosmolar coma e hypoglycemic coma ¢ secondary diabetes with hyperosmolarity —

e In addition, the following:

1. Intraoperative or immediately postoperative death ina ASA class 1 patient

2. Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

3. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended. .

4. Patient death or serious disability associated with patient elopement (disappearance)

5. Patient suicide or attempted suicide resulting in serions disability, while being cared for in a healthcare facility \ .

7. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

8. Death or serious disability (kernicterys) associated with failure to identify and treat hyperbilirubinemia in neonates. .

9. Patient death or serious disability due to spinal manipulative therapy

10. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility

11. Death or significant injury of a patient or staff member resulting from a physical assault (ie., battery) that occurs within or on the grounds of a healthcare facility

No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior.to the initiation of treatment for that patient by that provider. :

Reductions in provider payment may be limited to the extent that the following apply: (i) The identified Provider preventable conditions would otherwise result in an increase in payment, (ii) The State can

reasonably isolate for noripayment the portion of the payment directly related to treatment for, and related to, the provider preventable condition. ‘ :

TN: 011-012 Approved JUN 1.2 2012eftective Date: 07/01/12 Supersedes New :

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Attachment 4.19-A(3) Page 29 State Plan under Title XIX of the Social Security Act State: Massachusetts Metheds Used to Determine Rates of Payment for Services in State-Owned Non-Acute Hospitals

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method A. State-Owned Non-Acute Hospitals Operated by the Department of Mental Health

For inpatient services, provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (‘““OPPCs”) above. The OPPCs consist of the three National Coverage Determinations (the “NCDs”) that are listed above.

For outpatient services, provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs consist of the three National Coverage Determinations (the “NCDs”) that are listed above.

When a hospital reports a PPC that the hospital indicates was not present on admission, MassHealth will reduce payments to the hospital by not paying for services which the hospital indicates are PPC-related, excluding PPC-related costs/services during any retrospective reconciliation, and excluding any PPC-related costs /services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursements according to the methodology above.

B. State-Owned Non-Acute Hospitals Operated by the Department of Public Health

EOHHS will pay hospitals in accordance with the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4), 1902(a)(6) and 1903 with respect to non-payment for

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Attachment 4.19-A(3) Page 30 State Plan under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Services in State-Owned Non-Acute Hospitals

provider-preventable conditions, effective for dates of service on or after July 1, 2012.

For inpatient services, provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

For outpatient services, provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Other Provider-Preventable Conditions (“OPPCs”) above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

When a hospital reports a PPC that the hospital indicates was not present on admission, MassHealth will reduce payments to the hospital by not paying for services which the hospital indicates are PPC-related, excluding PPC-related costs/services during any retrospective reconciliation, and excluding any PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

If a hospital reports that it provided follow-up services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license, MassHealth will not pay for the reported follow-up services. If the hospital reports that non-PPC-related services were provided during the follow- up stay or visit, payment will be made, but MassHealth will exclude PPC-related costs/services during any retrospective reconciliation and will exclude any PPC-related costs /services when

determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth. :

Charges for services, including co-payments and deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the commonwealth shall adjust reimbursements according to the methodology above.

XII. Serious Reportable Events for State-Owned Non-Acute Hospitals Operated by the Department of Public Health

The non-payment provisions set forth in this Section XII apply to the following serious reportable events (SREs) only for state-owned non-acute hospitals operated by the Department of Public Health, where applicable:

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Attachment 4,19-A(3) Page 31 State Plan under Title XIX of the Social Security Act State: Massachusetts _ Methods Used to Determine Rates of Payment for Services in State-Owned Non-Acute Hospitals

1, Infant discharged to the wrong person.

2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.

3. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

4, Abduction of a patient of any age.

5. Sexual assault on a patient within or on the grounds of a healthcare facility.

1. All services provided during the inpatient stay during which a preventable SRE occurred, from the date the SRE occurred through discharge, not to exceed 60 days; and

2. All services provided during the outpatient visit during which a preventable SRE occurred; and

3. All services provided during readmissions and follow-up outpatient visits as a result of a non-billable SRE provided:

a. ata facility under the same license as the Hospital at which a non-billable SRE occurred; or

b. on the premises of a separately licensed hospital with common ownership or a common corporate parent of the Hospital at which a non-billable SRE occurred.

4. Charges for services, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the Member.

Non-payment provisions also apply to third-party liability and crossover payments by MassHealth.

A Hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria in number 3 above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE may bill MassHealth for all medically necessary Hospital services provided to the patient following a preventable SRE.

TN: 011-012 Approved JUN 1 2 2012Effective Date: 07/01/12 Supersedes New

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Attachment 4.19-A (1) Page 36

State Plan Under Title XIX of the Social Security Act

State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

VI. Provider Preventable Conditions

Citation Payment Adjustment for Provider Preventable Conditions

42 CFR 447,434,438 and

1902(a) (4), 1902 (a) (6) and 1903

The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902 (a) (4), 1902 (a) (6) and 1903 with respect to non-payment for provider-preventable conditions.

Health Care-Acquired Conditions

The State identifies the following Health-Care Acquired Conditions for non- payment under Attachment 4.19-A(1), (Acute Inpatient Hospital Services) under this State plan.

Hospital Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE) following total knee

replacement or hip replacement surgery in pediatric and obstetric patients.

Other Provider-Preventable Conditions

The State identifies the following Other Provider-Preventable Conditions for non-payment under Attachment 4.19-A(1), (Acute Inpatient Hospital Services) under this State plan.

Wrong surgical or othér invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure perforined on the wrong patient,

Additional Other Provider-Preventable Conditions identified below.

. Intraoperative or immediately postoperative death in a ASA class 1 patient

Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.

Patient death or serious disability associated with patient. elopement (disappearance)

Patient suicide or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Patient death or serious disability associated with a medication error (e.g.,

" errors involving the wrong drug, wrong dose, wrong patient, wrong time,

wrong rate, wrong preparation or wrong route of administration) Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.

TN: 011-012 Supersedes: New

JUN 12 202

Approval Date: Effective Date: 07/01/12

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Attachment 4.19-A (1) Page 37 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

8. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates.

9. Patient death or serious disability due to spinal manipulative therapy

10. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility

11. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

A State plan must ensure that nonpayment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

Payment Method:

Provider preventable conditions (“PPCs”) are defined as those conditions that are identified as Health Care-Acquired Conditions (“HCACs”) and Other Provider-Preventable Conditions (“OPPCs”) listed above. The OPPCs include the three National Coverage Determinations (the “NCDs”) and the Additional Other Provider Preventable Conditions (“Additional OPPCs”) that are listed above.

When a Hospital reports a PPC that the Hospital indicates was not present ‘on admission, MassHealth will reduce payments to the Hospital as follows:

1. SPAD:

a. MassHealth will not pay the SPAD if the Hospital reports that only PPC-related services were delivered during the first 20 days of the inpatient admission, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. MassHealth will pay the SPAD if the Hospital reports that non-PPC related services were also delivered during the first 20 days of the inpatient admission, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

TN: 011-012 . Supersedes: New Approval Date: JUN 19 2012 Effective Date: 07/01/12

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Attachment 4.19-A (1) Page 38 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

2. Psychiatric, Rehabilitation, Administrative Day , Outlier or Transfer Per Diem payments:

a. MassHealth will not pay the per diem if the Hospital reports that only PPC-related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. MassHealth will pay the per diem if the Hospital reports that non-PPC related services

. were also delivered on that day, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

3. Inpatient Hospital payments for Hospital-Based Physician Services: MassHealth will not pay for inpatient Hospital-based physician services reported as PPC-related services.

4. Follow-up Care in Same Hospital: If a hospital reports that it provided follow-up inpatient hospital services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license, MassHealth will not pay for the reported follow-up services. If the Hospital reports that non-PPC-related services were provided during the follow-up stay, payment will be made, but MassHealth will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

The federal non-payment provision also applies to third-party liability and crossover payments by MassHealth.

Charges for service, including co-payments or deductibles, deemed non-billable to MassHealth are not billable to the member.

In the event that individual cases are identified throughout the PPC implementation period, the Commonwealth shall adjust reimbursement according to the methodology above.

VU. Serious Reportable Events

This Section VII supersedes in its entirety Section IV.C., above, effective for dates of service on or after July 1, 2012. Effective for dates of service on or after July 1, 2012, the non-payment provisions set forth in this Section VII apply to the following serious reportable events (SREs):

1. Infant discharged to the wrong person

2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances

3. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

4. Abduction of a patient of any age.

5. Sexual assault on a patient within or on the grounds of the healthcare facility.

TN: 011-012 . Supersedes: New Approval Date: JUN 1 2 2012 Effective Date: 07/01/12

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Medicaid Eligibility

OFFICIAL OMB Control Number 0938-1148

OMB Expiration date: 10/31/2014

Non-Financial Eligibility 588 State Residency 42 CFR 435.403

State Residency

The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

Individuals are considered to be residents of the state under the following conditions:

oh Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and:

f= Intends to reside in the state, including without a fixed address, or (@] Entered the state with a job commitment or seeking employment, whether or not currently employed.

my Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live.

[@] Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: {@] Residing in the state, with or without a fixed address, or

i The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides.

im Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married:

im Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or

im Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or

If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the [@] institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state.

i Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement.

[@] Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state.

im Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state.

{@] IV-E eligible children living in the state, or

TN 13-0018-MM5 S88 Approval Date: 05/30/2014 Massachusetts Page 1 of 4 Effective Date: 01/01/2014

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Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Massachusetts 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. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First Year $ Second Year $ Subject of Amendment Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Alison Kirchgasser Last Revision Date: Mar 24, 2014 Submit Date: Dec 30, 2013 DATE RECEIVED: 12/30/2013 EFFECTIVE DATE OF APPROVED MATERIAL: 10/01/2013 TYPED NAME: Richard R. McGreal PLAN APPROVED – ONE COPY ATTACHED DATE APPROVED: 03/26/2014

SIGNATURE OF REGIONAL OFFICIAL:

/s/

TITLE: Associate Regional Administrator, Division of Medicaid & Children’s Health Operations Boston Regional Office MA-13-0027 10/01/2013 42 CFR 435, Subpart J and Subpart M 2014 0.00 2015 0.00 MA, through this amendment, seeks approval for its alternative single streamlined app. for all insurance affordability programs in MA. This app. was developed in accordance with section 1413(b)(1)(A) of the ACA. MA continues to make changes to the online app. based on field testing and federal guidance. The online app. materials enclosed reflect the system as of 10/1/13. To facilitate review we are including a list of systems tickets that reflect the changes being made. The online application gap analysis highlights the differences between the MA’s 10/1 online app. and the CMS 4/29/13 model app. The paper app. materials enclosed are the 10/1/13 and 1/1/14 versions. The paper app. gap analysis highlights the differences between MA’s 1/1 version and the CMS 4/29/13 model app. MA will be in compliance with the requirement at 42 CFR 435.916 to provide members with a pre-populated renewal form containing the information already available as soon as the HIX/IES has the functionality to do so. This is expected to occur for renewals beginning between 4/1/14- 7/1/14. Until this functionality is available within HIX/IES, members will be selected for review on the date of their annual anniversary and they will have 45 days to respond, if the member’s financial eligibility is based on MAGI. The f ill b l d hi i i di d b b ill ll i f i d d f b d i li ibili MA h d l d i i i f f i 2014 ll i f i d d f b k MAGI b d li ibili d i i f h fi i MA h h d Not required under 42 CFR 423.0129(b)(2)(ii)

(ma-13-0027-mm2)(approval-document)(page-9)Page 9#

OFFICIAL Medicaid Eligibility

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

42 CFR 435, Subpart J and Subpart M

Eligibility Process

The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid.

Application Processing

Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard.

Oo The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act

An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the

Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary.

An attachment is submitted.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the [1] agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard:

The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and

(CZ approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary.

An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which “~ minimizes the burden on applicants, submitted to the Secretary.

An attachment is submitted.

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person.

The agency also accepts applications by other electronic means:

@ Yes € No

Page 1 of 2

TN 13-0027-MM2 $94-1

Approval Date: 03/26/2014 Massachusetts

Effective Date: 10/01/2013

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OFFICIAL

Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description

+ Fax Applicants are able to fill out a paper application and fax it to | the agency. | x

The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title 1V-A program, including Federally-qualified health centers and disproportionate share hospitals.

Parents and Other Caretaker Relatives

Pregnant Women

Infants and Children under Age 19 Redetermination Processing

Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916:

[Ml Once every 12 months

ml Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [Mj] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

rl Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply):

Once every 12 months

(FJ Once every 6 months

(1) Other, more often than once every 12 months Coordination of Eligibility and Enrollment

The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs.

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

Page 2 of 2

TN 13-0027-MM2 $94-2 Approval Date: 03/26/2014 Massachusetts Effective Date: 10/01/2013

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OFFICIAL

HEALTH

Application for Health Coverage ( me assacwuserrs s

*) and Help Paying Costs Instruction

CONNECTOR

Commonwealth of Massachusetts | EQHHS .

Please read these instructions before you fill out the application.

Apply faster online! Go to: MAhealthconnector.org. You will get results quickly. You can create a secure online account where you can see copies of notices and get important news fast.

Please read the attached Member Booklet carefully before you fill out the application. Keep the booklet.

It may answer questions you have later.

Use this application to apply for subsidized health coverage

This is your application for MassHealth, the Children’s Medical Security Plan (CMSP), the Massachusetts Health Connector (Health Connector) plans, and the Health Safety Net (HSN). MassHealth gives health care coverage and helps pay for health insurance premiums for families, children, and individuals.

The Massachusetts Health Connector is the state’s marketplace for health and dental insurance. The Health Connector can help you shop for and enroll in insurance plans from leading health insurers in the state. You can also find out through the Health Connector if you are eligible for any programs that help you pay for health insurance premiums and lower your out-of-pocket health care costs. For more information about programs that are available through the Health Connector, see pages 3 and 19-20 in the Member Booklet.

For information about the CMSP or the HSN, see page 18 for CMSP and pages 21-22 for HSN in the Member Booklet.

The kind of health coverage you get depends on your household size, income, and other circumstances. This information helps us make sure everyone gets the best coverage. Fill out all information for each person in your household. After you fill out your application and submit it, we will review it. If you are eligible, you will get the most complete coverage available.

Who can use this application

This application is for people who need health insurance and/ or help paying for it, and who:

* live in Massachusetts, * are not living in or about to go into a nursing home, and * are under age 65.

This application may also be used by people of any age who are: * parents of children under age 19, adult relatives living with and taking care of children under age 19 when neither parent is living in the home, or disabled and either: ¢ work 40 or more hours a month or are currently working and have worked at least 240 hours in the

six months immediately before the month of the application, or ° not working (only if under age 65). If this application is not for you, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

Tell us about your household

Tell us about all household members who live with you

and are applying for health coverage. You must answer all questions and fill out all supplements (if applicable) for each household member who is applying.

Do include

* Yourself

* Your spouse

* Your natural, adoptive, or step children under age 19

* Your unmarried partner if you have children together who are under age 19

* Your unmarried partner’s children who live with you and who are under age 19, if you also include your unmarried partner

* Anyone you include on your tax return (even if they do not live with you)

* Anyone your unmarried partner included on his or her tax return (even if they do not live with you), if you also include your unmarried partner

* Anyone else under age 19 who you live with and take care of

You do not have to include

* Your unmarried partner, unless you have children together

* Your unmarried partner’s children, unless they live with you

* Your parents who you live with and who file their own taxes if they do not claim you as a tax dependent (if you are aged 19 or older)

* Other adult relatives who you do not claim as a tax dependent

€ ACA-2 (Rev. 01/14)

over >

TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014 Massachusetts Page 1 of 28 Effective Date: 10/01/2013

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OFFICIAL

Filling out the application

Start with yourself, and then add other adults and children. If you have more than four people in your household including yourself, you will need to make copies of the pages for Person 4 before you fill them out, and attach them to the application.

Generally, you do not need to give us the citizenship or immigration statuses, or the social security numbers (SSNs) of household members who are not applying. However, you must give us an SSN or proof that one has been applied for for every household member who is applying, unless one of the following exceptions applies. * You or any household member has a religious exemption as described in federal law. * You or any household member is eligible only for a nonwork SSN. * You or any household member is not eligible for an SSN. Unless an exception applies, we need SSNs for all persons applying for health coverage. An SSN is optional for persons not applying for health coverage, but giving us an SSN can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If someone does not have an SSN or needs help getting one, call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778 for people who are deaf, hard of hearing, or speech disabled), or go to socialsecurity.gov. Please see the Member Booklet for more information.

We keep the information provided to us private, and only use and disclose it in accordance with applicable law.

We will try to prove your information and determine eligibility with matches through federal data sources, such as the Social Security Administration (SSA), the Internal Revenue Service (IRS), the Department of Homeland Security (DHS), and state data sources, such as the Department of Revenue (DOR), the Registry of Motor Vehicles (RMV), and other state-run public programs. If we are not able to prove your information or need more information, we will contact you. We may give you provisional coverage for up to 90 days during the time period that we are waiting for proof of information (other than a determination of disability). See the Member Booklet for more information about disability.

To help us see if you are eligible:

* fill out the application completely,

* be sure to tell us in Part 3 about health insurance you may be able to get through your job,

* fill out the parts of Supplement A that apply, if you answer yes to any questions about injury, illness, disability, accommodation, or applying due to an accident or injury caused by someone else; do not leave any answer blank,

* answer all questions in Part 4 and in Supplement C about any health insurance that you may have now, and

¢ fill out Supplement B, if you or any household member is an American Indian or Alaska Native.

Remember, you must read, sign, and date the Rights and

Responsibilities and Signature pages (Part 6, pages 16-18)

after you have filled out the application. When we get the signed and dated application, we will _ review it. If we need more information after we complete the data matches, we will contact you. Once we get all needed information, we will make a decision about your eligibility. We will send you a written notice about this decision. If you need medical care and you pay for it before you get an approval notice from us, you may be able to get a refund from your health care provider for what you paid.

To start filling out this application, go to page 1.

You can submit your application in any of the following ways.

* Sign on to your account at www.MAhealthconnector.org. You can create an online account if you do not already have one.

* Send your filled-out, signed application to: Health Insurance Processing Center P.O. Box 4405 Taunton, MA 02780.

* Fax your filled-out, signed application to: 617-887-8770.

* Call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

If you have any questions about this application or the information you need to send, please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648

for people who are deaf, hard of hearing,

or speech disabled).

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Application for Health Coverage ( me aszacsusstrs

. HEALTH ; and Help Paying Costs CONNECTOR Commonwealth of Massachusetts | EQHHS

Please print clearly. Be sure to answer all questions. Fill out all parts of the application and all supplements that apply. If you need more space, attach a separate piece of paper to the application. Put Person 1’s name and social security number at the top of any attached paper.

We need one adult in your household to be the contact person for your application (Person 1).

7. ai ee! Tell us about you (Person 1)—Fill out this part for yourself.

1.Firstname Middle initial Last name Suffix (ex., Jr.) Relationship to you SELF

2. Home street address Apt. #

City State Zip code 3. Are you homeless? 4, Mailing address (if different from home address)

[JYes [_]No

City State Zip code 5. Telephone number Other telephone number 6. Email address 7 Date of birth (mm/dd/yyyy) 8.Gender 9, Written language choice 10. Spoken language choice

(JM CIF

We need a social security number for every person applying for health coverage who has one. An SSN is optional for persons not applying for health coverage, but giving us an SSN can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If someone needs help getting an SSN, call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778 for people who are deaf, hard of hearing, or speech disabled), or go to socialsecurity.gov. Please see the application instructions or the Member Booklet for more information.

11. Doyou have a social security number (SSN)? [Yes [__]No If yes, give us the number. - - (Optional, if not applying) If no, check one of the reasons below. [_JApplied, but have not received SSN [__]Religious exemption [__] Only eligible for nonwork SSN {_]Not eligible to get SSN [_] Eligible for SSN, but have not applied 12. Willyou file a federal income tax return next year? [_]Yes [_JNo (To get a tax credit, you must file taxes for the year you are requesting benefits. You can still apply for health coverage even if you do not file a federal income tax return.) If yes, answer 12.a., 12.b., and 12.c. If no, answer 12.c. 12.a. Will you file jointly with a spouse? [__]Yes [_]No Ifyes, name of spouse: (If married, you must file federal taxes jointly for the year you are requesting benefits.) 12.b. Will you claim any dependents on your income tax return? [_]Yes [__]No If yes, list name(s) of dependents:

12.c. Will someone else claim you as a dependent on his or her tax return? [~ }Yes [_]No

If yes, name of tax filer: How are you related to the tax filer? 13. Are you pregnant? [__]Yes [_]No 13.a.{f yes, how many children are you expecting? 13.b. What is the due date? (mm/dd/yyyy) 1 Please go to the next page. >

ACA-2 (Rev. 01/14)

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14. Are you applying for health coverage for yourself? [_ ]Yes [JNo

If no, go to Part 2: Tell us about other people in this household on page 3. If yes, answer all questions below for Person 1 (yourself). 15, Are you living in Massachusetts and planning to stay? [__]Yes [_]No 16. Do you live with at least one child under age 19? [_]Yes [_]No ‘ 16.a. if yes, are you the main person taking care of this child? [_]Yes [_]No 17. Areyou in jail or prison? [_]Yes [_]No If no, go to the next question. T7a. If yes, are you (Check one.): [_]Convicted? What is your expected release date? (mm/dd/yyyy) {_]Not convicted? (For example: confined only) 18. Did you age out of foster care at the age of 18 or older? [_ Yes L] No if yes, were you enrolled in Medicaid when you aged out of foster care? [Yes | No

“Aging out" means the individual was in the custody of a state child welfare agency in any state or of a tribe in any state when he or she turned 18 years of age, or older if the individual decided to stay in placement after age 18. 19. Are you a U.S. citizen, national, or naturalized U.S. citizen? [ _]Yes [__]No If yes, go to Question 20. 19.a. Ifnno, do you have an eligible immigration status? (See the Member Booklet for more information.) [\"es CE] No | Noresponse —

Ifno or no response, you may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children's Medical Security Plan (CMSP), or the Health Safety Net (HSN). Go to Question 20.

19.b. Ifyes, do you have an immigration document? [—]Yes [_]No

We will try to prove your immigration status. Please list all the immigration statuses and/or conditions that have applied to you since you entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)

Immigration status

Status award date* (mm/dd/yyyy)| Immigration document type Document ID number

* For battered persons, status award date is date petition was approved as properly filed. 19.c. Did you come to live in the U.S. before August 22, 1996? [_]¥es [_]No

19.d. Did you use a different name to get your immigration status? []Yes [_]No If yes, what is it?

First name Middle name Last name Suffix (ex., Jr.)

19.e. Are you an honorably discharged veteran or an active-duty member of the U.S. military? [Yes [_]No

19.f. Are you a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [_]Yes [—]No

19.g. Are you an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [_]¥es [_]No

20. Do you have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months?

({f legally blind, answer yes.) [_]Yes [_]No Ifo, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 19.

21. Do you need reasonable accommodation(s) because of a disability or injury? [JYes [_]No

Ifno, go to the next question. If yes, fill out Part B of Supplement A: Illness, Disability, or Accommodation on page 19. 22. Are you applying because of an accident or injury that someone else might be responsible for? [_]Yes [_]No

If no, go to the next question. If yes, fill out Part C of Supplement A: Iliness, Disability, or Accommodation on page 19.

ACA-2 (Rev. 01/14) 2 Please go to the next page. >

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23.Do you have breast or cervical cancer? [__]Yes [_]No (Optional) MassHealth has special coverage rules for people who need treatment for breast or cervical cancer. If no, go to the next question. If yes, we will send you a certificate to be filled out by your doctor to prove your breast or cervical cancer diagnosis. Then MassHealth can see if your MassHealth benefits give you the most coverage possible. 24. Are you HIV positive? [Wes [No (Optional) If you are HIV positive, you may be eligible for additional coverage or benefits. If no, go to the next question. If yes, you will need to give us proof of your HIV-positive status. Then MassHealth can see if your MassHealth benefits give you the most coverage possible. 25. Did you ever get Supplemental Security Income (SSI)? [__]Yes [_]No If no, go to the next question. If yes, answer questions 25.a. and 25.b. 25.a. When did you last get SSI? (mm/yyyy) 25.b. Do you (Please check one.): [_]live alone? [__]live with a spouse? [_]live in arest home? [_Tlive and share expenses with another or others (not a spouse)? [__Jlivein an assisted living facility? [_]live in someone else's home? 26. Check the box below that best describes you. (Optional) [_]American Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [_JAmerican Indian/Alaska Native (Other Tribal Nation) [_]Asian [_]Black or African American [__|Hispanic/Latino/Black [_]Hispanic/Latino/White [_]Hispanic/Latino/Other [_]Native Hawaiian or other Pacific Islander [_]White [_]Other 27. If you are an American Indian or Alaska Native, fill out Supplement B: American Indian (Al)/Alaska Native (AN) on page 20. American Indians ‘and Alaska Natives may not have to pay premiums or copayments, and may get special monthly enrollment periods. Go to Part 2 to add other household members, if needed, or go to Part 3: Current Job and Income Information on page 10.

dN. tee Tell us about other people in this household

Fill out this part for your spouse or partner and children who live with you and/or anyone included on your federal income tax return, if you file one. See the application instructions for more information about who to include. If you do not file an income tax return, remember to add other persons who live with you.

Person 2 L.Firstname Middle initial Last name Suffix (ex., Jr.) | Relationship to Person 1 2. Home street address Apt. #

City State Zip code 3. Is Person 2 homeless? 4, Mailing address (if different from home address)

{es []No

City State Zip code 5. Telephone number

6. Email address 7.Date of birth (mm/dd/yyyy)| 8. Gender 9, Written language choice 10. Spoken language choice

Cl (IF We need a social security number for every person applying for health coverage who has one. Please see the application instructions or the Member Booklet for more information. 11. Does Person 2 have a social security number (SSN)? [_]Yes [_]No

If yes, give us the number. - - (Optional, if not applying)

If no, check one of the reasons below. [_JApplied, but have not received SSN [_]Religious exemption [_]Only eligible for nonwork SSN [_]Not eligible to get SSN [__] Eligible for SSN, but have not applied

ACA-2 (Rev. 01/14) 3 Please go to the next page. >

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12. Will Person 2 file a federal income tax return next year? [__]Yes [_]No

(To get a tax credit, Person 2 must file taxes for the year he or she is requesting benefits. Person 2 can still apply for health coverage even if he or she does not file a federal income tax return.) If yes, answer 12.a., 12.b., and 12.c. If no, answer 12.c. 12.a.Will Person 2 file jointly with a spouse? [—]Yes [_]No If yes, name of spouse:_, (If married, Person 2 must file federal taxes jointly for the year he or she is requesting benefits.) 12.b. Will Person 2 claim any dependents on his or her income tax return? [__]Yes [_]No If yes, list name(s) of dependents:

12.c, Will someone else claim Person 2 as a dependent on his or her tax return? [_]Yes [_]No

If yes, name of tax filer: How is Person 2 related to the tax filer? 13. Is Person 2 pregnant? [_]Yes [_]No 13.a. If yes, how many children is she expecting? 13.b. What is the due date? (mm/dd/yyyy)

14. Is Person 2 applying for health coverage? [_]Yes [__]No If no, go to Person 3 or Part 3: Current Job and Income Information on page 10. If yes, answer all questions below for Person 2. 15. Is Person 2 living in Massachusetts and planning to stay? [_]Yes [_]No 16. Does Person 2 live with at least one child under age 19? [_]Yes [_]No 16.a. If yes, is Person 2 the main person taking care of this child? [_]Yes [_]No 17. IsPerson 2 in ail or prison? [_]Yes [_]No If no, go to the next question. T7a. If yes, is Person 2 (Check one.): []Convicted? What is his or her expected release date? (mm/dd/yy) [_ Not convicted? (For example: confined only) 18. Did Person 2 age out of foster care at the age of 18 or older? [_]Yes [_]No if yes, was this person enrolled in Medicaid when he or she aged out of foster care? [Yes [_]No

“Aging out” means the individual was in the custody of a state child welfare agency in any state or of a tribe in any state when he or she turned 18 years of age, or older if the individual decided to stay in placement after age 18. 19. ls Person 2a US. citizen, national, or naturalized U.S. citizen? [_]Yes [_]No If yes, go to Question 20. 19.a. If no, does Person 2 have an eligible immigration status? (See the Member Booklet for more information.) [_ yes [No [No Tesponse

Ifno or no response, Person 2 may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Health Safety Net (HSN). Go to Question 20.

19. Ifyes, does Person 2 have an immigration document? [_]Yes [_]No

We will try to prove Person's 2 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 2 since he or she entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)

Immigration status

Status award date* (mm/dd/yyyy)| Immigration document type Document ID number

* For battered persons, status award date is date petition was approved as properly filed. 19. Did Person 2 come to live in the U.S. before August 22, 1996? [__]Yes [_]No

19.d. Did Person 2 use a different name to get his or her immigration status? [_]Yes [_]No if yes, what is it?

First name Middle name Last name Suffix (ex., Jr.)

19.. Is Person 2 an honorably discharged veteran or an active-duty member of the U.S. military? ["]¥es [_]No

194. ls Person 2a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member ofthe U.S. military? [_}Yes [_]No

ACA-2 (Rev. 01/14) 4 Please go to the next page. >

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19.g. Is Person 2 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member ofthe U.S. military? [_]Yes [_]No 20. Does Person 2 have an injury, illness, or disability {including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? (If legally blind, answer yes.) [_]Yes [_]No , If no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 19. 21. Does Person 2 need reasonable accommodation(s) because of a disability or injury? [_]Yes [__]No if no, go to the next question. if yes, fill out Part B of Supplement A: Illness, Disability, or Accommodation on page 19. 22. Is Person 2 applying because of an accident or injury that someone else might be responsible for? [_]Yes [_]No If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on page 19. 23. Does Person 2 have breast or cervical cancer? [_]Yes [~ ]No (Optional) MassHealth has special coverage rules for people who need treatment for breast or cervical cancer. If no, go to the next question. If yes, we will send a certificate to be filled out by Person 2's doctor to prove his or her breast cancer or her cervical cancer diagnosis, Then MassHealth can see if Person 2's MassHealth benefits give him or her the most coverage possible. 24. Is Person 2 HIV positive? [_]Yes [_]No (Optional) If Person 2 is HIV positive, he or she may be eligible for additional coverage or benefits. ; If no, go to the next question. If yes, Person 2 will need to give us proof of his or her HIV-positive status. Then MassHealth can see if Person 2's MassHealth benefits give him or her the most coverage possible. 25. Did Person 2 ever get Supplemental Security Income (SSI)? [_]Yes [_]No If no, go to the next question. If yes, answer questions 25.a. and 25.b.

25.a. When did Person 2 last get SSI? (mm/yyyy) 25.b. Does Person 2 (Please check one.): [_ live alone? [_ live with a spouse? [__]live ina rest home? [live and share expenses with another or others (not a spouse)? [__]live in an assisted living facility? [_]live in someone else's home?

26. Check the box below that best describes Person 2. (Optional) [_JAmerican Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) (_]American Indian/Alaska Native (Other Tribal Nation) [_]Asian [_]Black or African American [_]Hispanic/Latino/Black [_Jkispanic/Latino/White [_]Hispanic/Latino/Other [_]Native Hawaiian or other Pacific Islander [_]White [_]Other

27. If Person 2 is an American Indian or Alaska Native, fill out Supplement B: American Indian (Al)/Alaska Native (AN) on page 20. American Indians or Alaska Natives may not have to pay premiums or copayments, and may get special monthly enrollment periods. Continue adding other household members, if needed, or go to Part 3: Current Job and Income Information on page 10.

Person 3 1.Firstname Middle initial +Last name Suffix (ex., Jr.) | Relationship to Person 1 2. Home street address Apt. # Relationship to Person 2 City State Zip code 3. Is Person 3 homeless? 4, Mailing address (if different from home address) [Wes [No City State Zip code 5. Telephone number 6. Email address 7 Date of birth (mm/dd/yyyy)} 8. Gender 9. Written language choice 10. Spoken language choice

CJm CIF We need a social security number for every person applying for health coverage who has one. Please see the application instructions or the Member Booklet for more information.

ACA-2 (Rev. 01/14) 5 Please go to the next page. >

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11. Does Person 3 have a social security number (SSN)? [—]Yes [_]No If yes, give us the number. - - (Optional, if not applying) If no, check one of the reasons below. [JApplied, but have not received SSN [_]Religious exemption [—] Only eligible for nonwork SSN [_]Not eligible to get SSN [__] Eligible for SSN, but have not applied

12. Will Person 3 file a federal income tax return next year? [__]Yes [_]No (To get a tax credit, Person 3 must file taxes for the year he or she is requesting benefits. Person 3 can still apply for health coverage even if he or she does not file a federal income tax return.) If yes, answer 12.a., 12.b., and 12.c. If no, answer 12.c. 12.a. Will Person 3 file jointly with a spouse? [__]Yes [_]No Ifyes, name of spouse: (If married, Person 3 must file federal taxes jointly for the year he or she is requesting benefits.) 12.b. Will Person 3 claim any dependents on his or her income tax return? [— ]Yes [_]No If yes, list name(s) of dependents: 12.c. Will someone else claim Person 3 as a dependent on his or her tax return? [_]Yes [_]No Ifyes, name of tax filer: How is Person 3 related to the tax filer? 13. IsPerson 3 pregnant? [Yes [_]No 13.a. If yes, how many children is she expecting? 14. Is Person 3 applying for health coverage? [_]Yes [_]No {f no, go to Person 4 or Part 3: Current Job and Income Information on page 10. If yes, answer all questions below for Person 3. 15. Is Person 3 living in Massachusetts and planning to stay? [_]Yes [__]No 16. Does Person 3 live with at least one child under age 19? [_]Yes [_]No 16.a.|f yes, is Person 3 the main person taking care of this child? [_]Yes [_]No 17. IsPerson 3 in jail or prison? [_]Yes [_]No If no, go to the next question. T7a. If yes, is Person 3 (Check one.): [_ Convicted? What is his or her expected release date? (mm/dd/yyyy) {_ Not convicted? (For example: confined only) 18. Did Person 3 age out of foster care at the age of 18 or older? [_]Yes [_]No If yes, was this person enrolled in Medicaid when he or she aged out of foster care? [ves CL] No

13.b. What is the due date? (mm/dd/yyyy)

19. Is Person 3.a U.S. citizen, national, or naturalized U.S. citizen? [_]Yes [_]No If yes, go to Question 20. 19.2. If no, does Person 3 have an eligible immigration status? (See the Member Booklet for more information.) [_]yes | No []No response

if no or no response, Person 3 may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Health Safety Net (HSN). Go to Question 20.

19.b. If yes, does Person 3 have an immigration document? [_]Yes [_]No

We will try to prove Person's 3 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 3 since he or she entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)

Immigration status

Status award date* (mm/dd/yyyy)| Immigration document type Document ID number

* For battered persons, status award date is date petition was approved as properly filed. 19.c. Did Person 3 come to live in the U.S. before August 22,1996? [_]Yes [~]No

ACA-2 (Rev. 01/14) 6 Please go to the next page. >

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19.d. Did Person 3 use a different name to get his or her immigration status? [_]Yes [_]No If yes, what is it? First name Middle name Last name Suffix (ex., Jr.)

19.e.Is Person 3 an honorably discharged veteran or an active-duty member of the U.S. military? [_]Yes [—]No 19, ls Person 3 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [—]Yes [_]No 19.g. Is Person 3 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member ofthe U.S. military? [_]Yes [_]No 20. Does Person 3 have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? (If legally blind, answer yes.) [_]Yes [_]No If no, go to the next question. if yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 19. 21. Does Person 3 need reasonable accommodation(s) because of a disability or injury? [__]Yes [_]No If no, go to the next question. If yes, fill out Part B of Supplement A: Illness, Disability, or Accommodation on page 19. 22. Is Person 3 applying because of an accident or injury that someone else might be responsible for? [_]Yes [_]No If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on page 19. 23. Does Person 3 have breast or cervical cancer? [_]Yes [_]No (Optional) MassHealth has special coverage rules for people who need treatment for breast or cervical cancer. If no, go to the next question. If yes, we will send a certificate to be filled out by Person 3's doctor to prove his or her breast cancer or her cervical cancer diagnosis. Then MassHealth can see if Person 3's MassHealth benefits give him or her the most coverage possible. 24. Is Person 3 HIV positive? [ ]Yes [_]No (Optional) If Person 3 is HIV positive, he or she may he eligible for additional coverage or benefits. If no, go to the next question. If yes, Person 3 will need to give us proof of his or her HIV-positive status. Then MassHealth can see if Person 3's MassHealth benefits give him or her the most coverage possible. 25. Did Person 3 ever get Supplemental Security Income (SSI)? [_]Yes [_]No If no, go to the next question. If yes, answer questions 25.a. and 25.b, 25.a. When did Person 3 last get SSI? (mm/yyyy) 25.b. Does Person 3 (Please check one.): [__|live alone? [_Jlive with a spouse? [_]live ina rest home? [live and share expenses with another or others (not a spouse)? [_] live in an assisted living facility? [live in someone else's home? 26. Check the box below that best describes Person 3. (Optional) (_Jamerican indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) {_]American Indian/Alaska Native (Other Tribal Nation) [_]Asian [_]Black or African American (_]Hispanic/Latino/Black [_Jispanic/Latino/White [_]Hispanic/Latino/Other [__]Native Hawaiian or other Pacific Islander [_]White [_]Other 27. If Person 3 is an American Indian or Alaska Native, fill out Supplement B: American Indian (Al)/Alaska Native (AN) on page 20. American Indians or Alaska Natives may not have to pay premiums or copayments, and may get special monthly enrollment periods. Continue adding other household members, if needed, or go to Part 3: Current Job and Income Information on page 10.

If you have more than three people to add, make a copy of Person 4's blank information pages (pages 7-9) before you fill them out.

Person 4 1.Firstname Middle initial +Last name Suffix (ex., Jr.) | Relationship to Person 1 2. Home street address Apt.# Relationship to Person 2

City State Zip code Relationship to Person 3 3. ls Person 4 homeless? 4. Mailing address (if different from home address)

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City State Zip code 5. Telephone number 6. Email address 7 Date of birth (mm/dd/yyyy)| 8. Gender 9, Written language choice 10. Spoken language choice CJM (JF

We need a social security number for every person applying for health coverage who has one. Please see the application instructions or the Member Booklet for more information.

11. Does Person 4 have a social security number (SSN)? [_]Yes [_]No If yes, give us the number. - - (Optional, if not applying) If no, check one of the reasons below.

[_JApplied, but have not received SSN [__]Religious exemption [_] Only eligible for nonwork SSN [_INot eligible to get SSN [__] Eligible for SSN, but have not applied 12. Will Person 4 file a federal income tax return next year? [_]Yes [—]No

(To get a tax credit, Person 4 must file taxes for the year he or she is requesting benefits, Person 4 can still apply for health coverage even if he or she does

not file a federal income tax return.) If yes, answer 12.a., 12.b., and 12.c. Ifno, answer 12.c. 12.a. Will Person 4 file jointly with aspouse? [_]Yes [_]No Ifyes, name of spouse: (If married, Person 4 must file federal taxes jointly for the year he or she is requesting benefits.) 12.b. Will Person 4 claim any dependents on his or her income tax return? [_]Yes [_]No If yes, list name(s) of dependents:

12.c. Will someone else claim Person 4 as a dependent on his or her tax return? [_]Yes [_]No

If yes, name of tax filer: How is Person 4 related to the tax filer? 1B. IsPerson 4 pregnant? [~|Yes [_]No 13.a. If yes, how many children is she expecting? 13.b. What is the due date? (mm/dd/yyyy)

14. Is Person 4 applying for health coverage? [__]Yes [_]No fno, go to Part 3: Current Job and Income Information on page 10. If yes, answer all questions below for Person 4. 15. |s Person 4 living in Massachusetts and planning to stay? [__]Yes [_]No 16. Does Person 4 live with at least one child under age 19? [__]Yes [_]No 16.a. If yes, is Person 4 the main person taking care of this child? [_]Yes [_]No 17, Is Person 4 injail or prison? [_]Yes [_]No If no, go to the next question. T7a. If yes, is Person 4 (Check one.): {_]Convicted? What is his or her expected release date? (mm/dd/yyyy) [_)Not convicted? (For example: confined only) 18. Did Person 4 age out of foster care at the age of 18 or older? [__]Yes [_]No Ifyes, was this person enrolled in Medicaid when he or she aged out of foster care? [__]Yes [_]No

“Aging out" means the individual was in the custody of a state child welfare agency in any state or of a tribe in any state when he or she turned 18 years of age, or older if the individual decided to stay in placement after age 18. 19. Is Person 4a US. citizen, national, or naturalized U.S. citizen? [_]Yes [_]No If yes, go to Question 20. 19.a. Ifno, does Person 4 have an eligible immigration status? (See the Member Booklet for more information.) [les CE] No | No response

If no or no response, Person 4 may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Health Safety Net (HSN). Go to Question 20.

19.b. ifyes, does Person 4 have an immigration document? [_]Yes [_]No

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We will try to prove Person's 4 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 4 since he or she entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)

Immigration status

Status award date* (mm/dd/yyyy)} Immigration document type Document ID number

* For battered persons, status award date is date petition was approved as properly filed. 19.c. Did Person 4 come to live in the U.S. before August 22,1996? [_]Yes [_]No

19.d. Did Person 4 use a different name to get his or her immigration status? [_ ]Yes [[JNo If yes, what is it?

First name Middle name Last name Suffix (ex., Jr.)

19.e. Is Person 4 an honorably discharged veteran or an active-duty member of the U.S. military? [—]Yes [_]No 19. Is Person 4 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? [_]Yes [—]No 19.g. Is Person 4 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member of the U.S. military? []Yes [_]No ; 20. Does Person 4 have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? (If legally blind, answer yes.) [_]Yes [_]No If no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 19. 21. Does Person 4 need reasonable accommodation(s) because of a disability or injury? [_]Yes [__]No If no, go to the next question. If yes, fill out Part B of Supplement A: Illness, Disability, or Accommodation on page 19. 22. Is Person 4 applying because of an accident or injury that someone else might be responsible for? [__]Yes [_]No If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on page 19. 23. Does Person 4 have breast or cervical cancer? [__]Yes [_]No (Optional) MassHealth has special coverage rules for people who need treatment for breast or cervical cancer. If no, go to the next question. If yes, Person 4 will send a certificate to be filled out by Person 4's doctor to prove his or her breast cancer or her cervical cancer diagnosis. Then MassHealth can see if Person 4's MassHealth benefits give him or her the most coverage possible, 24, Is Person 4 HIV positive? [~]¥es [_]No (Optional) If Person 4 is HIV positive, he or she may be eligible for additional coverage or benefits. Ifno, go to the next question. If yes, Person 4 will need to give us proof of his or her HIV-positive status. Then MassHealth can see if Person 4's MassHealth benefits give him or her the most coverage possible. 25. Did Person 4 ever get Supplemental Security Income (SSI)? [—_]Yes [—]No If no, go to the next question. If yes, answer questions 25.a. and 25.b. 25.a. When did Person 4 last get SSI? (mm/yyyy) 25.b. Does Person 4 (Please check one.): [_]live alone? [_]livewithaspouse? [_]live ina rest home? [_Jlive and share expenses with another or others (not a spouse)? [live in an assisted living facility? [_]live in someone else's home? 26. Check the box below that best describes Person 4. (Optional) [_]American Indian/Alaska Native (Mashpee Wampanoag) [_JAmerican Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [american Indian/Alaska Native (Other Tribal Nation) [_]Asian [__]Black or African American [_}Hispanic/Latino/Black [_]ispanic/Latino/White [_]Hispanic/Latino/Other [_]Native Hawalian or other Pacific Islander [_]White [_]Other 27. If Person 4 is an American Indian or Alaska Native, fill out Supplement B: American Indian (Al)/Alaska Native (AN) on page 20. American Indians or Alaska Natives may not have to pay premiums or copayments, and may get special monthly enrollment periods. Continue adding other household members, if needed, or go to Part 3: Current Job and Income Information on page 10.

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7:\; gece Current Job and Income Information

We use your income to see if you are eligible for health coverage. See the Member Booklet. If you are self-employed, and pay yourself wages, fill out both the Current Job and Self-employed income sections.

About You (Person 1)

1, (Check all that apply.)

[_JEmployed (Go to Current Job 1.) [_]Self-employed (Go to Self-employed income.) [_]Not employed (Go to Money from other sources section.) Current Job 1

2. Employer name

Employer address City State Zip code

Employer telephone Employer Identification Number (EIN—if you know)

3. Does this job offer health insurance? [_]Yes [_]No

If yes, check one. [This job offers health insurance now.

[This job will offer health insurance, starting (mm/dd/yyyy). 3.a. If this job offers health insurance now or will at a later date, can the health plan cover an employee's spouse or dependent(s)? [_}¥es List the name(s): [No

+ How much will the employee pay for the lowest-cost individual health plan? $ How often? (Check one.) [_]Weekly [_]Monthly [_]Twice a month [_]Yearly + — [fan employee joins a program to stop smoking or using tobacco, how much money could he or she save on the monthly premium? $ * Does the health insurance plan(s) offered by the employer meet the “minimum value” standard? [_]Yes [_]No Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 3.b. What health insurance changes will this job make for the next year? (if you know) [_TThis job will stop offering health insurance, [this job will start offering health insurance to employees or change the premium for the lowest-cost available plan. + How much will the employee's premiums be (for an individual plan)? $ How often? (Check one.) [_]Weekly [_]Monthly [Twice amonth [—]Yearly + Date of change: (mm/dd/yyyy) 3.c.[_]No health insurance plans offered by the employer will meet the “minimum value” standard.

Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.)

4. Does this employer have 50 or fewer full-time employees? [__]Yes [—]No (If you do not know, answer no to this question.) Ifyes, we may be able to help you pay for your coverage. For more information, see the Member Booklet for description of coverage.

5. Isthis job a sheltered workshop? [_]Yes [—]No 6. How much do you currently earn in gross wages, less pre-tax deductions? $

6.a. How often are you paid? (Check one.) [_]Weekly [_]Every 2 weeks [_]Twice amonth [_]Monthly [_]Yearly

6.b. About how many hours do you work each WEEK?

6.c. When did you begin getting this income? (mm/dd/yyyy) 7. \fyour income from this job changes during the year (such as seasonal or contract employment), check the months you have worked or expect to

work. [Jan [_]Feb [_JMar [_JApr [_]May [C]June [July [_JAug [_]Sept [Joct [_]Nov [_]Dec

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Self-employed Income

8.a.(Check one.) [_]Partnership [_]S-Corporation [_]Self-employed 8.b. Business name:

8.c. What is your expected yearly income from this source, less any business expenses? (Do not include your wages and tips.) $ 8.d. Date you began getting this income (mm/dd/yyyy)

Current Job 2 (Ifnone, go to Money from other sources section.) 9, Employer name

Employer address City State Zip code

Employer telephone Employer Identification Number (EIN—if you know)

10. Does this job offer health insurance? [_]Yes [_]No

If yes, check one. [_IThis job offers health insurance now.

[_]This job will offer health insurance, starting (mm/dd/yyyy). 10.a. If this job offers health insurance now or will at a later date, can the health plan cover an employee's spouse or dependents)? [Wes List the name(s): [No

+ How much will the employee pay for the lowest-cost individual health plan? $

How often? (Check one.) [_]Weekly [_]Monthly [Twice amonth [| early + Ifan employee joins a program to stop smoking or using tobacco, how much money could he or she save on the monthly premium? $ + Does the health insurance plan(s) offered by the employer meet the “minimum value” standard? [_]Yes [_]No

[This job will stop offering health insurance. [_]This job will start offering health insurance to employees or change the premium for the lowest-cost available plan. + Howmuch will the employee's premiums be (for an individual plan)? $ How often? (Check one.) [_]Weekly [_]Monthly [—]Twice a month [~ |Yearly + Date of change: (mm/dd/yyyy)

10.c.[__] No health insurance plans offered by the employer will meet the “minimum value” standard,

Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.)

11. Does this employer have 50 or fewer full-time employees? [_]Yes [_]No (If you do not know, answer no to this question.) Ifyes, we may be able to help you pay for your coverage. For more information, see the Member Booklet for description of coverage. 12. Is this job a sheltered workshop? [_]¥es [__]No 13. How much do you currently earn in gross wages, less pre-tax deductions? $ 13.a. How often are you paid? (Check one.) [_]Weekly [_]Every2weeks [_]Twiceamonth [_]Monthly [_]Yearly

13.b. About how many hours do you work each WEEK? 13.c. When did you begin getting this income? (mm/dd/yyyy)

14. If your income from this job changes during the year (such as seasonal or contract employment), check the months you have worked or expect to

work. [Jan []feb []Mar [_JApr [_JMay [_]June [[]July [JAug [_]Sept [JOct [Nov [_]Dec

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Self-employed Income 15.a.(Check one.) [_]Partnership [_]$-Corporation [_]Self-employed 15.b. Business name: 15.c, What is your expected yearly income from this source, less any business expenses? (Do not include your wages and tips.) $

15.d. Date you began getting this income (mm/dd/yyyy)

Money from other sources

16. Do you get money from other sources? [~ ]Yes [_]No Check all of the sources, give the amount, and how often you get it.

(You do not need to tell us about child support, nontaxable veterans’ payments, or Supplemental Security Income (SSI).)

[_]Unemployment $ How often? [_JOrdinary or qualified dividend $ How often? [Pension $ How often? L_Itusts $ How often? LJannuity $ How often? [interest $ How often? [Social Security $ How often? [Net farming/fishing $ How often? [_]Netrentalincome $ How often? [Royalty $ How often? [Jcapital gains $ How often? [_JAlimony received $ How often? {]Gambling proceeds $ How often? [“Jlax-excluded foreign income $ How often? [Taxable military retirement pay (not paid through the Veterans’ Administration) $ How often?

{_JTax refund, credit, or offset of state or local income taxes $ How often?

[_Jother income (Specify:) $ How often?

Deductions allowed on federal tax return Allor part of certain expenses can be deducted from income so that you do not pay taxes on them. These amounts are not counted in your income, and may lower the cost of your health coverage.

17, Do you have any of the deductible expenses below? [_]Yes [_]No If yes, please check all of the types you have, fill in the deductible amount, and how often you have this expense. Do not include an expense that you already claimed under self-employment income above. {_]Alimony paid $ How often? [Student loan interest $ How often? [_ Other tax deductions (such as business expenses, IRA contributions, contributions to taxable retirement income, deductible part of self- employment tax, educator expenses, health savings account contributions (deduction), moving expenses, penalty on early withdrawal of savings, self-employment health insurance, self-employment retirement plan, and tuition and other school-related costs)

Type: $ How often? Type: $ How often? Type: $ How often?

Total income (Person 1)

18. Do you expect your total income (including earned income and money from other sources) to be the same next year? [__]Yes [_]No (If you are not sure, answer no to this question.)

If no, what do you expect your total income to be next year? $ (Estimate)

Person 2 (Second adult) (If you have income to report for more than two persons, make a copy of pages 12-15 before you fill them out.)

Name: 1. (Check all that apply.) [_JEmployed (Goto Current Job 1.) [_]Self-employed (Go to Self-employed income.) [_]Not employed (Go to Money from other sources section.)

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Current Job 1 2. Employer name

Employer address City ‘ State Zip code

Employer telephone Employer Identification Number (EIN—if you know)

3. Does this jab offer health insurance? [__]Yes [_]No

lf yes, check one. [_Jthis job offers health insurance now.

[_ JThis job will offer health insurance, starting (mm/dd/yyyy). 3.a. If this job offers health insurance now or will at a later date, can the health plan cover an employee's spouse or dependent(s)? [Wes List the name(s): [No

+ How much will the employee pay for the lowest-cost individual health plan? $

How often? (Check one.) [_]Weekly [_]Monthly [~]Twiceamonth [_]Yearly + Ifan employee joins a program to stop smoking or using tobacco, how much money could he or she save on the monthly premium? $ + Does the health insurance plan(s) offered by the employer meet the “minimum value” standard? [—]Yes [_]No

Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.) 3.b. What health insurance changes will this job make for the next year? (if you know) L_Jhis job will stop offering health insurance. [This job will start offering health insurance to employees or change the premium for the lowest-cost available plan. + —Howmuch will the employee's premiums be (for an individual plan)? $ How often? (Check one.) [_]Weekly [_]Monthly [_]Twiceamonth [~ ]Yearly + Date of change: (mm/dd/yyyy)

3.c.[_]No health insurance plans offered by the employer will meet the “minimum value” standard. Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.)

4. Does this employer have 50 or fewer full-time employees? [_]Yes [_]No (If you do not know, answer no to this question.) Ifyes, we may be able to help pay for this coverage. For more information, see the Member Booklet for description of coverage. 5, Isthisjob a sheltered workshop? [_]Yes [_]No 6. How much does this person currently earn in gross wages, less pre-tax deductions? $ 6.a. How often is this person paid? (Check one.) [__]Weekly [_]Every 2 weeks [~|Twiceamonth [—]Monthly []Yearly 6.b. About how many hours does this person work each WEEK? 6.c. When did this person begin getting this income? (mm/dd/yyyy) 7. Ifthis person's income from this job changes during the year (such as seasonal or contract employment), check the months this person has worked or expects towork. ["]Jan [_]Feb [_JMar [_]Apr [_]May [June [_JJuly [_JAug [_]Sept [Joct [Nov [_]Dec Self-employed Income

8.a.(Check one.) [_]Partnership [_]S-Corporation [_]Self-employed 8.b. Business name:

8.c. What is this person's expected yearly income from this source, less any business expenses? (Do not include his or her wages and tips.) $

8.d. Date this person began getting this income (mm/dd/yyyy) ACA-2 (Rev. 01/14) 13 Please go to the next page. > TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014

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Current Job 2 (If none, go to Money from other sources section.) 9. Employer name

Employer address City , State Zip code

Employer telephone Employer Identification Number (EIN—if you know)

10. Does this job offer health insurance? [__]Yes [_]No

If yes, check one.

[_] This job offers health insurance now.

[J This job will offer health insurance, starting (mm/dd/yyyy).

10.a. If this job offers health insurance now or will at a later date, can the health plan cover an employee's spouse or dependent(s)? [Wes List the name(s): [No * How much will the employee pay for the lowest-cost individual health plan? $

How often? (Check one.) [_]Weekly [_]Monthly [_]Twice a month [_]Yearly

+ Ifan employee joins a program to stop smoking or using tobacco, how much money could he or she save on the monthly premium? $ + Does the health insurance plan(s) offered by the employer meet the “minimum value” standard? [_]Yes [_]No Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.)

10.b. What health insurance changes will this job make for the next year? (if you know) [_JThis job will stop offering health insurance. [_JThis job will start offering health insurance to employees or change the premium for the lowest-cost available plan. + How much will the employee's premiums be (for an individual plan)? $ How often? (Check one.) [_]Weekly [_]Monthly [__]Twice a month [__]Yearly + Date of change: (mm/dd/yyyy)

10.c.[__]No health insurance plans offered by the employer will meet the “minimum value” standard.

Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or insurance company will know this information.)

11. Does this employer have 50 or fewer full-time employees? [__]Yes [_]No (If you do not know, answer no to this question.) If yes, we may be able to help pay for this coverage. For more information, see the Member Booklet for description of coverage. 12. |s this job a sheltered workshop? [_]Yes [__]No 13. How much does this person currently earn in gross wages, less pre-tax deductions? $ 13.a. How often is this person paid? (Check one.) [_]Weekly [_]Every2weeks [_|Twiceamonth [_|Monthly [_]Yearly 13.b. About how many hours does this person work each WEEK? 13.c. When did this person begin getting this income? (mm/dd/yyyy)

14. If this person's income from this job changes during the year (such as seasonal or contract employment), check the months this person has worked or expects towork. [Jan [Feb []Mar [_JApr [JMay [June [JJuly [JAug [Sept [Joct [Nov [_JDec Self-employed Income

15.a.(Check one.) [_]Partnership [_]S-Corporation [_]Self-employed 15.b. Business name:

15.c, What is this person's expected yearly income from this source, less any business expenses? (Do not include his or her wages and tips.) $

15.d. Date this person began getting this income (mm/dd/yyyy) ACA-2 (Rev. 01/14) 14 Please go to the next page. > TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014

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Money from other sources

16. Does this person get money from other sources? [__]Yes [_]No Check all of the sources, give the amount, and how often this person gets it. (You do not need to tell us about child support, nontaxable veterans’ payments, or Supplemental Security Income (SSI).)

[]Unemployment $ How often? [_JOrdinary or qualified dividend $ How often? [_]Pension $ How often? [_]Trusts $ How often? (_JAnnuity $ How often? [ Jinterest $ How often? [_]Social Security $ How often? [_]Net farming/fishing $ How often? [_JNet rental income $ How often? [_JRoyalty $ How often? [_|Capital gains $ How often? [_]Alimony received $ How often? [_JGambling proceeds $ How often? [_}lax-excluded foreign income $ How often? [_}Taxable military retirement pay (not paid through the Veterans’ Administration) $ How often?

[_}1ax refund, credit, or offset of state or local income taxes $ How often?

[_]Other income (Specify:) $ How often?

Deductions allowed on federal tax return

All or part of certain expenses can be deducted from income so that this person does not pay taxes on them. These amounts are not counted in this person's income, and may lower the cost of his or her health coverage.

17. Does this person have any of the deductible expenses below? [_]Yes [_]No If yes, please check all of the types he or she has, fill in the deductible amount, and how often this person has this expense. Do not include an expense that he or she already claimed under self-employment income above. [Alimony paid $ How often? [_]Student loan interest $ How often? [_] Other tax deductions (such as business expenses, IRA contributions, contributions to taxable retirement income, deductible part of self- employment tax, educator expenses, health savings account contributions (deduction), moving expenses, penalty on early withdrawal of savings, self-employment health insurance, self-employment retirement plan, and tuition and other school-related costs)

Type: $ Howoften? Type: $ Howoften? Type: $ How often?

Total income (Person 2)

18. Do you expect Person 2's total income (including earned income and money from other sources) to be the same next year? [__]Yes [_]No (If you are not sure, answer no to this question.) If no, what do you expect Person 2's total income to be next year? $ (Estimate)

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wee Health Insurance You Have Now

Please answer the questions below about health insurance, and follow the instructions. If you or any household member has enrolled in one of the health insurance plans below, but the benefits have not yet started, check yes to the question. MassHealth may be able to help pay premiums. 1. Doyouor any household member have Medicare? [__]Yes [_]No Ifyes, fill out Part A of Supplement C: Health Insurance on page 21. 2. Doyou or any household member have federal health insurance provided by the U.S. military (Veterans’ Affairs or TRICARE) or other federal coverage? [_]Yes [_]No Ifyes, fill out Part B of Supplement C: Health Insurance on page 21. 3. Do you or any household member currently have any other type of health insurance? (This includes insurance through an employer, union, college or university, former employer (COBRA), and coverage bought by you or any household member, or a parent who is not living in the household.)

(]Yes [_]No

Ifyes, fill out Part C of Supplement C: Health Insurance on page 21. If you answered no to all three questions above, go to Part 5: Parental Information.

4m Parental Information

For all children in the household, please answer the following three questions. 1. Was any child in the household adopted by a single parent? [— ]Yes [_]No If yes, list child’s(rens’) name(s): 2. Does any child in the household have a parent who has died? [__]Yes [_]No If yes, list child's(ren's) name(s): 3. Does any child in the household have a parent who is unknown? [_]Yes [_]No If yes, list child’s(ren's) name(s): If there are any children in the household who have a noncustodial parent (a parent who does not live with the child) but are not listed above, give us the following information. Child’s(ren’s) name(s): We will send a form to the child’s(ren's) custodial parent to fill out and return to us. This form asks questions about any parents who do not live with the child. Go to Part 6: Rights and Responsibilities and Signature Page.

Ziti Rights and Responsibilities and Signature Page

On behalf of myself and all persons listed on this application, | understand, represent, and agree as follows.

1. MassHealth may require eligible persons to enroll in available employer-sponsored health insurance if that insurance meets the criteria for MassHealth payment of premium assistance.

2. Employers of eligible persons may be notified and billed in accordance with state regulations for any services that hospitals or community health centers provide to these persons that are paid for by the Health Safety Net.

3. Health coverage premiums must be paid for all persons listed on this application who are applying. Failure to pay any premium due may result in the State deducting the amount owed from the tax refunds of responsible persons. If any person applying is a certain American Indian or Alaska Native, MassHealth premiums may not have to be paid.

4. MassHealth has the right to pursue and get money from third parties who may be obligated to pay for health services provided to eligible persons enrolled in MassHealth programs. These third parties may include other health insurers, spouses, or parents obligated to pay for medical support, or individuals obligated to pay under accident settlements. Eligible persons must cooperate with MassHealth in establishing third-party support and obtaining third-party payments for themselves and anyone whose rights they can legally assign. Eligible persons may be exempted from this obligation if they believe and tell MassHealth that cooperation could result in harm to them or anyone whose rights they can legally assign.

5. Aparent and/or guardian of minor children must agree to cooperate with state efforts to collect medical support from a noncustodial parent unless they believe and tell MassHealth that cooperation will harm the children or the parent or guardian.

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6. Eligible persons who are injured in an accident, or in some other way, and get money from a third party because of that accident or injury must use that money to repay MassHealth or the Health Safety Net for certain services provided.

7. Eligible persons must tell MassHealth or the Health Safety Net, in writing, within 10 calendar days, or as soon as possible, about any insurance claims or lawsuits filed because of an accident or injury. ,

8. The status of this application may be shared with a hospital, community health center, other medical provider, or federal or state agencies when necessary for treatment, payment, operations, or the administration of the programs listed above.

9. To the extent permitted by law, MassHealth may place a lien against any real estate owned by eligible persons or in which eligible persons have a legal interest. If property is sold, money from the sale of that property may be required to be used to repay MassHealth for medical services provided.

10. To the extent permitted by law, for any eligible person aged 56 or older, or for any eligible person for whom MassHealth helps pay for care in a nursing home, MassHealth may seek money from the eligible person's estate after death.

11. Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their household's income or employment, household size, health insurance coverage, health insurance premiums, and immigration status, or about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the change. Eligible persons can make changes by calling 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled). A change in information could affect eligibility for these persons or for persons in their household.*

12. MassHealth, the Massachusetts Health Connector, and the Health Safety Net will obtain from eligible persons’ current and former employers and health insurers all information about health insurance coverage for these persons. This includes, but is not limited to, information about policies, premiums, coinsurance, deductibles, and covered benefits that are, may be, or should have been available to these persons or members of their household.

18. MassHealth, the Massachusetts Health Connector, and the Health Safety Net may get any records or data about persons listed on this application to document medical services claimed or provided to them. We will keep such information private, and only use and disclose it in accordance with applicable law.

14. MassHealth, the Massachusetts Health Connector, and the Health Safety Net may get records or data from federal and state data sources and programs, such as the Social Security Administration, the Internal Revenue Service, the Department of Homeland Security, the Department of Revenue, and the Registry of Motor Vehicles, to prove any information given on this application and any supplements, or other information once an individual becomes amember, and to support continued eligibility. We will keep all records and data provided to us private, and only use and disclose it in accordance with applicable law.

(For renewal of coverage in future years)

15. MassHealth, the Massachusetts Health Connector, and the Health Safety Net will use income data, including information from federal tax returns, to determine eligibility. To make it easier to check income at renewal time, | may authorize MassHealth, the Massachusetts Health Connector, and the Health Safety Net to use data from federal tax returns to redetermine eligibility in future years. MassHealth, the Massachusetts Health Connector, and the Health Safety Net will use this data to the extent | authorize, and will send me a notice, let me make any changes, and allow me to opt out at any time.

On behalf of all persons applying for health coverage, |: (Check one.) {_] permit use of the data for the next five years; or

(_] permit use of the data for: (Check one.)

[CJ one year, [| two years, [_] three years, [_] four years [-] do not permit the use of federal tax data to renew eligibility for help paying for health coverage.

16. MassHealth, the Health Connector, and the Health Safety Net may send notices and share information pertaining to the eligibility, renewal of eligibility or enrollment of persons listed on this application to me and to the other persons listed on this application.

17. If lam acting on behalf of someone in filling out this application and any supplements, | have filled out and sent the enclosed Authorized Representative Designation Form with this application or have such form on record. | understand that my signature on this application and any supplements as an authorized representative certifies that the information on this application and any supplements, including those submitted with this application as well as any other forms or documents that may be submitted to or required by MassHealth, the Health Connector, the Children’s Medical Security Plan, or the Health Safety Net, is correct and complete to the best of my knowledge.

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18. If | think that MassHealth or the Health Connector has made a mistake in eligibility for me and/or other applicants, | have the right to appeal or file a grievance. If| disagree with the action taken by MassHealth or the Health Connector, | have the right to appeal and ask for a hearing before an impartial hearing officer. | can also ask for a hearing if | did not receive a notice telling me about the action that was taken. To find out how to appeal, please call 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled). | understand that | may be eligible to continue getting benefits while my appeal is being decided. | may have a lawyer or other person represent me, but | may also represent myself. MassHealth or the Health Connector will not pay for anyone to represent me. Additional information about appeals will be provided with any notices | receive, as well as during the appeal process.

19. Under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. | can file a complaint of discrimination by going to www.hhs.gov/ocr/office/file.

* You can also report changes in any of the following ways.

+ — Sign onto your account at www.MAhealthconnector.org. You can create an online account if you do not already have one. + — Send the change information to: Health Insurance Processing Center

P.O. Box 4405 Taunton, MA 02780.

* — Fax the change information to: 617-887-8770.

| certify under the penalties of perjury that:

* [have read or have had read to me the information on this application, including any supplements and instruction pages, and understand that the Member Booklet contains important information;

+ [have permission to submit this application for and receive eligibility enrollment information about all persons listed on this application and as may be allowed by any legal documents | have submitted with this application;

* — |understand my rights and responsibilities and the rights and responsibilities of all persons for whom | am submitting this application, as explained in the rights and responsibilities before this signature page;

+ |have told or will tell all persons for whom | am submitting this application about these rights and responsibilities so they also understand their rights and responsibilities;

+ |understand and agree that MassHealth and the Health Connector will treat electronic, faxed, telephonic, or copies of signatures with the same force and effect as an original signature(s);

+ The information | have supplied is correct and complete to the best of my knowledge about myself and other persons for whom | am submitting this application; and

¢ — Imay be subject to penalties under federal law if | intentionally provide false or untrue information.

xX Signature of Person 1 or authorized representative Print name Date

Important: If you are submitting this application as an authorized representative, you must submit an Authorized Representative Designation Form to us for us to process this application.

For certified application counselors, navigators, agents, and brokers only. Fill out this section if you are a certified application counselor, navigator, agent, or broker filling out this application for someone else.

First name, middle initial, last name, suffix

Organization name

Send the filled-out application to: Health Insurance Processing Center PO. Box 4405

Taunton, MA 02780 or fax to 617-887-8770.

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SUPPLEMENT A ( a icRTh Iliness, Disability, or Accommodation CONNECTOR

Part A

Ifyou answered yes to Question 20 in Parts 1 and/or 2 about you or any household member having an injury, illness, or disability that has lasted or may last for at least 12 months, answer the next three questions.

1. Does this person get money from Social Security for a disability? [_]Yes [_}No

If yes, name(s): 2. Did this person ever get Supplemental Security Income (SSI)? [_]Yes [_]No

If yes, name(s): 3. Isthis person legally blind? [“]Yes [_]No

If yes, name(s): Part B Ifyou answered yes to Question 21 in Parts 1 and/or 2 about you or any household member needing reasonable accommodation because of a disability or injury, check all that apply below, and list name(s). 1.Condition []Lowvision—Name(s): L1Blind—Name(s): [_]Deaf—Name(s): [_]Hard of hearing—Name(s): [Developmentally disabled—Name(s): [intellectually disabled—Name(s): L_JPhysically disabled—Name(s): [other (Please explain.)—Name(s): 2. Accommodation [_Trexttelephone (TTY)—Name(s): [_JLarge print publications—Name(s): [_JAmerican Sign Language interpreter—Name(s): [_JVideo Relay Service (VRS)—Name(s): [Communication Access Real-time Translations (CART)—Name(s): {Publications in Braille-Name(s): {_]Assistive listening device—Name(s): [_}Publications in electronic format—Name(s): [_Jother (Please explain.)—Name(s): Part C

If you answered yes to Question 22 in Parts 1 and/or 2 about you or any household member applying because of an accident or injury that someone else may be responsible for, answer the next two questions.

1. Did someone else cause this person's injury, illness, or disability, or could someone else's insurance or this person's own insurance, other than health insurance (like homeowner's or auto insurance) cover it? [_]Yes [_]No

Ifyes, name the injured person(s): 2. Has this person filed a lawsuit, a workers’ compensation claim, or an insurance claim for this accident or injury? [_]Yes [_]No Ifyes, name the injured person(s):

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SUPPLEMENT B ( oa ~) American Indian (Al)/Alaska Native (AN) CONNECTOR

Fill out this supplement if you or any household member is an American Indian or Alaska Native.

American Indians and Alaska Natives who enroll in MassHealth can also get services from the Indian Health Services, tribal health programs, or urban Indian health programs.

If you or any household members are American Indians or Alaska Natives, you may not have to pay premiums or copayments, and may get special monthly enrollment periods. To make sure you and your household members get the most help possible, please fill out this supplement.

AI/AN Person 1 Name: First Middleinitial Last Suffix

1. Isthis person a member of a federally recognized tribe? [_]Yes [_]No If yes, check the box that applies. [American Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [_ American Indian/Alaska Native (Other Tribal Nation)

2. Did this person ever get a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? [_]Yes [_]No

2.a. If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? [Ves [_]No

3. Certain money received may not be counted for MassHealth. List the combined income from the following sources, if applicable. + Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

+ Payments from natural resources, farming, ranching, fishing, leases or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

* — Money from selling things that have cultural significance

$ How often? [_]Weekly [_]Biweekly [—]Monthly [_]Other (Explain) AI/AN Person 2 Name: First Middle initial Last Suffix

1. Isthis persona member of a federally recognized tribe? [_]Yes [_]No If yes, check the box that applies. {_JAmerican Indian/Alaska Native (Mashpee Wampanoag) [_]American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah)) [_JAmerican Indian/Alaska Native (Other Tribal Nation)

2. Did this person ever get a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? [_]Yes [_]No 2.a. If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? [__]Yes [_]No

¢ — Money from selling things that have cultural significance

$ How often? [_]Weekly [—]Biweekly [Monthly [—]Other (Explain) ACA-2 (Rev. 01/14) 20 Go back to the application. > TN 13-0027-MM2 Attachment 1 Approval Date: 03/26/2014

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SUPPLEMENT C ( aici . Health insurance CONNECTOR

Part A: Medicare Fill out this part if any household member answered yes to having Medicare in the health insurance part (Part 4).

1. Name: Medicare claim number: When did coverage start? (mm/dd/yyyy)

1a. Does this person have a Medicare Part D plan? [_]Yes [_]No If yes, when did coverage start? (mm/dd/yyyy)

L.b. Does this person have a Medigap/Medicare supplemental policy? [_]Yes [_]No

If yes, name of coverage plan: When did coverage start? (mm/dd/yyyy) 2. Name: Medicare claim number: When did coverage start? (mm/dd/yyyy)

2.a. Does this person have a Medicare Part D plan? [__]Yes [_]No Ifyes, when did coverage start? (mm/dd/yyyy)

2.b. Does this person have a Medigap/Medicare supplemental policy? [_]Yes [_]No If yes, name of coverage plan: When did coverage start? (mm/dd/yyyy)

3.Do any of the persons above want to apply for help paying for the Medicare Part B premiums? [_]Yes [_]No If yes, name(s):

Part B: Federal health insurance benefits

Fill out this part if any household member answered yes in the health insurance part (Part 4) to having federal health insurance provided by the U.S. military (Veterans’ Affairs or TRICARE) or other federal coverage.

Name of insurance plan or policy: Policyholder name:

Names of covered household members:

Claim/policy number: When did coverage start? (mm/dd/yyyy)

Part C: Other health insurance

Fill out this part if any household member answered yes in the health insurance part (Part 4) to having any other type of health insurance.

This includes insurance through an employer, union, college or university, former employer (COBRA), and coverage bought by a household member or parent who is not living in the household.

1. Name of insurance plan or policy: Policyholder name: Date of birth: (mm/dd/yyyy)} SSN (if you know):

Names of covered household members:

Policy number: Group number (if you know): When did coverage start? (mm/dd/yyyy)

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Authorized Representative le me essences

. . HEALTH ; Designation Form CONNECTOR Commonwealth of Massachusetts i EOHHS

Note that you don’t need to fill out this form if you live in an institution and want copies of eligibility notices sent to you, and to your spouse who still lives at home. We will do that automatically.

You can choose someone to help you.

You may choose an authorized representative to help you get health care coverage through programs offered by MassHealth and the Massachusetts Health Connector. You can do this by filling out this form (the Authorized Representative Designation Form) or a sufficiently similar designation document. You can sign for yourself, and for any of your dependent children under the age of 18 for whom you are the custodial parent. You are not required to have a representative in order to apply for or receive benefits.

Who can help me?

1. An authorized representative can be a friend, family member, relative, or other person or organization of your choosing who agrees to help you. It is up to you to choose an authorized representative if you want one. Neither MassHealth nor the Massachusetts Health Connector will choose an authorized representative for you. You must designate in writing using this form (fill out Section I, Part A) the person or organization who you want to be your authorized representative. Your authorized representative must also fill out Section I, Part B.

2. If, because of a mental or physical condition, you cannot designate an authorized representative in writing, a person (not an organization) who is acting responsibly on your behalf can be your authorized representative if that person certifies, by filling out Section II, that you are not able to provide a written designation, and that he or she is acting responsibly on your behalf.

3, An authorized representative can also be someone who has been appointed by law to act on your behalf. This person must fill out Section III and either you or this person must submit to us, together with this form, a copy of the applicable legal document stating that this person is lawfully representing you.

4. A person appointed by law to act on behalf of the estate of an applicant or member who has died can also serve as an authorized representative by following the instructions above. An authorized representative under Section III may be a legal guardian, conservator, holder of power of attorney, or health care proxy, or, if the applicant or member has died, the estate’s administrator or executor. What this person is authorized to do for you or for the applicant or member's estate will depend on the wording of the legal appointment.

You must provide the authorized representative’s date of birth and an e-mail address, if he or she has one, so that we can prove his or her identity and protect your privacy.

What can an authorized representative do? An authorized representative may:

¢ fill out your application or eligibility review forms,

¢ fill out other MassHealth or Massachusetts Health Connector eligibility or enrollment forms;

* give proof of information reported on these forms;

* report changes in income, address, or other circumstances;

* get copies of all of your MassHealth and Massachusetts Health Connector eligibility and enrollment notices; and * act on your behalf in all other matters with MassHealth and the Massachusetts Health Connector.

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If you decide that you no longer want a Section I or Section II authorized representative, you must notify us at the time you want the designation to end by:

* Signing on to your account at www.MAhealthconnector.org to remove your representative from your case (you can create an account if you don’t already have one) (effective 1/1/14); * Mailing a letter notifying us that the designation has ended to:

Health Insurance Processing Center P. 0. Box 4405 Taunton, MA 02780;

* Faxing a letter notifying us that the designation has ended to (617) 887-8770; or * Calling us at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

If you mail or fax this notice to us, the notice must include your name, address, and date of birth, the name of your authorized representative, a statement that the designation has ended and your signature or, if you cannot provide written notice, the signature of someone acting on your behalf (in the case of a Section II authorized representative only).

In addition, if your authorized representative notifies us that such person or organization is no longer acting on your behalf, we will no longer recognize the person or organization as your authorized representative.

A Section II authorized representative's designation ends when his or her legal appointment ends. The authorized representative must notify us as instructed above.

In addition, an authorized representative’s designation for a minor child ends on the child’s 18" birthday.

How do | submit this form? If you are applying for health benefits, send your filled-out Authorized Representative Designation form to us with your application. If you are already getting benefits, you must submit the form to us at the time you want to designate an authorized representative by: * Signing on to your account at www.MAhealthconnector.org (you can create an account if you don’t already have one)

(effective 1/1/14);

* Mailing your form to:

Health Insurance Processing Center ee

Taunton, MA 02780;

* Faxing your form to (617) 887-8770; or * Calling us at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

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SECTION I: Authorized Representative Designation (if applicant or member is able to sign)

Part A—to be filled out by applicant or member—please print, except for signature. Please note: Your social security number (SSN) is required if one has been issued.

Applicant's/Member's Name:

SSN (if you have one): xxx/xx/xxxx Date of birth: (mm/dd/yyyy)

Applicant’s/Member’s e-mail address:

| certify that | have chosen the following person or organization to be the authorized representative for myself and any dependent children under the age of 18 for whom | am the custodial parent and that | understand the duties and responsibilities this person or organization will have (as explained earlier

in this form). Applicant’s/Member's signature: Date: Authorized Representative's Name: Authorized Representative's phone number:

Authorized Representative's Address: (mailing address, city, state, zip)

Part B:—to be filled out by authorized representative. Please print, except for signature

B1. Complete if authorized representative is a person. | certify that | will at all times maintain the confidentiality of any information regarding the applicant or member set forth above and, if applicable, the dependent children of such applicant or member, that is provided to me by MassHealth or the Massachusetts Health Connector. If |am also a provider, staff member, or volunteer affiliated with an organization, and am acting in my capacity as a provider, staff member, or volunteer in connection with my designation as an authorized representative, | certify that | will at all times adhere to all applicable state and federal laws and regulations regarding confidentiality of information and conflicts of interest including those set forth at 42 C.F.R. part 431, subpart F, 42 C.F.R. § 447.10 and 45 C.FR. § 155.260(f).

Authorized Representative's signature: Date:

Authorized Representative's printed name: Authorized Representative's date of birth: (mm/dd/yyyy)

Authorized Representative's e-mail address:

B2. Complete if authorized representative is an organization. | certify, on behalf of the organization set forth below, that such organization will at all times maintain the confidentiality of any information regarding the applicant or member set forth above and, if applicable, the dependent children of such applicant or member, that is provided to the organization by MassHealth or the Massachusetts Health Connector. |, the provider, staff member, or volunteer of the organization set forth below, completing this form, certify on behalf of myself and on behalf of the organization | represent, that any providers, staff members, or volunteers acting on behalf of the organization in connection with this authorized representative designation will at all times adhere to all applicable state and federal laws and regulations regarding confidentiality of information, and conflicts of interest, including those set forth at 42 C.F.R. part 431, subpart F, 42 C.F.R. § 447.10 and 45 C.ER. § 155.260(f).

Authorized Representative's printed name (organization):

Printed name of provider, staff member, or volunteer completing form:

Signature of provider, staff member, or volunteer completing form: Date:

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SECTION II: Authorized Representative Designation

(if applicant or member cannot provide written designation)

To be filled out by authorized representative. Please print, except for signature. Please provide a separate form for each applicant or member.

An organization is not eligible to be an authorized representative under this section.

| certify that | know enough about the applicant or member set forth below to take responsibility for the correctness of the statements made on his or her behalf during the eligibility process and in other communications with MassHealth or the Massachusetts Health Connector, that | understand my duties and responsibilities as this person's authorized representative (as explained earlier in this form), and that this person cannot provide written designation. If this person can understand, | have told the person that MassHealth and the Massachusetts Health Connector will send me a copy of all MassHealth and Health Connector eligibility and enrollment notices and this person agrees to this, and | have told this person that he or she may remove or replace me as his or her authorized representative at any time by the methods described earlier in this form.

| further certify that | will at all times maintain the confidentiality of any information regarding the applicant or member set forth below, that is provided

tome by MassHealth or the Massachusetts Health Connector.

Please note that the applicant's or member's social security number (SSN) is required-if one has been issued.

Applicant's/Member's Name:

Applicant's/Member's SSN: xxx/xx/xxxx Applicant's/Member's date of birth: (mm/dd/yyyy)

Authorized Representative’s Name:

Authorized Representative's Address: (mailing address, city, state, zip)

Authorized Representative's phone number:

Authorized Representative's date of birth: (mm/dd/yyyy)

Authorized Representative's e-mail address:

Authorized Representative's signature:

Date:

SECTION lil: Authorized Representative Designation (appointed by law)

To be filled out by an authorized representative appointed by law (as explained earlier on this form). Please print, except for signature.

Please submit a copy of the applicable legal document with this form.

| certify that | will at all times maintain the confidentiality of any information regarding the applicant or member as set forth below, that is provided to

me by MassHealth or the Massachusetts Health Connector.

Please note that the applicant's or member's social security number (SSN) is required if one has been issued.

Applicant's/Member's Name:

Applicant's/Member’s SSN: xxx/xx/Xxxx Applicant's/Member's date of birth: (mm/dd/yyyy)

Authorized Representative's Name:

Authorized Representative's Address: (mailing address, city, state, zip)

Authorized Representative's phone number:

Authorized Representative's date of birth: (mm/dd/yyyy)

Authorized Representative's e-mail address:

Authorized Representative's signature:

Date:

ARD (Rev. 01/14)

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1.1 My Appeals

My Appeals

IMPORTANT: This Form Cannot Be Used to Appeal Your MassHealth Decision

You cannot use this online form to appeal your MassHealth decision. If you would like to appeal your

MassHealth decision, you must use the form that came in the mail with your MassHeaith letter, For more information about appealing your MassHeaith decision, please call the MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997). .

if you are trying to update your account, correct a mistake you made in your application, have a problem with enroliment, or have a problem with billing, you should contact the Health Connector’s Customer Service at 1-877-MA-ENROLL (1-877-623-6765). Customer Service can help you with the following:

If you disagree with the action taken by the Massachusetts Health Connector, you have the right to appeal and ask for a hearing before an impartial hearing officer. Issues thet may be addressed through an appeal include:

© Whether you qualify to shop for heaith insurance through the Health Connector, based on © Your residency © Your incarceration status © Your citizenship/immigration status © Whether you qualify for subsidies to help you pay for insurance or the amount of subsidies you qualify for, based on ¢ Income © Family size ® Access to other insurance © Whether you qualify for other benefits because of your American indian status * Failure of the Health Connector to give you timely notice of its action or its failure to take action on you request © Denial of a Financial Hardship Walver or Reduction of Premium Application in most cases, if you would like to appeal an action by the Health Connector, you must submit your appeal request within 30 days from the day you receive notice of the action.

Need more information about submitting an appeal online to the Health Connector. You may also send in the paper appeal request form that you received with the notice you are appealing.

Type Content Functions Mandatory Possible (¥/N/NA) Validation Static IMPORTANT: This Form Cannot Be Used

to Appeal Your MassHealth Decision

You cannot use this online form to appeal your MassHealth decision. If you would like to appeal your MassHealth decision, you must use the form that came in the

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Start your Application: Begin Process

Learn More

Manage Customer Create Customer

My Account Profile

G BS CONNECTOR he ra place for Bre ght pian

Application Year 2015

Start Your Application: Begin Process

You will be asked In this application if you are interested in getting help paying for heaith coverage. if you are hot interested in getting help paying for coverage, you will not need to answer any questions about your Income,

However, if you would like to see if you can qualify for help, we will ask you a number of questions about your household, your income, and other things that will help us find the best programs and plans for you.

Ifyou are already enrolled in MassHealth, and you still qualify, you may not qualify for additional benefits ‘through the Massachusetts Health Connector.

Ifyou currently are receiving Medicare or are 65 or older and low-income, you may also apply for additional benefits through www.mass.gov/MassHealth.

‘Notice of Consent and Authorization

f You want to use the Massachusetts Health Insurance Exchange (HIX) application service to apply for health benefits and/or health plans such as Advance Premium Tax Credits, Health Connector plans, ConnectorCare, MassHealth, Health Safety Net, Children’s Medical Security Plan, and premium subsidies from the Massachusetts Health Connector for yourself and/or members of your household.

Eom >

To complete this application and obtain initial determinations of eligibility, you must provide personal information about everyone In your household who Is applying. If you are applying for subsidized health benefits you will also have to provide health, health-coverage, and Income information about you and everyone in your household who Is applying. You may have to. provide information about others if their information will affect the eligibility ofthe applicants. We may verify the accuracy of such information using various government and private sources including. ‘our electronic databases as well asthed databases of the Department of Homeland

fet ancltne Secial Gactussin. seach ~

View Privacy Act Statement

‘ ()*! hereby certify under the pains and penalties that | have the authority and consent described above and will, if necessary, perform the actions described above.

SPecAAACCCHPOCRAALOSECLCSEECLSRDSEALEOGEHOLEFEPOREAOAOCHIEEOESCAPVERIDEEETAOESRSESIEES SESE VEDEAELELIELLESLESESCELEUIEESYSEAEEDAISNGEDSIADEAGABEAAERSGOLIEY AAS

Contact | Accessiblity statement

Q OPTUM" Page 1

Confidential and proprietary | Use pursuant to company instructions | Optum

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Type Content Functions Mandatory (Y/N/NA) Possible Validation

To complete this application and obtain initial determinations of eligibility, you must provide personal information about everyone in your household who is applying. If you are applying for subsidized health benefits you will also have to provide health, health-coverage, and income information about you and everyone in your household who is applying. You may have to provide information about others if their information will affect the eligibility of the applicants. We may verify the accuracy of such information using various government and private sources including our electronic databases as well as the databases of the Department of Homeland Security and the Social Security Administration. Household members who do not want coverage will not be asked questions about citizenship or immigration status.

If you are applying for subsidized health benefits we may also verify the accuracy of such information by using the databases of the Internal Revenue Service and the Massachusetts Department of Revenue. If the information does not match, we may ask you to send us proof of your circumstances. We also will be automatically redetermining eligibility and may check your information at a later time to make sure your information is up to date. We will notify you if something has changed.

We will keep the information provided to us private and only use and disclose it in accordance with applicable law.

To proceed, you must give us certifications about your authority to complete the application and eligibility process on behalf of those individuals applying for benefits, and if applicable, your authority to provide and see information about others.

If applying for benefits for 1) yourself, 2) your own minor child or children, and/or 3) any minor or incapacitated person for whom you are either the legal guardian or for whom you have sufficient information to act responsibly on their behalf, then by electronically signing below, you will be certifying under penalty of perjury that you consent to the use of government and private sources to verify information about you and any such minor child and incapacitated person.

If applying for benefits on behalf of anyone else other than those described above, then by electronically signing below, you also will be certifying under penalty of perjury that you have consent and authorization from such individuals or, if applicable, their parent, guardian, or other legally authorized representative, to act on their behalf to complete this application and any ongoing or subsequent eligibility process and activity, including as examples:

. providing personal information about them, and seeing such information as may be provided by us;

° making choices about coverage options and methods of communication with us

° making changes to the application or related eligibility documents;

° completing and making changes to renewal forms and related documents

. providing information about any change in their circumstances;

. providing consent on their behalf to use government and private sources to verify information provided in

this application and related documents and as may be necessary for continued eligibility; and

° if applying for subsidized health benefits, providing health, health-coverage, and income information about them, and seeing such information as may be provided by us.

4 OPTUM” Page 3

Confidential and proprietary | Use pursuant to company instructions | Optum

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Type Content Functions Mandatory (Y/N/NA) Possible Validation

By signing electronically below, you also certify under penalty of perjury that

. you have the authorization of all individuals (or their authorized representatives) not seeking coverage but whose information is necessary for eligibility determinations for others on this application to see and provide their personal information to us and consent to the use of private and government sources to verify such information;

. if applying for subsidized health benefits you also have the authorization of all individuals (or their authorized representatives) not seeking coverage but whose income information is necessary for eligibility determinations for others on this application to see and provide their income information to us and consent to the use of private and government sources to verify such information;

° you have obtained sufficient information from all individuals for whom you are submitting this application or if applicable, from their parent or legally authorized representative, to act responsibly and provide accurate information in completing the application and other related eligibility documents and forms;

. you have informed, or will inform as soon as possible, all adults in your household and the parent or legal guardian of any minor who is not your child about their rights and responsibilities as set forth in this application; and

. you are either:

e over eighteen years of age; or © younger than eighteen years of age and applying on behalf of yourself and/or your minor child.

Link View Privacy Act Statement Active link to Health Connector Privacy Statement — link out to mahealthconnec tor.org

MassHealth Privacy Statement:

http://www.mas s.gov/eohhs/gov /laws- regs/privacy- security/masshe alth/member- information/noti ce-of-privacy-

QQ optum Page 4

Confidential and proprietary | Use pursuant to company instructions | Optum

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Type Content Functions Mandatory Possible (¥/N/NA) Validation Security benefits, rental income, income from a job, income from a pension, and unemployment benefits. You don’t need to include child support or Supplemental Security Income (SSI). Dynamic Based on the information you entered | Response to here, it looks like you may be able to | question “Based on qualify for help paying for health your best guess, do coverage. you expect your total household To begin the application and see income to be less which programs you qualify for, than $_in the year change your selection to ‘Yes’ on the | you want health question above this tool. insurance?” Only shown if radio button is “Yes” Based on what you told us, your Response to income may be too high to get help question “Based on paying for health insurance. You may | your best guess, do still want to answer ‘Yes’ to the you expect your question above this tool if you want total household to find out for sure whether you can income to be less get help with costs. If you answer ‘No’ | than $_ in the year you will have fewer questions to you want health answer but you definitely won’t be insurance?” able to get help paying for coverage. Only shown if radio button is “No” Based on the information you entered | Response to here, it looks like you may be able to question “Based on qualify for help paying for health your best guess, do coverage. you expect your total household To begin the application and see income to be less which programs you can qualify for, | than $_ in the year choose ‘Yes’ on the question above you want health this tool. insurance?” Only shown if radio button is “t do not know” Button Save and Continue Only shown if Yes

or No are selected to the question “Do you want to find out if you can

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Egas Wahs - Citizenship/Immigration Status

More information on immigration Document Types

Federal services are unable to verify your citizenship/immigration status at this time. Please choose an immigration status from the list below that best represents you so that we can provide you with benefits. You may also be asked to provide supporting documentation. if you do not have one of the eligible immigration statuses listed below, use the Back button to go back to the last page to review and correct your answers. *

@Amerasian

@Granted asylum

@Cuban Haitian entrant

@Deportation Withheld

®Native Americans born in Canada or non U.S. territories

®Refugee

@vVictim of severe trafficking or his or her spouse, child, sibling or parent.

®lraqi Special immigrant

@Afghan Special immigrant

@eteran or active duty member of military or his/her spouse or dependent

@Lewful permanent resident

| Grented parole for at least one year

@Battered spouse or child (or his or her parent or child)

®Non-immigrant status (visa)

@Granted parole for less than one year

©Granted temporary resident status

©Granted Temporary Protected Status (TPS ) or applicant for TPS with employment authorization @Granted employment authorization under 8 CRF 274a(12Xc)

Family Unity beneficiaries

@Deferred Enforced Departure

@©Deferred Action Status except for Deferred Action for Childhood Arrivals Process (DACA) @Granted an administrative stay of removal under 8 CFR 241

Approved visa petition with a pending application for adjustment of status

@Applicant for asylum or for withholding of removal with employment authorization @Applicant (for at least 180 days) under age 14 for asylum or withholding of removal @Granted Withholding of Removal under the Convention Against Torture

@Applicant for Special immigrant Juvenile status

@Applicant or granted status under Deferred Action for Childhood Arrivals (DACA)

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Content Functions Mandatory Possible (¥/N/NA) Validation

Rights and Responsibilities NA

Read and check the box next to each NA

statement if you agree.

Checkbox This application will be used to determine Checkbox

eligibility for subsidized health care Selection including MassHealth and Premium Tax Credits and state premium subsidies administered through the Commonwealth of Massachusetts. This application will also be used to determine eligibility for Health Safety Net.

On behalf of myself and all persons listed on this application | understand, represent and agree as follows:

MassHealth may require eligible persons to enroll in available employer-sponsored health insurance if that insurance meets the criteria for MassHealth payment of premium assistance.

Employers of eligible persons may be notified and billed in accordance with MassHealth regulations for any services hospitals or community center provide to such persons that are paid for by the Health Safety Net.

I may have to pay a premium for health coverage for myself and others on this application. Failure to pay any premium due may result in the State deducting the amount owed from the tax refunds of responsible persons. If | am a certain American Indian or Alaskan Native, | may not have to pay premiums for MassHealth.

MassHealth has the right to pursue and get money from third parties who may be obligated to pay for health services provided to eligible persons enrolled in MassHealth programs. Such third parties may include other health insurers, spouses or parents obligated to pay for medical support, or individuals obligated to pay under accident settlements. Eligible persons must cooperate with MassHealth in establishing third party support and obtaining third-party payments for themselves and anyone whose rights they can legally assign. Eligible persons may be exempted from this obligation if they believe and tell MassHealth that cooperation could result in harm to them or anyone whose rights they can legally assign.

A parent and/or guardian of minor children must agree to cooperate with state efforts to collect medical support from an absent parent unless they believe and tell MassHealth that cooperation will harm the children or the parent or guardian.

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Type

Content Functions Mandatory Possible (¥/N/NA) Validation

10.

11.

12.

13.

Eligible persons who are injured in an accident, or some other way, and get money from a third party because of that accident or injury must use that money to repay MassHealth or the Health Safety Net for certain services provided.

Eligible persons must tell MassHealth or the Health Safety Net, in writing, within 10 calendar days, or as soon as possible, about any insurance claims or lawsuit filed because of an accident or injury.

The status of this application may be shared with a hospital, community health center, other medical provider or federal or state agencies when necessary for treatment, payment, operations or the administration of the programs listed above.

To the extent permitted by law, MassHealth may place a lien against any real estate owned by eligible persons or in which eligible persons have a legal interest. If MassHealth puts a lien against such property and it is sold, money from the sale of that property may be used to repay MassHealth for medical services provided.

To the extent permitted by law, for any eligible person age 55 or older, or any eligible person for whom MassHealth helps:pay for care in a nursing home, MassHealth may seek money from the eligible person’s estate after death.

Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their family's income or employment, family size, health-insurance coverage, health-insurance premiums, and immigration status, or about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the change. Eligible persons who enroll through mahealthconnector.org can make changes by calling 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled). A change in information could affect eligibility for such persons or for persons in their household.

MassHealth, the Massachusetts Health Connector, and the Health Safety Net will obtain from eligible persons’ current and former employers and health insurers all information about health-insurance coverage for such persons. This includes, but is not limited to, information about policies, premiums, co- insurance, deductibles, and covered benefits that are, may be, or should have been available to such persons or members of their household.

MassHealth, the Massachusetts Health Connector and the Health Safety Net may get records or data about persons listed on this application from federal and state data sources and programs, such as the Social Security Administration, the Internal Revenue Service, the Department of Homeland Security, the Department of Revenue, and the Registry of Motor Vehicles, as well as private data sources, 1) to prove any information given on this application and any supplements, or other information given once a person becomes a member, 2) to document medical services claimed or provided to such persons, and 3) to support continued eligibility.

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Type Content Functions Mandatory Possible (Y/N/NA) Validation

14. In connection with the eligibility and enrollment process, MassHealth, the Massachusetts Health Connector, and the Health Safety Net may send notices that contain personal information about persons listed on this application to other persons on this application, or otherwise communicate such information to such persons.

15. Under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. | can file a complaint of discrimination by going to www.hhs.gov/ocr/office/file.

Checkbox To make it easier to determine my eligibility | Checkbox for help paying for health coverage in future | Selection years, | agree to allow the Massachusetts Health Connector to use Income data, including information from tax returns for the next three coverage years. The Massachusetts Health Connector will send me a notice and let me make changes. I understand that if | am eligible for an Advance Premium Tax Credit (APTC) and/or Reduced Co-pays and Deductibles these payments will be made directly to my selected insurance carrier(s). Acceptance of APTC and/or Reduced Co-pays and Deductibles may impact my tax liability for this year. | will be given the option to apply all, some, or none of any APTC amount | may be eligible for to my monthly premium.

Checkbox No one applying for health insurance on Checkbox (if this application is in prison or in jail. checked, “Who is in prison...?” will be hidden)

Tooltip In prison or in jail applies to an individual Action: Show

under the supervision of the criminal justice | on Mouseover; system, who has been convicted of a crime, | Hide on Mouse and is housed in a jail, prison or other penal | Off

institution. The individual is generally known as an inmate or offender. Specific examples include: an individual who is serving time in a jail or prison and an individual who is housed in a community corrections center or “half-way house.”

Keyboard: Tab

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4 Rights and Responsibilities (for applicants not applying for subsidies)

‘VStar Your Aocdeation Rights and Responsibilities ‘Family & Household Read and check the box next to each statement if you agree. ‘VW Adéitional Questions, yrs gon wil be used to determine eighty for: health care through the Gi ith of 4 Review & Sign

[F)"0 ove applying for heath insurance on this application is in prison or in jal. > & ‘Who Is in prison or in jail? frye Pashia

aa] 1. The Massachusetts Health Connector may gat sny records or data to prove any information given on this apptication and any or other (give once | am a ‘and to support eighty. 2. You have permission to submit this application for health insurance benefits for all adults and all minor chikiren sted on | this application, according to the statements on the Consent & Authorization page atthe beginning of this application. i and as allowed by any legal you have ‘with this. 3. You understand your rights and responsibaities and the rights and responsibilities of all persons for whom you are ‘submitting this application, as explained on this signature page; 4. You have of will tell such parsons about such rights and responsibiéties and the other individuals for whom you are signing also understand thelr rights and responsibiities;

5. You understand and agree that the Health wil treat and faxed or copies of signatures with the seme force and effect as an original signatures):

0. The information you have supped is comect and complate to the best of your knowledge about yourself and other members of your household; and

7. You may be subject to penalties under federal law if you intentionally provide false or untrue information.

By signing in this box, | hereby certify under the pains and penalties of pedury that the submissions | have made in this } are true and to the best of my and } agree to accept and comply with the above Rights and Responsibiities.

{[Etecronic ‘Signature

Voter Registration

Bo you or anyone alse in your application want to ragister to vote?

Yes ENo

‘Your decision whether or not to register to vote has no effect on your gatting health coverage.

{The forms to register to vote are found here:

Massachusetts Mail-in Voter Registration form (PDF) - Engish

Formulario de inscripeiin de votante por corres oficial de Uassachusetts (PDF) - Spanish i

‘The Massachusetts Secretary of State's Elections Division has more information on how to register to vote. If you have any ‘questions about the voter registration process, or if you nend help {ling out the form, please call MassHealth Customer Service i at 1-800-841-2900 (TTY: 1-200-497-4048 for people who are deaf, hard of hearing, or speech disabled).

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2015 Eligibility Results

We automatically made the changes that you reported for 2015 to your 2016 application. Your 2016 application is used to determine which Health Connector plans and programs you qualify for in 2016. Ifyou want to change your application information for 2016, click here.

To begin shopping for Heatth Connector plans, click the “Find a Plan for 2015" button below. .

Please note: Make sure you understand who can qualify as an eligible dependent in your tex household before you enroll in a health or dental family plan. A list of eligible dependents can be found in the Health Connector policy on Dependent Eligibility(NG-3A). If you buy a plan as a family and include people who do not qualify as a dependent, your insurance carrier could reject your enroliment and retroactively cancel your coverage.

Household[1]- Application Resuit FPL: 207.18

This household also qualifies for a tax credit (Advance Premium Tax Credit) to help lower monthly health coverage costs, Maximum monthly tax credit amount: $ 22 .

NAME PROGRAMS ELIGIBLE FOR DOCUMENTS REQUIRED EGAS ConnectorCare Plans Type 3A(Advance Premium Tax Proof of Residency WAHS Credit plus Massachusetts state subsidy) @ Proof of Immigration Status

Proof of Income

CHILD MassHealth Children's Health Insurance Program Proof of US. Citizenship

WAHS (CHIP) (MassHeaith Family Assistance) ® Status Proof of American

Indian/Alaska Native Status

SPOUSE Not Eligibleg : WAHS

Congratulations, Based on your MassHealth Income (FPL), you or some of your household members have been approved for coverage through MassHealth. Your MassHealth FPL maybe different than the Household FPL displayed on this page. You will get a letter from MassHealth in the next 3-5 days with more information about your coverage, including the coverage start date. You may also go to the MassHeaith website for more information.

[tis not an open enrollment period right now. But, you may still be able to shop if you experienced certain qualifying life events. If you experienced 8 qualifying event, you can have a special enroliment period to pick a plan. If the system was unable to verify your qualifying event, you may need to send us proof. Please see below to find out if you are able to shop and if you need to send us anything.

Your household Is ellginie for Special Enroliment Period:

You qualify to enroll in a new or different health insurance plan until 12/15/2015 .if you would like to enroll in new or different coverage, you must choose a plan and pay the first monthly premium before coverage can start.

Date Submitted = 10/16/2015

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Required Documents

if the system was not able to verify your information during your application, you may be required to submit documentation to confirm your eligibility results. In the table above, the type of documentation that fs required is shown next to each household member's eligibility results under “Documents Required’.Based on the type of document(s) required for each member, you will need to mail or fax in documentation of each type shown.

The following table lists the documents that may be submitted in order to verify a members eligibility.

Carefully review the list of accepted types of documentation below. In most cases, only one document from each category is needed, but there are some that may require more than one document. If you have! questions about the requested documents, please contact us at 1-877-MA-ENROLL (1-877-622-6765), TTY: 1-877-623-7772 or 1-800-841-2900, TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled.

Document

Category Document Type

Proof of . copy of deed and record of most recent t morgage payment (if mortgage i is paid Residency in full, provide a copy of property tax bill from the most recent year)

= Copy of lease and record of most recent rent payment

= Mortgage deed showing primary residence

= Nursery school or daycare records (if school is private, additional documentation may be requested)

® Current utility bill or work order dated within the past 60 days

= Statement from a homeless shelter

® School records (if school is private, additional documentation may be requested)

™ Section 8 agreement

= Homeowner's insurance agreement

™ Proof of enrollment of custodial dependent in public school

® Notarized affidavit supporting residency

Type Content Functions Mandatory Possible (Y/N/NA) Validation

Static Results NA Button <Printer Image> Print results page Static To begin shopping for Health Link to policy:

Connector plans, click the “Find a Plan”

button below. https://www.mahealthe

onnector.org/wp- Please note: Make sure you understand | content/uploads/policie who can qualify as an eligible $2014/Policy_NG_3A.pdf

dependent in your tax household before you enroll in a health or dental family plan. A list of eligible dependents can be found in the Health Connector policy on Dependent Eligibility (NG-3A). If you buy a plan as a family and include people

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Type Content Functions Mandatory Possible (Y/N/NA) Validation who do not qualify as a dependent, your insurance carrier could reject your enrollment and retroactively cancel your coverage. Static Household [1] — Application Result Displays for each household Dynamic FPL: Static This household also qualifies for a tax Display if household credit (Advance Premium Tax Credit) to | qualifies for APTC help lower monthly health coverage costs. Maximum monthly tax credit amount: $<APTC Amount> Static NAME; PROGRAMS ELIGIBLE FOR; Household member DOCUMENTS REQUIRED; First Name name is dynamic text Last Name Programs Eligible For is dynamic text Documents Required is dynamic text Static Text Congratulations. Based on your Displayed ONLY if a

MassHealth Income (FPL), you or some of your household members have been approved for coverage through MassHealth. Your MassHealth FPL maybe different than the Household FPL displayed on this page. You will get a letter from MassHealth in the next 3-5 days with more information about your coverage. You may also go to

member of the household is eligible for MassHealth

Link to MassHealth member booklet: http://www.mass.gov /eohhs/gov/departme nts/masshealth/applic ations-and-member-

the MassHealth website for more forms.html information. If you or some of your household members are disabled Text at the end, (and have not been determined starting with “if you or eligible for MassHealth Standard or | come of your CommonHealth), you (or they) may | pousehold be eligible for MassHealth but your | members...” was application requires additional added through CR-988 processing. While MassHealth is (R6.0) processing your application, you have been determined eligible for the following coverage. You will be receiving a letter from MassHealth explaining any additional next steps you need to take. Click here to find

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State: Massachusetts

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3 Find a Health Plan

Find a Health Plan

‘The monthly premium shown below has been reduced by an Advance Premium Tax Credit of 372°. You are eligible for an Advance Premium Tax Credit of up to $22. For individuals eligible for Catastrophic Health Plans, premium amounts do not reflect any Advance Premium Tax Credits as Catastrophic Health Plans are not eligible

‘to recelve tax credits, Change Tax Credic @

Plan Quick Filters | conaweosien | &y Find a Provider [Sor by- Be Use the filters below to narrow your = plen search results. nn (5) ED - +50fS Monthly Premium @ S78 To $155. MONTHLY ANNUAL EST. OUT-OF- PREMIUM CARRIER DETAILS PLAN DETAILS DEDUCTIBLES POCKET COSTS —_ INCLUDED BENEFITS sano 0500 (oman teecttsotuimuasnarnysetneeusinesees intent tnancaetinananmeeee ee sva Tersgtetiyie ‘Tues Health Direct Individual indtviguat Stiver so $1500.00 Gum ° meeene Femily Family Selectto 8 Not Applicable $3,000.07 Annual Deductible (Per Person) : compare e i 00 100 $09.00 — BMC Plan- a= nals ne Sera soe 51,500. Preferred Drug List so ow =| EE recorsven Fam Fer Selectto Not Appticable $3,000.90 compare 5109, & MyDoc HMO Silver individual Individual Annual Deductible (Per Family) re Basic soe $1,500. $ ¢ i |

Find a Health Plan

The monthly premium shown below has been reduced by an Advance Premium Tax Credit of s22™ . You are eligible for an Advance Premium Tax Credit of up to $22.. For individuals eligible for Catastrophic Health Plans, premium amounts do not reflect any Advance Premium Tax Credits as Catastrophic Health Plans are not eligible to receive tax credits. Change Tax Credit @

& Find a Provider Sort By-

Sort By- evious Monthly Premium - Low to High Annual Deductible - High to Low Plans Annual Deductible - Low to High 1-50f5 DB] Type Content Functions Mandatory Possible (Y/N/NA) Validation TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

State: Massachusetts

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7 Enroll Enroll

Read the User Agreement and add your signature to submit your application.

TERMS AND CONDITIONS OF ENROLLMENT AGREEMENT

You have applied for a medical or dental insurance plan ("Plan") offered through the Commonwealth Health insurance Connector Authority ("Connector"). The Connector is responsible for enrolling you, billing and collecting premiums from you, sending your premiums to the Plan in which you enroll, and, when appropriate, terminating your coverage. When we use the word "Connector" in this Agreement, it means the Connector or its Agents, Designees or subcontractors.

BY APPLYING FOR AND ENROLLING IN A PLAN THROUGH THE CONNECTOR, | UNDERSTAND AND AGREE TO, ON BEHALF OF MYSELF AND MY ENROLLED DEPENDENTS, THE FOLLOWING TERMS AND CONDITIONS:

1. Eligibility.

My dependents and I are eligible to purchase insurance under state and federal law and Connector policies. 2. Termination of Current Health Plan.

If am currently enrolled in a Health Connector Plan, my enrollment in this new Plan indicates my request for the termination of my previous health plan. t will not have an overlap of health plan coverage through the Connector. 3. Enrollment Requirements. i

a. My enrollment in a Plan is subject to acceptance by the Issuer.

' b. My coverage in a Plan will begin on the first day of the calendar month selected for coverage if all documentation and payments are received by the required due date. This is called my “Effective Date".

c. If requested, ! will give the Connector complete information and documentation to establish my dependents’ and my own eligibility, including, but not limited to, proof of residency, citizenship, or incarceration status. If! fail to comply with the request(s), the Connector may not be required to issue a Plan to me. ! will promptly notify the Connector of any changes to my address or citizenship or residency status, and, if! am receiving any federal or state subsidies, any changes in income or access to other health insurance. | attest that { will enroll in a plan only with my eligible dependents, in accordance with Connector policy and state law. My dependents eligible to enroll with me may or may not be part of my tax household.

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4, Plan Selection.

a. 1 am free to select among any of the Plans offered by the Connector as long as ! meet the eligibility requirements for enrolling in that Plan.

b. Each Plan has its own written description of the benefits, terms and conditions that will apply to people enrolled in that Plan. This description is in a booklet usually called an "Evidence of Coverage". When | am accepted for enrollment in a Plan, my coverage will be provided according to all the terms and conditions of that Plan's Evidence of Coverage. The Issuer and not the Connector will:

i. provide me with an Evidence of Coverage; and li. provide me coverage for medical or dental benefits according to that Evidence of Coverage. 5. Coverage Period.

a. For Platinum/Gold/Silver/Bronze Health Plans and ConnectorCare Plans. i. My coverage will end on December 31, 2015.

i, Once my coverage Is effective, I cannot change to a different Plan outside of the open enrollment periods, as defined by state or federal law, unless an exception

’ applies or I experience a triggering event in accordance with state and federal law.

iii. If | become eligible for employer-sponsored coverage through the Connector, | may switch to that Plan regardless of the date.

b. For Catastrophic Plans.

1 My coverage will end December 31, 2015.

ii. If my 30th birthday occurs prior to the coverage end date and | do not have a Certificate of Exemption granted on the basis of financial hardship or a lack of affordable coverage available to me, | may remain in the Catastrophic Plan until my renewal date, be disenrolled at the end of my pian year, or be offered an Individual/family non group plan prior to my termination date.

ili. Once fam enrolled, ! cannot change to a different Catastrophic Plan, except as permitted by state or federal law and Connector policies.

iv. If | become eligible for employer-sponsored coverage through the Connector, | may switch to that plan regardless of the coverage end date. c. For Dental Plans

i. My coverage will last twelve (12) months from the date of enrollment.

ii. ff | become eligible for employer-sponsored coverage through the Connector, | may switch to that Plan regardless of the date. |

ili. | understand that if | cancel coverage, | may not be able to repurchase a dental plan i through the Health Connector for a period of time, depending on my Plan Issuer's i policies.

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8. Cancellation and Termination.

a. | may cancel my coverage at any time by notifying the Connector at least two business days in advance by phone, fax, email, or regular mail. My coverage will end on the last day of the calendar month in which | notify the Connector. | am not permitted to cancel my coverage retroactively (back in time). If! cancel my coverage, | am responsible for paying the premiums up until the effective date of my cancellation.

b. For persons receiving non-subsidized coverage, if the Connector does not receive my full premium by the due date indicated in the Notice of Delinquency, then the coverage is terminated on the day following that date when my account is two months past due. The coverage end date is retroactive to the last day of the coverage month for which my monthly premium was paid in full in accordance with Connector policies.

For subsidized coverage (receiving any state or federal subsidies), if the Connector does not receive my full premium by the due date indicated in the Notice of Delinquency, then the coverage is terminated on the day following that date. The coverage end date is retroactive to the last day of the first coverage month in which | was delinquent (i.e. one month grace period) in accordance with Connector policies.

if my coverage is terminated, | may be entitled to have my coverage reinstated with the same Plan and Issuer if my coverage has not lapsed for more than thirty (30) days from the termination date. To do so, | must pay all overdue premiums, the current month's premium, and any fees, if applicable, including charges due to insufficient funds, wire transfer fees, and reinstatement fees.

c. The Connector may cancel my Pian if:

i. ! failto pay my premiums; ii | commit fraud; iii, | misrepresent my dependents’ or my eligibility for the Plan or specific benefits of the Plan; iv. | misrepresent any information relevant to my enrollment in the Plan; v. | fail to comply in a material manner with the Plan requirements, including, but not limited to, by moving outside of the Carrier's service area; or vi. My mail is returned as undeliverable and I do not confirm my correct address with the Health Connector. The Connector will provide written notice of the effective date of the Plan’s cancellation and | will be responsible for the cost of any medical care services that I or my dependents receive after that date.

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By signing this agreement, you are also agreeing to the following statements:

You understand that because advance payments of the premium tax credit will be paid on your behalf to reduce the cost of health coverage for yourself and/or your dependents:

e You must file a federal income tax return in 2016 for the tax year 2015.

You also expect that: © No one else will be able to claim you as a dependent on their 2015 federal income tax return. © You will claim a personal exemption deduction on your 2015 federal income tax return for any individual listed on this application as a dependent who Is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments.

if any of your information changes, you understand that it may impact your ability to get an Advance Premium Tax Credit. You also understand that when you file your 2015 federal income tax return, you must reconcile the amount of advance payments actually made with the amount of any | premium tax credit you are entitled to receive. You understand that if the amount of the advance payments made on your behalfis less than the amount of any premium tax credit you are entitled to receive, you may be entitled to an additional credit amount. Alternatively, ifthe amount of advance payments made on your behalf exceeds the amount of any credit you are entitled to receive, you may owe additional federal income tax.

You understand that failure to make the first premium payment towards your policy to the Massachusetts Health Connector could result in a delay in the start of your plan or cancellation of your enrollment. {

You understand that providing this payment information does not guarantee approval or coverage. The Health Connector must process your enrollment request. Please contact the Massachusetts Health Connector if you have any questions or concerns.

(41 have read and agreed to terms and services.

* Head of Household E-Signature

Date Submitted : 10/16/2015 Previous Type Content Functions Mandatory Possible (¥/N/NA) Validation Static Enroll TN 13-0027-MM2 Attachment 3 Approval Date: 11/09/2015

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Medicaid Eligibility

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

Non-Financial Eligibility Citizenship and Non-Citizen Eligibility ee)

1902(a)(46)(B)

8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4)

42 CFR 435.4

42 CFR 435.406

42 CFR 435.956

Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42

CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status.

[B] The state provides Medicaid eligibility to otherwise eligible individuals: [B) Who are citizens or nationals of the United States; and

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity {H] Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or

a satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process.

@ Yes (No

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual.

@ Yes CNo The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status. @ The date the reasonable opportunity notice is sent.

C Other date, as described:

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OFFICIAL

Medicaid Eligibility

The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613).

@ Yes C No

The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act.

@ Yes (No [X} Pregnant women KX] Individuals under age 21: @ Individuals under age 21 C Individuals under age 20 C Individuals under age 19

a An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan.

{@) An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. Is a non-citizen who belongs to one of the following classes: {@) Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively;

Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

Granted employment authorization under 8 CFR 274a.12(c); Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; Under Deferred Enforced Departure (DED) in accordance with a decision made by the President;

Granted Deferred Action status;

He @ ee @

Granted an administrative stay of removal under 8 CFR 241; {m) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who -

{@] Has been granted employment authorization; or

[Bi] Is under the age of 14 and has had an application pending for at least 180 days;

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OFFICIAL

Medicaid Eligibility

6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b));

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

(J Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN:

[BH] Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613;

im Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b).

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Medicaid Eligibility

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

42 CFR 435.1110

One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision.

@ Yes (No

The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: [Ml A qualified hospital is a hospital that:

Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of [li its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures.

Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance

[ with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency.

Assists individuals in completing and submitting the full application and understanding any documentation requirements.

@ Yes (No

[lM] The eligibility groups or populations for which hospitals determine eligibility presumptively are:

[Mi] Pregnant Women

[M] Infants and Children under Age 19

{M Parents and Other Caretaker Relatives

[M] Adult Group, if covered by the state

[Mf] Individuals above 133% FPL under Age 65, if covered by the state

{M] Individuals Eligible for Family Planning Services, if covered by the state

[i] Former Foster Care Children

[ll] Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state

(J Other Family/Adult groups:

(Z Eligibility groups for individuals age 65 and over

(1 Eligibility groups for individuals who are blind

([] Eligibility groups for individuals with disabilities

{X] Other Medicaid state plan eligibility groups

Describe: {Reasonable Classification of Individuals Under 21

Demonstration populations covered under section 1115

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Medicaid Eligibility OFFICIAL

Describe: [individuals who are HIV positive and individuals with Breast and Cervical Cancer

The state establishes standards for qualified hospitals making presumptive eligibility determinations. @Yes (CNo

Select one or both:

The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular ~ application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period.

Description of standards: |MassHealth expects to set this standard at 75%

‘The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the S submission of an application before the end of the presumptive eligibility period.

In the initial phase of implementation, EOHHS will monitor all participating hospitals to assess

Description of standards: . . PI the average rate of success and will formulate a measure based on this assessment.

[Ml] The presumptive period begins on the date the determination is made. [Ml] The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[] Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year.

C No more than one period within two calendar years.

= No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

C Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. C Yes @ No [li The presumptive eligibility determination is based on the following factors: The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is [Ml being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements

specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group)

ry Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group.

State residency

Citizenship, status as a national, or satisfactory immigration status

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: PE Overview HPE Interim Application Process

Future plans are for hospitals to access the HPE application via the HIX. Until that time, the following HPE Interim Process will be used: * Hospitals will use a PDF-fillable version of the short-form HPE application provided by MassHealth to determine eligibility and then fax the information to MassHealth. * An HPE unit at MassHealth will receive HPE applications. * MassHealth will enter Hospitals’ HPE determinations directly into MA21 (MassHealth Legacy System). » Providers (including hospitals) will be able to view eligibility in My Account Page* (MAP) and EVS the next business day. * HPE Approval/Denial notices will be provided to the applicant by the hospital. « If approved, MassHealth will send an approval confirmation letter to the applicant.

* Reminder: Certain cases, such as individuals reporting HIV or that have no SSN, do not display in MAP. Check EVS for eligibility information.

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~HPE Overview —

How the HPE Process Works

* An individual seeks health care coverage at an HPE-Qualified hospital, outpatient department or satellite clinic.

* An HPE-trained CAC assists applicants and completes one HPE application per individual (i.e. not per household)

* AnHPE-trained CAC helps the hospital determine HPE eligibility and coverage type*. Hospitals may not delegate the actual HPE determination to an HPE-trained CAC who is a contractor, rather than employee, of the hospital.

* Approved individuals receive MassHealth coverage effective immediately, for a limited amount of time.

° An HPE-trained CAC transmits approved HPE applications to MassHealth.

® The HPE-trained CACs are required to offer to assist individuals in completing a full Application for Health Coverage and Help Paying for Costs (“full MassHealth application”) but such full application is not required to receive temporary coverage through HPE.

* Details and steps for the HPE process are covered later in this gourse.

2 i fy Hospital-Determined Presumptive Eligibility 10 a) }

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ospital Requirements and Performance Standards

* Future evaluations will also be based on a second compliance standard - the percentage of HPE members that are determined eligible for MassHealth based on a full application.

° In the initial phase of implementation, EOHHS will monitor all participating hospitals to assess the average rate of full eligibility and will formulate a compliance standard based on this assessment.

* Once the compliance standard is determined, EOHHS will

inform hospitals of the metrics and the applicable timeline that will be used to measure the second compliance standard.

@ =

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ospital Requirem and Performance Standards

If a hospital does not follow state or federal laws, regulations, policies, and procedures, EOHHS may require the hospital, its CACs completing HPE applications, or both, to participate in additional training or take other reasonable corrective actions as appropriate.

* Hospitals that do not meet performance standards will be given an opportunity to improve before being disqualified from making HPE determinations.

e The state will notify the hospital in writing of any retraining or other corrective action plans.

* If the hospital is disqualified from making presumptive eligibility determinations, it will not necessarily impact whether or not the hospital can participate in Medicaid or in any agreements other than this one between the hospital and EOHHS.

* Beyond the specific HPE provisions in state and federal law, hospitals are also bound by all applicable federal and state requirements, including anti-fraud requirements.

Hospital-Determined Presumptive Eligibility 20 & pesto

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: Application Process Overview

In order to further assist HPE-trained CACs with the HPE process, the following resources are available in the LMS":

® Toolkit for HPE-Trained CACs (Interim Process)

* This toolkit provides guidance and tools to help HPE-trained CACs through the HPE Application process. It is a supplement to this LMS training course and can be used as a desk guide resource for HPE-Trained CACs.

¢ CAC HPE Checkiist (Interim Process) » This checklist is an optional tool HPE-trained CACs may use to help ensure he/she has completed all the HPE Application steps.

* The following slides reference these resources and how they can be used. Both documents are available in the Resource area of this course”.

* Select the Resources button that displays on the left when you open the Hospital-Determined Presumptive Eligibility course.

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pplication Process ~ Overview

The information below is included on the MassHealth Application for Hospital-Determined Presumptive Eligibility. The HPE-trained CAC must fill out the application in full. While most fields are self- explanatory, certain fields (noted with an *) require additional explanation and are detailed in this training.

Name, residential address, mailing address, date of birth, gender.

Citizenship and immigration status”.

Massachusetts residency status.

Household size and income”.

Whether the individual aged out of foster care (only if the individual is between the

ages of 18 and 26).

* Optional responses for Social Security Number and phone number.

* Optional responses for breast or cervical cancer status and HIV status.

* Attest you have read the Rights and Responsibilities section to the applicant, and applicant acknowledges their understanding and accepts these rights and responsibilities.

* if approved, indicate HPE determined coverage type”.

gE) 8 oy Hospital-Determined Presumptive Eligibility 26 w

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ep 3: Submit the Application |

Submitting the HPE Application

* Completed applications and the MassHealth Fax Coversheet for HPE must be submitted by the CAC (not the individual) by fax to MassHealth to the following HPE-dedicated fax number (only HPE applications can be faxed to this number):

HPE Fax: 617-887-8754

* HPE applications cannot be mailed, delivered personally, or faxed to any other fax number.

* No additional forms are required to be submitted to MassHealth with the HPE application*. * Reminder: HPE-trained CAC should check with applicant on whether they would like the CAC to

receive eligibility information from MassHealth on their case. If so, the HPE-trained CAC may need to request a signed PS! (Permission to Share Information) form from the individual to check for eligibility

information in MAP or speak with MassHealth about benefits.

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de ! ppl icant Approval/Denial Process

HPE-trained CACs must provide individuals with a written notice after the HPE determination is made.

ff approved, complete the approval letter which must include HPE coverage type and beginning and ending dates of the HPE period.

» HPE coverage begin date: Date of HPE determination.

» HPE coverage end date: Last day of the month following the month in which the HPE-trained CAC makes the HPE determination.

« HPE-trained CAC must inform the applicant:

+ That their HPE coverage will end on the last day of the month following the month in which the HPE-trained CAC makes the HPE determination, ifthe individual does not file a full application by that time, or

* For an individual who does file a full application before that time, the end date will be the eligibility determination date.

“Hf approved,” continues on next slide...

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OFFICIAL

MassHealth Hospital-Determined Presumptive Eligibility Quiz

Required in order to complete HPE Training in Learning Management System (online training tool)

June 13, 2014

1. HPE stands for:

b. c d

Hospital Provisional Eligibility

Hospital Determined Presumptive Eligibility

Hospital Predetermined Eligibility

None of the above

Answer b: HPE stands for Hospital Determined Presumptive Eligibility. Starting in 2014, the Affordable Care Act allows qualified hospitals to make presumptive eligibility determinations for certain individuals who appear to be eligible for Medicaid coverage. Qualified hospitals must make the choice to participate in HPE and enter into a contract with MassHealth to do so.

2. Which of the following are benefits of HPE?

Provides temporary yet immediate access to MassHealth coverage for eligible individuals

Improves individuals’ access to Medicaid and necessary services by providing another channel to apply for coverage

Provides individuals with an opportunity to potentially get connected to longer-term coverage options

All of the above

Answer d: Hospital Presumptive Eligibility (HPE): 1) Improves individuals’ access to Medicaid and necessary services by providing another channel to apply for coverage, 2) Provides temporary benefits but allows for immediate access to MassHealth coverage for eligible individuals. 3) Provides individuals with an opportunity to get connected to longer-term coverage options as well as 4) Ensures the hospital will be reimbursed for services provided

3. Who determines an individual’s HPE eligibility?

b. c. d

TN 14-0009-MM7 Massachusetts

MassHealth

Hospitals with HPE Contracts

Any CAC

All of the Above

Answer b: Only hospitals with a signed agreement with MassHealth may make HPE determinations. The hospital must use HPE-trained CACs to assist with HPE applications and determinations, but a hospital may not delegate the actual HPE determination to an HPE-trained CAC who is a contractor, rather than employee, of the hospital. Hospitals may choose not to sign up with MassHealth to perform HPE — it is at the hospital’s option.

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OFFICIAL

MassHealth Hospital-Determined Presumptive Eligibility Quiz

4. Hospitals’ CACs are required to offer assistance to individuals who are determined presumptively eligible in completing a full MassHealth application for coverage.

a. True

b. False Answer a: Hospital CACs are required to offer to assist individuals in completing a full MassHealth application for coverage. MassHealth will monitor each hospital participating in HPE to evaluate the percentage of people with HPE who go on to submit a full MassHealth application. This is necessary to ensure that HPE is a pathway to longer-term coverage, everyone’s ultimate goal.

5. An applicant is determined eligible for HPE on May 15, 2014, and coverage starts that day. The individual submits a full MassHealth application prior to June 30th. On what day does the HPE coverage end?

a. June 30, 2014

b. The eligibility determination date based on the full application for MassHealth benefits

c. July 31, 2014

d. None of the above Answer b: For an individual who does file a full application before the last day of the month following the month in which the HPE application was approved, the HPE period lasts until an eligibility determination is made on a full MassHealth application.

6. Anapplicant is determined eligible for HPE on May 15, 2014, and coverage starts that day. The individual does not submit a full application prior to June 30th. On what day does the HPE coverage end?

a. May 31, 2014

b. June 30, 2014

c. June 1, 2014

d. None of the Above Answer b: The HPE period ends on the last day of the month following the month in which the HPE application was approved, if the individual does not file a full MassHealth application by that time.

7. The state has the authority to take corrective action against hospitals, including termination from the HPE program, if the hospital does not follow federal or state policies, or meet state established performance standards. a. True b. False Answer a: If a hospital does not follow state or federal laws, regulations, policies, and procedures, or is not successful in helping individuals submit full MassHealth

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OFFICIAL

MassHealth Hospital-Determined Presumptive Eligibility Quiz

applications in accordance with the state-developed performance standards, EOHHS will require the hospital, its HPE-trained CACs, or both, to participate in additional training or take other reasonable corrective actions as appropriate. If a Hospital fails to comply with any corrective action plan or the Performance Standards, the Contract may be suspended or permanently terminated.

8. Hospitals are expected to have at least__ of the individuals determined presumptively eligible complete a MassHealth application for full coverage by the end of the presumptive eligibility period. a. 80% b. 55% c. 65% d. 75% Answer d: Participating hospitals will be required to meet performance standards.. Hospitals are expected to have at least 75% of the individuals determined presumptively eligible complete a MassHealth application for full coverage by the end of the presumptive eligibility period.

9. Who is not Eligible for HPE coverage?

a. Individuals who are not Massachusetts residents

b. Individuals with existing comprehensive MassHealth coverage

c. Individuals whose incomes are too high

d. None of the above

e. All of the above Answer e: An eligible individual must: 1) Not currently have comprehensive MassHealth coverage (MassHealth Standard, CommonHealth, CarePlus, or Family Assistance); 2) Be a Massachusetts resident; 3) Meet certain income criteria.

10. The individual must provide proof of income.

a. True

b. False Answer b: The hospital must accept self-attestation of income and all other information requested in the HPE application. The hospital may not require verification or documentation of information of self-attested information, including income, residency, and citizenship or immigration status as part of the HPE application or determination process.

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OFFICIAL

oy, Hospital-Determined Presumptive Eligibility Toolkit — Interim Process

Table of Contents

|. General Hospital Determined Presumptive Eligibility OVerVieW .........:csecsessseeseseeeeeenteeesneenees 3 I]. HPE Application Process.........ssssesssssssssssesssssasssessssasesseseeseesseessessssssensecsnesnseencssecsnecsissasenssseneenessneenes 5 Step 1: Determine if Individual May Be HPE Eligible ............scesssesseseesesseeeensennensenneeneraeeneenee 5 Step 2: Complete the Application .......cccsecsccessssecssesseeseesssssssecssecsneccsessneesseecsueeeseecseeeniesaneeanersneenne 5 Determine Current Subsidized Health INSUPANCE.......cscssssseessssesseesesseeneeseeseeseeseseesenseseanennenentens 6 Determine Citizenship or Immigration Status (QUESTION 5) ...ssssessesseseenenneeeeseenieneenenienes 6 Determine Household Size (QUESTION 9) ....ssscsesssecseeseerssessecsessneenseresssecsenessecneensaneeneenteasnarsensnye 7 Determine INCOME? ..secsessssesesssecsnecsseesseseessseseessessessessssusssesssssascssesasessssssssseesseeseeasecnscesesscaneaneeneensesaesses 8 De@termin@ FP Liu..cecsssessesssssssessesesseseessessssssssesssesssssssessessssssssssessesseaeesssaesssaneaneaneneeaeesssneaessenseneeseensees 9 Determine Coverage TyP@.n..sssssssssssessssesssessssesssesseesseessesseesssesssesssesssneccsccaseesnecenseecneesueenneeneesnees 10 Step 3: SuUbMiIt Application... cessecssscssesssessseesssessecssesseesssessnecsseessuesssecesiessseessneessecsueeateenienneeese 13° Step 4: Provide Notice to Applicant Approval/Denial ProCeSs ........s.sesssssssserseceenseneentecnsenteneens 13 Step 5: Explanation of Full Application Process.........cccccsseseeseeesesetenentenseneeeerenseeseanearaness 14 HPE Interim Process FIOW Chatt......csccssssssssssssessssesseenssesessssssecenesesssssessseseeseeseenecseeneeneseerennsaieananes 15 Appendix A: Citizenship and Immigration Status .........scscsssesseesssnsenesneeseeneeneessensenenseneenneensennes 16

Appendix B: Toolkit for HPE CACs.

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OFFICIAL

ay, Hospital-Determined Presumptive Eligibility Toolkit — Interim Process

1. General Hospital Determined Presumptive Eligibility Overview

How HPE Works

« An individual seeks health care coverage at an HPE-Qualified hospital, outpatient department, or satellite clinic.

» An HPE-trained CAC assists applicants and completes one HPE application per individual (i.e. not per household).

« An HPE-trained CAC helps the hospital determine HPE eligibility and coverage type. Hospitals may not delegate the actual HPE determination to an HPE-trained CAC who is a contractor, rather than employee, of the hospital.

" Approved individuals receive MassHealth coverage effective immediately, for a limited amount of time.

» An HPE-trained CAC transmits approved HPE applications to MassHealth.

"The HPE-trained CACs are required to offer to assist individuals in completing a full Application for Health Coverage and Help Paying for Costs (“full MassHealth application”) but such full application is not required to receive temporary coverage through HPE.

HPE Duration

* For approved individuals, the HPE period begins with, and includes: o The day on which the HPE-trained CAC makes the HPE determination.

= HPE period ends on:

o The last day of the month following the month in which the HPE application was submitted, ff the individual does not file a full application by that time, or

o Foran individual who does file a full application before that time, HPE ends on the eligibility determination date.

Who can make HPE Determinations

Once a hospital has a signed HPE contract with EOHHS and Certified Application Counselors (CACs) trained in HPE, it can make HPE determinations. Hospitals may not delegate the actual HPE determination to an HPE-trained CAC if the CAC is a contractor.

Only HPE-trained CACs at participating hospitals may make HPE recommendations, as long as the hospital takes responsibility for all presumptive eligibility determinations made based on such recommendations. HPE-trained CACs that may assist hospitals and consumers with the HPE process may be hospital staff or contractors, including those in hospital-based physician practices, outpatient departments or satellite clinics operating under a qualified hospital's license, including those in off-site locations, who have already successfully completed CAC training in the MassHealth/Health Connector Learning Management System (LMS). However, if the HPE-trained CAC is a contractor, rather than employee of the hospital, then the contractor may not make the HPE determination.

HPE-trained CACs at participating hospitals are required to:

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OFFICIAL

ay, Hospital-Determined Presumptive Eligibility Toolkit — Interim Process

ll. HPE Application Process

Upon the applicant's initial visit, the HPE-trained CAC should take the following steps to help the hospital determine an individual's HPE eligibility, HPE coverage type (if eligible), and complete the HPE application.

Step 1: Determine if Individual May Be HPE Eligible

To be eligible for HPE, an individual must:

= Be under age 65 (unless a parent or caretaker relative)

= Be acitizen or meet satisfactory immigration status requirements «Bea Massachusetts resident

= Meet certain income criteria

Important Information to know about the HPE application

" The HPE-trained CACs must accept self-attestation for all information requested in the HPE application.

= The HPE-trained CACs cannot require any verification or documentation of information, including income, residency, and citizenship/immigration status.

«Applicants cannot be required to provide information that is not necessary to determine HPE.

" The HPE-trained CACs may not require the applicant to answer the optional questions, such as HIV status or if the individual has breast or cervical cancer but should explain to the applicant it may result in HPE coverage for certain applicants at higher income levels. The HPE application shall be processed even if the applicant declines to answer optional questions.

" No verification requests will be sent from MassHealth to the individual applicant based on an HPE application.

Step 2: Complete the Application

The HPE-trained CAC collects information from the applicant to help the hospital determine HPE eligibility and coverage type and then submits the approved application to MassHealth. This section provides guidance on how to collect information provided by the applicant to make the determination, and how to complete certain questions on the application. For ease of use, this information can be collected on the CAC HPE Checklist —- Appendix B.

The following topics are covered in Step 2:

" Determine if individual currently has comprehensive MassHealth coverage (Standard, CommonHealth, CarePlus, or Family Assistance)

= Determine citizenship or immigration status

= Determine household size

= Determine income

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= Determine FPL = Determine Coverage Type

Determine if individual has Current MassHealth Coverage

To determine if individual currently has MassHealth coverage:

* Look individual up in My Account Page* and/or EVS. If you find individual has comprehensive MassHealth coverage (Standard, CommonHealth, CarePlus, or Family Assistance), inform individual that MassHealth coverage has already been established and they do not need time-limited HPE benefits, and assist individual in understanding how to access their current benefits.

«Ifo comprehensive eligibility is found proceed with HPE application and determination.

* Reminder: An HPE-trained CAC should check with applicant on whether they would like the CAC to receive eligibility information from MassHealth on their case. If so, the HPE-trained CAC may need to request a signed PSI (Permission to Share Information) form from the individual to check for eligibility information in MAP or speak with MassHealth about benefits.

Determine Citizenship or Immigration Status, (Question 5)

The questions on the HPE application related to Citizenship and Immigration Status are:

5. Citizenship or Immigration Status (required) a) Are you a U.S. Citizen, U.S. National igi immigration status (if applicable)

b) If you answered No, have you ever been issued a document from U.S. Immigration Officials?

Dyes [No

To determine an applicant’s immigration status:

"Ask applicant for their status and check it against the Citizen and Immigration Section Information - Appendix A of this Toolkit.

Question 5a: Are you a U.S. Citizen, U.S. National, or Eligible Immigrant? Answer “Yes” to Question 5. a) if the applicant has one of the following statuses.

o Citizen /National

e Born in the U.S. or its territories (including Puerto Rico, the Virgin Islands, Commonwealth of the Northern Mariana Islands, and Guam)

e Born to a parent who is a U.S. citizen e Naturalized citizen e AU.S. national

o Eligible Immigrant

¢ Ask applicant for their status and check it against Appendix A of this Toolkit for the full list of Eligible Immigrant statuses.

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= Hospital-Determined Presumptive Eligibility Toolkit — Interim Process

¢ If applicant has one of the Eligible Immigrant statuses, you need to answer “Yes” to 5a and write the applicant's self-declared immigrant status on application.

Question 5b: If you answered No, have you ever been issued a document from U.S. Immigration officials?

If the applicant answers “No” to: 5a Are you a U.S. Citizen, U.S. National, or Eligible Immigrant?, then ask this additional question:

5.b) If you answered No, have you ever been issued a document from U.S. Immigration officials?

e A person who answers “Yes” to question 5b is considered a Nonqualified PRUCOL and may be eligible for HPE

e Apperson who answers “No” to 5a and has never been issued a document from U.S. Immigration should answer “No” to question 5b. These individuals are not eligible for HPE unless they are pregnant and at or below 200% FPL.

Determine Household Size (Question 9,

The following Household Size and Income questions are on the HPE application:

9. Household Size and Income (required) a) How many people are in your household (including yours b) What is your household's total gross monthly income?

Question 9.a): How many people are in your household (including yourself)? Use the following to determine who to count for Household Size.

Family: Count all family members to answer question 9a

«Parent (natural, step, or adoptive) who lives together with a child under age 19, including parents who are mutually responsible for one or more children who live with them.

* Achild under age 19 who is absent from home to attend school is considered as living in the home.

"Siblings under age 19, including any of their children who live together, even if no adult is present.

"Caretaker Relative: Any adult who is the primary caregiver for a child and is related to the child by blood, adoption, or marriage and lives in the same home as that child. Neither parent may be living in the home.

Couple: The answer to 9a is “2”.

» Two persons married to each other and living together with no children under age 19 living with them.

Individual: The answer to 9a is “1”

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Step 3: Submit Application

Reminder: An HPE-trained CAC submits one HPE application per individual (e.g. not household)

Completed HPE applications along with the MassHealth Fax Coversheet for HPE must be submitted by the CAC (not the individual) by fax to MassHealth: _ :

_HPE Fax: 617-887-8754

HPE Applications Cannot Be Mailed, Delivered Personally, or Faxed To _Any OtherFaxNumber :

Step 4: Provide Notice to Applicant Approval/Denial Process

Hospitals must provide individuals with a written notice after the HPE determination is made:

If approved, complete the approval letter which must include HPE coverage type and beginning and ending dates of the HPE period.

= HPE coverage begin date: Date of HPE determination.

= HPE coverage end date: Last day of the month following the month in which the HPE determination was made.

= HPE-trained CAC must inform the applicant:

o That their HPE coverage will end on the last day of the month following the month in which the HPE application was submitted if the individual does not file a full application by that time, or

o Foran individual who does file a full application before that time, the end date will be the eligibility determination date.

«The letter explains benefits will be extended if the individual files a full MassHealth application and eligibility is not determined by HPE end date.

= HPE-trained CAC must review the notification letter with the applicant and ensure he/she fully understands it.

The HPE-trained CACs should explain to approved applicants that MassHealth will also be

sending an approval confirmation letter directly to the applicant.

If denied, complete the denial letter which must include the reason for the denial. The letter explains the option to submit a full MassHealth application and includes options on how to submit one.

» HPE-trained CACs must review the notification letter with the applicant and ensure he/she fully understands it.

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Appendix A: Citizenship and Immigration Status

For the question 5a: Are you a U.S. Citizen, U.S. National, or Eligible Immigrant?

(required)

Below is the list of Citizenship and Immigration Statuses considered to be eligible under federal law. If an applicant has one or more of these statuses, it is appropriate to answer “yes” to this question. You will also need to write in the immigration status on the application

Citizens

Born in the U.S. or its territories (including Puerto Rico, the Virgin Islands, Commonwealth of the Northern Mariana Islands, and Guam)

Born to a parent who is a U.S. citizen

Naturalized citizen

AU.S. national

Eligible Immigrants

Asylees

Refugees

Deportation withheld

US Armed Forces Veterans and their spouses and dependents

Conditional entrants

Cuban or Haitian entrants

Native Americans born in Canada or other non-U.S. territories

Amerasians

Victims of severe forms of trafficking or their spouse, child, sibling, or parent

Iraqi Special Immigrant

Afghan Special Immigrant

Legal permanent residents

Granted parole for at least one year

Battered spouse, battered child, child of battered parent, or parent of a battered child Paroled into the U.S. less than one year

Granted temporary resident status

Granted Temporary Protected Status (TPS), including individuals with pending applications for TPS granted Employment Authorization

Granted Employment Authorization

Family Unity beneficiaries. Deferred Enforced Departure (DED)

Granted Deferred Action status, except for Deferred Action for Childhood Arrivals Process (DACA)

Granted an administrative stay of removal

Beneficiary of approved visa petition pending adjustment of status

Pending application for asylum or withholding of removal, including under the Convention Against Torture who have been granted employment authorization; or who are under 14 and have an application pending for at least 180 days

Have been granted a withholding of removal under the Convention Against Torture A child has a pending application for Special Immigrant Juvenile status Non-immigration status (VISA)

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3/9/2018 MA - Submission Package - MA2017MS0001O - (MA-17-0021) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOES… 2/8 Priority Code P2 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MA2017MS0001O | MA-17-0021 Package Header Package ID MA2017MS0001O Submission Type OÕcial Approval Date 2/27/2018 Superseded SPA ID N/A SPA ID MA-17-0021 Initial Submission Date 12/27/2017 E×ective Date N/A State Information State/Territory Name: Massachusetts Medicaid Agency Name: Executive OÕce of Health and Human Services/OÕce of Medicaid Submission Component Submission Type Allow this oÕcial package to be viewable by other states? Key Contacts Name Title Phone Number Email Address Konefal, Kaela State Plan Coordinator (617)573-1807 stateplanamendments@state.ma.us SPA ID and E×ective Date SPA ID MA-17-0021 Reviewable Unit Proposed E×ective Date Superseded SPA ID Financial Eligibility Requirements for Non-MAGI Groups 12/14/2017 Mandatory Eligibility Groups 12/14/2017 Former Foster Care Children 12/14/2017 MA-13-0024 Executive Summary Summary Description Including Goals and Objectives The purpose of this amendment to the Medicaid State Plan is to remove the authority for eligibility for former foster care youth up to age 26 who aged out of foster care in another state from the State Plan as it will now be included in the Massachusetts Section 1115 Demonstration waiver. The requested e×ective date for this amendment is December 14, 2017. Note: the only change we are making through this SPA is to conÒrm coverage of former foster care youth, e×ective 12/14/17. The only language that is being superseded through this SPA is for former foster care youth. Dependency Description Description of any dependencies between this submission package and any other submission package undergoing review None Not Started In Progress Complete State Plan Amendment Medicaid CHIP OÕcial Submission Package Draft Submission Package Yes No

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3/9/2018 MA - Submission Package - MA2017MS0001O - (MA-17-0021) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOES… 4/8 Package Header Package ID MA2017MS0001O Submission Type OÕcial Approval Date 2/27/2018 Superseded SPA ID N/A SPA ID MA-17-0021 Initial Submission Date 12/27/2017 E×ective Date N/A One or more Indian health programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct e×ect on Indians, Indian health programs or Urban Indian Organizations Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 11/8/2017 EOHHS consulted the Massachusetts Indian Tribes about this proposed amendment during its quarterly tribal consultation call on November 8, 2017. A synopsis of the call is enclosed. The Tribes were asked to respond with any advice or feedback by December 4, 2017. None was received. Date of solicitation/consultation: Method of solicitation/consultation: 11/8/2017 EOHHS consulted the Massachusetts Indian Tribes about this proposed amendment during its quarterly tribal consultation call on November 8, 2017. A synopsis of the call is enclosed. The Tribes were asked to respond with any advice or feedback by December 4, 2017. None was received. States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 11/8/2017 EOHHS consulted the Massachusetts Indian Tribes about this proposed amendment during its quarterly tribal consultation call on November 8, 2017. A synopsis of the call is enclosed. The Tribes were asked to respond with any advice or feedback by December 4, 2017. None was received. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Ty pe TN-017-021 (FFC Change) Follow up to 11_8_17 Tribal Consultation call (112017) 1 12/22/2017 11:06 AM EST TN-017-021 (FFC Change) Follow up to 11_8_17 Tribal Consultation call (112017) 2 12/22/2017 11:07 AM EST Indicate the key issues raised (optional) Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, prior to submission of this SPA All Indian Health Programs All Urban Indian Organizations All Indian Tribes Access

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3/9/2018 MA - Submission Package - MA2017MS0001O - (MA-17-0021) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOES… 5/8 Medicaid State Plan Eligibility Financial Eligibility Requirements for Non-MAGI Groups MEDICAID | Medicaid State Plan | Eligibility | MA2017MS0001O | MA-17-0021 Package Header Package ID MA2017MS0001O Submission Type OÕcial Approval Date 2/27/2018 Superseded SPA ID N/A SPA ID MA-17-0021 Initial Submission Date 12/27/2017 E×ective Date 12/14/2017 The state applies the following Ònancial methodologies for all eligibility groups whose eligibility is not based on modiÒed adjusted gross income (MAGI) rules (described in 42 C.F.R. §435.603): A. Financial Eligibility Methodologies B. Eligibility Determinations of Aged, Blind and Disabled Individuals Eligibility is determined for aged, blind and disabled individuals based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneÒciaries. For all other individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, the state requires a separate Medicaid application and determines Ònancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, including SSI beneÒciaries, to Òle a separate Medicaid application, and determines Ònancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, including SSI beneÒciaries, to Òle a separate Medicaid application, and determines Ònancial eligibility using income and resource methodologies more restrictive than SSI. C. Financial Responsibility of Relatives D. Additional Information (optional) Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MA2017MS0001O | MA-17-0021 Quality Cost Payment methodology Eligibility BeneÒts Service delivery Other issue Not Started In Progress Complete The state determines Ònancial eligibility consistent with the methodologies described in 42 C.F.R. §435.601. SSA Eligibility Determination State (1634 State) State Eligibility Determination (SSI Criteria State) State Eligibility Determination (209(b) State) The state determines the Ònancial responsibility of relatives consistent with the requirements and methodologies described in 42 C.F.R. §435.602. Not Started In Progress Complete

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3/9/2018 MA - Submission Package - MA2017MS0001O - (MA-17-0021) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOES… 8/8 Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group B. Individuals Covered 1. The state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) and were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act. 2. Additionally, the state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Additional Information (optional) PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. 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 OÕcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/9/2018 7:48 AM EST a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends.

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Revision: HCFA-PM-88-10 (BERC) Page 36a September 1988 OMB No.: 0938-0193 State Plan under Title XIX of the Social Security Act State: Massachusetts Section 4 General Program Administration TN: 018-025 Approval Date: 03/12/2019 Effective Date: 10/01/18 Supersedes: 010-010 4.5 Medicaid Audit Recovery Program The State attests that the contingency fee rate paid to the Medicaid RAC will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will only submit for FFP up to the amount equivalent to that published rate. Section 1902 (a)(42)(B)(ii)(II)(bb) of the Act Section 1902 (a)(42)(B)(ii)(III) of the Act Section 1902 (a)(42)(B)(ii)(IV)(aa) of the Act Section 1902(a)(42)(B)(ii)(IV(bb) of the Act Section 1902 (a)(42)(B)(ii)(IV)(cc) Of the Act The contingency fee rate paid to the Medicaid RAC that will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will submit a justification for that rate and will submit for FFP for the full amount of the contingency fee. The following payment methodology shall be used to determine State payments to Medicaid RACs for the identification of underpayments (e.g., amount of flat fee, the percentage of the contingency fee): Specific payment methodology is not yet determined as the State has not yet entered into a contract The State has an adequate appeal process in place for entities to appeal any adverse determination made by the Medicaid RAC(s). The State assures that the amounts expended by the State to carry out the program will be amounts expended as necessary for the proper and efficient administration of the State plan or a waiver of the plan. The State assures that the recovered amounts will be subject to a State’s quarterly expenditure estimates and funding of the State’s share. Efforts of the Medicaid RAC(s) will be coordinated with other contractors or entities performing audits of entities receiving payments under the State plan or waiver in the State, and/or State and Federal law enforcement entities and the CMS Medicaid Integrity Program. OFFICIAL

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Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | MA2019MS0001O | MA-19-0026 Package Header Package ID MA2019MS0001O Submission Type OŰcial Approval Date 12/12/2019 Superseded SPA ID N/A SPA ID MA-19-0026 Initial Submission Date 10/16/2019 Eſective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct eſect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 8/15/2019 EOHHS convened its quarterly tribal consultation call on August 15, 2019, to consult the Massachusetts Indian Tribes about this proposed amendment. Due to limited attendance, the consultation was completed by email on August 22, 2019. A copy of the email is enclosed. The Tribes were asked to respond with any advice or feedback by September 5, 2019. None was received. Date of solicitation/consultation: Method of solicitation/consultation: 8/15/2019 EOHHS convened its quarterly tribal consultation call on August 15, 2019, to consult the Massachusetts Indian Tribes about this proposed amendment. Due to limited attendance, the consultation was completed by email on August 22, 2019. A copy of the email is enclosed. The Tribes were asked to respond with any advice or feedback by September 5, 2019. None was received. States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 8/15/2019 EOHHS convened its quarterly tribal consultation call on August 15, 2019, to consult the Massachusetts Indian Tribes about this proposed amendment. Due to limited attendance, the consultation was completed by email on August 22, 2019. A copy of the email is enclosed. The Tribes were asked to respond with any advice or feedback by September 5, 2019. None was received. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created 09. TN-019-026 (MSP) Tribal Notice (081519) 9/30/2019 2:52 PM EDT Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes

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

FORMAPPROVED OMB No. 0938-0193

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

1. TRANSMITTAL NUMBER 2, STATE i 9—0 3 3. MA

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 12/20/2019

5. TYPE OF PLAN MATERIAL (Check One) (NEw STATE PLAN

(1 AMENDMENT TO BE CONSIDERED AS NEW PLAN

(1 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,-92,000 $10,932,000 42 CFR Part 447 b. FFY.2021 $ 14,000,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable)

Supplement 1 to Attachment 3.1-A pages 1k, 1I, 14m, 1n Supplement 1 to Attachment 3.1-B pages 1 k, 1l, 1m, 1n (new) Attachment 4.19-B pages —2A-2Aiii- 2Aiii - 2Aiv (new pages)

Supplement 1 to Attachment 3.1-A pages 1k, 1l, 1m, 1n Supplement 1 to Attachment 3.1-B pages 1k, 1I, 4m, in Attachment 4.19-B pages 2A-00 - 2Aii

10, SUBJECT OF AMENDMENT

Targeted Case Management for memebers eligible for Department of Children and Families services

11, GOVERNOR’S REVIEW (Check One)

CO GoveRNor’s OFFICE REPORTED NO COMMENT (0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

El OTHER, AS SPECIFIED Not required under 42 CFR 430.12(b)(2)(/)

12, SIGNATI [CIAL

13. TYPED NAME Marylou Sudders

14. TITLE Secretary

15, DATE SUBMITTED 12/31/2019

16, RETURN TO

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED 12/31/2019

18. DATE APPROVED

7/30/2020

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL

20, SIGNATURE OF REGIONAL OFFICIAL

12/20/2019 21. TYPED NAME 22. TIT. Todd McMillion Director, Division of Reimbursement Review 23. REMARKS

Block 7.a. FFP amount for FFY 2020 added due to non-legible box 8 data in the original approval package.

Technical correction to add correct coverage pages to approval package and update block 8 and 9.

FORM CMS 179 (07/92)

Instructions on Back

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Supplement 1 to Attachment 3.1-A Page 1k State Plan under Title XIX of the Social Security Act State: Massachusetts Amount, Duration, and Scope of Medical And Remedial Care and Services Provided to the Categorically Needy TN: 019-033 Approval Date: 07/30/20 Effective Date: 12/20/19 Supersedes: 94-017 Case Management Services (cont.) H. Children Served by the Department of Children and Families 1. Target Group The target group consists of Medicaid beneficiaries under 22 years of age who have been reported to the Department of Children and Families (DCF) as potentially abused or neglected, or are receiving services from the Department of Children and Families after being determined to either be at risk of abuse or neglect or substantiated as being abused or neglected children.  Target group includes individuals transitioning to a community setting and targeted case management services will be made available for up to 180 consecutive days of the covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are in Institutions for Mental Disease or individuals who are inmates of public institutions. 2. Areas of state in which services will be provided  Entire state.  Only in the following geographic areas (authority of Section 1915 (g) (1) of the Act is invoked to provide services less than statewide) 3. Comparability of services  Services are provided in accordance with Section 1902 (a) (10) (B) of the Act.  Services are not comparable in the amount, duration, and scope. Authority of Section 1915 (g) (1) of the Act is invoked to provide services without regard to the requirements of Section 1902 (a) (10) (B) of the Act. 4. Definition of Services Targeted case management are comprehensive services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, and other services. Targeted case management may include contacts with non-eligible individuals that are directly related to identifying the needs and supports for helping the eligible individual to access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual’s needs. Targeted case management services are coordinated with, and do not duplicate activities, provided as part of institutional services and discharge planning activities. Targeted Case management includes the following activities: OFFICIAL

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Supplement 1 to Attachment 3.1-A Page 1l State Plan under Title XIX of the Social Security Act State: Massachusetts Amount, Duration, and Scope of Medical And Remedial Care and Services Provided to the Categorically Needy TN: 019-033 Approval Date: 07/30/20 Effective Date: 12/20/19 Supersedes: 08-012 A. Comprehensive assessment of individual needs to determine the need for any medical educational, social or other services. Reassessments are conducted at least annually, or more frequently if necessary, to address changes in an individual’s condition. These assessment activities include: • Taking client history: • Identifying the individual’s needs and completing related documentation; and • Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the individual. B. Development of and periodic revision of an individualized care plan that may be reevaluated at any time to address changes in an individual’s condition. The care plan includes: • Information collected through the assessment; • Specific goals and actions to address the medical, social, educational, and other services needed by the individual; • Activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and • A course of action to respond to the assessed needs of the eligible individual. C. Coordinating and referral and related activities to assist the individual in gaining access to: • Needed services including activities that help link and individual with: o Medical, social, and educational providers; or o Other programs and services required to address identified needs and achieve goals specified in the care plan. D. Monitoring and follow-up activities to adequately address the needs of the eligible individuals. Monitoring and follow-up activities will occur as frequently as needed to determine whether the following conditions are met, and include at least one annual monitoring meeting. The monitoring and follow up activities include: • Activities and contacts necessary to ensure the care plan is implemented and adequately addresses the individual’s needs; and • Determining whether the following conditions are met: o Services are being furnished in accordance with the individual’s care plan; o Services in the care plan are adequate; and o Making necessary adjustments in the care plan and service arrangements with providers. 5. Qualifications of Providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): The case manager must be a qualified social worker according to the requirements of the Massachusetts Department of Children and Families. Social workers must have (A) a OFFICIAL

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Supplement 1 to Attachment 3.1-A Page 1m State Plan under Title XIX of the Social Security Act State: Massachusetts Amount, Duration, and Scope of Medical And Remedial Care and Services Provided to the Categorically Needy TN: 019-033 Approval Date: 07/30/20 Effective Date: 12/20/19 Supersedes: 08-012 bachelor’s degree or higher in social work, psychology, sociology, counseling, counseling education or criminal justice or a relevant human services degree and (B) a current and valid Licensures as a Licensed Social Work Associate, Licensed Social Worker, Licensed Certified Social Worker or Licensed Independent Clinical Social Worker issued by the Massachusetts Board of Registration. 6. Freedom of Choice (42 CFR 441.18(a)(1)): The State assures that the provision of targeted case management services will not restrict an individual’s free choice of providers in violation of section 1902(a) (23) of the Act. A. Eligible recipients will have free choice of any qualified Medicaid provider of targeted case management services within the specified geographic area identified in this plan. B. Eligible recipients will have free choice of any qualified Medicaid providers of other medical care under the plan. 7. Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6)): The State assures that: • Targeted case management services will not be used to restrict an individual’s access to other services under the plan; • Individuals will not be compelled to receive targeted case management services, condition receipt of targeted case management services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of targeted case management services; and • Providers of targeted case management services do not exercise the agency’s authority to authorize or deny the provision of other services under the plan. 8. Payment (42 CFR 441.18(a)(4)): Payment for targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. 9. Case Records (42 CFR 441.18(a)(7)): Providers maintain case records that documents for all individuals receiving targeted case management as follows: (i) The name of the individual; (ii) The dates of the targeted case management services; (iii)The name of the provider agency (if relevant) and the person providing the targeted case management service; (iv) The nature, content, units of the targeted case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan. OFFICIAL

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Supplement 1 to Attachment 3.1-B Page 1k State Plan under Title XIX of the Social Security Act State: Massachusetts Services: General Provisions TN: 019-033 Approval Date: 07/30/20 Effective Date: 12/20/19 Supersedes: 94-017 H. Children Served by the Department of Children and Families 1. Target Group The target group consists of Medicaid beneficiaries under 22 years of age who have been reported to the Department of Children and Families (DCF) as potentially abused or neglected, or are receiving services from the Department of Children and Families (DCF) after being determined to either be at risk of abuse or neglect or substantiated as being abused or neglected children.  Target group includes individuals transitioning to a community setting and targeted case management services will be made available for up to 180 consecutive days of the covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are in Institutions for Mental Disease or individuals who are inmates of public institutions. 2. Areas of state in which services will be provided  Entire state.  Only in the following geographic areas (authority of Section 1915 (g) (1) of the Act is invoked to provide services less than statewide) 3. Comparability of services  Services are provided in accordance with Section 1902 (a) (10) (B) of the Act.  Services are not comparable in the amount, duration, and scope. Authority of Section 1915 (g) (1) of the Act is invoked to provide services without regard to the requirements of Section 1902 (a) (10) (B) of the Act. 4. Definition of Services Targeted case management are comprehensive services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, and other services. Targeted case management may include contacts with non-eligible individuals that are directly related to identifying the needs and supports for helping the eligible individual to access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual’s needs. Targeted case management services are coordinated with, and do not duplicate activities, provided as part of institutional services and discharge planning activities. Targeted case management includes the following activities: OFFICIAL

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Supplement 1 to Attachment 3.1-B Page 1l State Plan under Title XIX of the Social Security Act State: Massachusetts Services: General Provisions TN: 019-033 Approval Date: 07/30/20 Effective Date: 12/20/19 Supersedes: 08-012 A. Comprehensive assessment of individual needs to determine the need for any medical, educational, social or other services. Reassessments are conducted at least annually, or more frequently if necessary, to address changes in an individual’s condition. These assessment activities include: • Taking client history; • Identifying the individual’s needs and completing related documentation; and • Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the individual. B. Development of, and periodic revision of an individualized care plan that may be reevaluated at any time to address changes in an individual’s condition. The care plan includes: • Information collected through the assessment; • Specific goals and actions to address the medical, social, educational, and other services needed by the individual; • Activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and • A course of action to respond to the assessed needs of the eligible individual. C. Coordinating and referral and related activities to assist the individual in gaining access to: • Needed services including activities that help link an individual with: o Medical, social, and educational providers; or o Other programs required to address identified needs and achieve goals specified in the care plan. D. Monitoring follow-up activities adequately address the needs of eligible individuals. Monitoring and follow-up activities will occur as frequently as needed to determine whether the following conditions are met, and include at least one annual monitoring meeting. The monitoring and follow up activities include: • Activities and contacts necessary to ensure the care plan is implemented and adequately addresses the individual’s needs; and • Determining whether the following conditions are met: o Services are being furnished in accordance with the individual’s care plan; o Services in the care plan are adequate; and o Making necessary adjustments in the care plan and service arrangements with providers. 5. Qualifications of Providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): OFFICIAL

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Supplement 1 to Attachment 3.1-B Page 1m State Plan under Title XIX of the Social Security Act State: Massachusetts Services: General Provisions TN: 019-033 Approval Date: 07/30/20 Effective Date: 12/20/19 Supersedes: 08-012 The case manager must be a qualified social worker according to the requirements of the Massachusetts Department of Children and Families. Social workers must have (A) a bachelor’s degree or higher in social work, psychology, sociology, counseling, counseling education or criminal justice or a relevant human services degree and (B) a current and valid Licensures as a Licensed Social Work Associate, Licensed Social Worker, Licensed Certified Social Worker or Licensed Independent Clinical Social Worker issued by the Massachusetts Board of Registration. 6. Freedom of choice (42 CFR 441.18(a)(1)):  The State assures that the provision of targeted case management services will not restrict an individual’s free choice of providers in violation of section 1902(a) (23) of the Act. A. Eligible recipients will have free choice of any qualified Medicaid provider of targeted case management services within the specified geographic area identified in this plan. B. Eligible recipients will have free choice of any qualified Medicaid providers of other medical care under the plan. 7. Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6)): The State assures that: • Targeted case management services will not be used to restrict an individual’s access to other services under the plan; • Individuals will not be compelled to receive targeted case management services, condition receipt of targeted case management services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of targeted case management services; and • Providers of targeted case management services do not exercise the agency’s authority to authorize or deny the provision of other services under the plan. 8. Payment (42 CFR 441.18(a)(4)): Payment for targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. 9. Case Records (42 CFR 441.18(a)(7)): Providers maintain case records that documents for all individuals receiving targeted case management as follows: (i) The name of the individual; (ii) The dates of the targeted case management services; (iii)The name of the provider agency (if relevant) and the person providing the targeted case management service; (iv) The nature, content, units of the targeted case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan. OFFICIAL

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Attachment 4.19— B Page 2Aiii State Plan under Title XIX of the Social Security Act State: Massachusetts ____________________________________________________________________________________ TN: 019-033 Approval Date: 07/30/20 Effective Date: 12/20/19 Supersedes: N/A (018-013) Methods and Standards for Establishing Payment Rates – Other Types of Care (cont.) (q. Case Management Services, cont’d) III. Reimbursement for Targeted Case Management Services provided by the Department of Children and Families (DCF) are claimed based on actual expenditures of employee salaries and associated overhead expenditures. Cost for TCM provided by state employed social workers are accumulated and recognized after expenses are incurred. The expenditures are captured via DCF’s cost allocation plan (CAP) as described in the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Children and Families Cost allocation plan narrative. The CAP utilizes a Random Moment Time Study (RMTS) to isolate expenditures associated with Targeted Case Management Services. a) Definitions and Cost Reimbursement Methodology: 1. Governmental providers – The Department of Children and Families state staff. 2. Claiming Period – The state fiscal year beginning July 1 and ending June 30 each year. 3. Cost Reimbursement Methodology – Payment is based on cost reimbursement of actual statewide expenditures for the service during the claiming period. The expenditures include costs for non-Medicaid children. MassHealth will step down costs to only account for Medicaid TCM services provided to Medicaid-eligible children through a quarterly data match of the children in DCF care to determine the appropriate Medicaid eligibility percentage. Only expenditures for Medicaid TCM services are included in the claim, based upon the Medicaid eligibility match. a. Agency Expenditures include: i. Targeted case management governmental providers salary and other personnel expenses; ii. Supervisory salary and other personnel expenses in support of Targeted Case Management Services; iii. Indirect costs, including administrative costs, allocated pursuant to an agency specific cost allocation plan; iv. Room and Board costs are excluded. OFFICIAL

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 August , 2020 Daniel Tsai, Deputy Secretary The Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid One Ashburton Place, Room 1109 Boston, MA 02108 Re: Massachusetts State Plan Amendment (SPA) 20-0006 Dear 'HSXW\ Secretary Tsai: 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) 20-0006. 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 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

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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 Massachusetts 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) RI WKH $FW CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of Massachusetts 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 Massachusetts Medicaid SPA Transmittal Number 20-0006 is approved effective March 1, 2020. Please note that the effective date to allow Hospital Presumptive Eligibility (HPE) for individuals aged 65 and over who are seeking eligibility in the Age and Disability-Related Poverty Level group is May 15, 2020. The effective date to allow for up to two hospital presumptive eligibility periods in a twelve-month period for all eligible individuals and to eliminate copays on acute inpatient hospital stays for all members is March 18, 2020. Also, effective March 18, 2020, the State does not require cost-sharing for COVID WHVWLQJ DQG WUHDWPHQW VHUYLFHV LQFOXGLQJ LQ YLWUR GLDJQRVWLF

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF _ MA STATE PLAN MATERIAL —E———— 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 03/01/20 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One)

(0 NEW STATE PLAN (0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [J 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 $ 903, 500 Title 19 of the Social Security Act; Section 1135 of the Social Security Act b. FFY 2021 $ 10,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION

OR ATTACHMENT (if Applicable)

Attachment 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency

10. SUBJECT OF AMENDMENT

Eligibility, Enrollment and Cost-Sharing flexibilities during the COVID-19 National Emergency

11. GOVERNOR'S REVIEW (Check One)

| GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED

(0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Not required under 42 CFR 430.12(b)(2)(i)

oO NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. CY OFFICIAL 16. RETURN TO 13. 13.

Daniel Tsai 14. TITLE Deputy Secretary

15. DATE SUBMITTED

05/29/2020

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED 18. DATEAPPROVED — august 18, 2020

05/29/2020

PLAN APPROVED - ONE COPY ATTACHED = “DIGHay SgNeT By ANSE

19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL @HRSiaLM. ia Daboy=SiN Onl

March 1, 2020 Deboy-S See, 2ases8 21. TYPED NAME 22. TITLE

, Director, Disabled and Elderly Health Programs Group, on behalf of

Alissa Mooney DeBoy Acting Director, Center for Medicaid and CHIP Services

23. REMARKS

Pen and Ink change approved by the state on July 28 2020 requesting updates to box 7 and 14

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

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State/Territory: _Massachusetts _________ TN: _20-006 ____________ Supersedes TN: NEW

Approval Date: 08/ϭϴ/20__ Effective Date: 03/01/20 This SPA is in addition to Disaster Relief SPA TN-20-0008 approved July 16, 2020 and TN-20-0007 approved ŽŶ July 20, 2020 and does not supersede anything approved in ƚŚŽƐĞ SPAƐ. Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency 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 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 waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. N/A NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 ___X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X___ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X___ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates).

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State/Territory: _Massachusetts _________ TN: _20-006 ____________ Supersedes TN: NEW

Approval Date: 08/ϭϴ/20__ Effective Date: 03/01/20 This SPA is in addition to Disaster Relief SPA TN-20-0008 approved ŽŶ July 16, 2020 and TN-20-0007 approved ŽŶ July 20, 2020 and does not supersede anything approved in ƚŚŽƐĞ SPAƐ. c. __X___ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [Massachusetts] Medicaid state plan, as described below: Please describe the modifications to the timeline. The timeframe for tribal consultation in the State Plan is at least 30 days prior to SPA submission and an allowance of at least 14 days for feedback. We request to change the tribal consultation timeframe during the emergency period to conduct consultation the same date as submission of the SPA with an allowance of a week for feedback. EOHHS consulted with the Massachusetts Indian Tribes by email on May 29, 2020 about the proposed state plan amendments included in this COVID-19 Disaster SPA Template. The Tribes were asked to respond with any advice or feedback regarding this state plan amendment by June 5, 2020. (Effective 3/1/20) Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows.

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State/Territory: _Massachusetts _________ TN: _20-006 ____________ Supersedes TN: NEW

Approval Date: 08/ϭϴ/20__ Effective Date: 03/01/20 This SPA is in addition to Disaster Relief SPA TN-20-0008 approved ŽŶ July 16, 2020 and TN-20-0007 approved ŽŶ July 20, 2020 and does not supersede anything approved in ƚŚŽƐĞ SPAƐ. Less restrictive income methodologies: Less restrictive resource methodologies: 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. __X___ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. Allow Hospital Presumptive Eligibility (HPE) for individuals aged 65 and over who are seeking eligibility in the Age and Disability-Related Poverty Level group (described at Section 1902(a)(10)(A)(ii)(X) of the Social Security Act) and meet the following financial requirements: income below 100% FPL, and resources that do not exceed $2,000 (individual)/$3000 (couple). (Effective 5/15/20) Allow for up to two hospital presumptive eligibility periods in a twelve month period for all eligible individuals beginning with the effective date of coverage of the initial PE period. (Effective 3/18/20)

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State/Territory: _Massachusetts _________ TN: _20-006 ____________ Supersedes TN: NEW

Approval Date: 08/ϭϴ/20__ Effective Date: 03/01/20 This SPA is in addition to Disaster Relief SPA TN-20-0008 approved ŽŶ July 16, 2020 and TN-20-0007 approved ŽŶ July 20, 2020 and does not supersede anything approved in thŽƐĞ SPAƐ. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and

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State/Territory: _Massachusetts _________ TN: _20-006 ____________ Supersedes TN: NEW

Approval Date: 08/ϭϴ/20__ Effective Date: 03/01/20 This SPA is in addition to Disaster Relief SPA TN-20-0008 approved ŽŶ July 16, 2020 and TN-20-0007 approved ŽŶ July 20, 2020 and does not supersede anything approved in ƚŚŽƐĞ SPAƐ. 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). Ǥ ̴̴̴̴̴ Ȁ Ǥ Ǥ ̴̴̴̴̴ Ȁ ǡ ǣ Please describe. Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted.

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State/Territory: _Massachusetts _________ TN: _20-006 ____________ Supersedes TN: NEW

Approval Date: 08/ϭϴ/20_ Effective Date: 03/01/20 This SPA is in addition to Disaster Relief SPA TN-20-0008 approved ŽŶ July 16, 2020 and TN-20-0007 approved ŽŶ July 20, 2020 and does not supersede anything approved in ƚŚŽƐĞ SPAƐ. _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change):

Location (list published location): _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: Ǥ ̴̴̴̴̴ Ǣ Ǥ ̴̴̴̴̴ Ǣ

Ǥ ̴̴̴̴̴ Ǣ Describe telehealth payment variation. Ǥ ̴̴̴̴̴ ǡ ȋ Ȍǡ ǣ Ǥ ̴̴̴̴̴ ǦǦ Ǥ Ǥ ̴̴̴̴̴ Ǥ Other: 4. _____ Other payment changes: Please describe.

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State/Territory: _Massachusetts _________ Section F – Post-Eligibility Treatment of Income ͳǤ ̴̴̴̴̴ Ǥ ǣ Ǥ ̴̴̴̴̴ ǯ Ǥ ̴̴̴̴̴ ͵ͲͲ

Ǥ ̴̴̴̴̴ ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴̴̴ Ǥ ȋǣ ǤͳǤ ǤȌ The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information 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 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. TN: _20-006_____________ Supersedes TN: _NEW _________ Approval Date: 08/ϭϴ/20__ Effective Date: 03/01/20 This SPA is in addition to Disaster Relief SPA TN-20-0008 approved ŽŶ July 16, 2020 and TN-20-0007 approved ŽŶ July 20, 2020 and does not supersede anything approved in ƚŚŽƐĞ SPAƐ.

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 April , 2021 MaryLou Sudders, Secretary The Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid One Ashburton Place, Room 1109 Boston, MA 02108 Re: Massachusetts State Plan Amendment (SPA) 20-0019 Dear Secretary Sudders: 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) 20-0019. 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.

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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 Massachusetts also 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 Massachusetts 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 DQG PRGLILFDWLRQV 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 Massachusetts’s Medicaid SPA Transmittal Number 21-00 is approved effective March 1, 2020. 3OHDVH QRWH WKDW WKH HIIHFWLYH GDWHV IRU FHUWDLQ SD\PHQW SURYLVLRQV DV VSHFLILHG LQ 6HFWLRQ & RI WKLV VWDWH SODQ DPHQGPHQW DUH GLIIHUHQW IURP WKH HIIHFWLYH GDWH RI WKLV 63$ This SPA is in addition to Disaster Relief SPA 20-0008 approved on July 16, 2020, Disaster Relief SPA 20-0007 approved on July 20, 2020, Disaster Relief SPA 20-0006 approved on August 18, 2020, Disaster Relief SPA 20-0018 approved on October 27, 2020, Disaster Relief SPA 20-0020 approved on December 10, 2020, Disaster Relief SPA 20-0025 approved January 19, 2021, Disaster Relief SPA 20-0017 approved February 12, 2021 and Disaster Relief SPA 21-0002 approved on March 25, 2021 and does not supersede anything approved in those SPAs. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

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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 2.0 — 0 1 9 MA

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

03/01/20 4. Proposed Effective Date

5. TYPE OF PLAN MATERIAL (Check One) (0 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 Title 19 of the Social Security Act; Section 1135 of the Social Security Act

7. FEDERAL BUDGET IMPACT

a. FFY2020 000 $ 3,800,000 a b, FFY.2021 ___ $ 15,080,000

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Attachment 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency

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

10. SUBJECT OF AMENDMENT

Cost-sharing requirements

11. GOVERNOR'S REVIEW (Check One)

(0 Governor's OFFICE REPORTED NO COMMENT (1 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

BOTHER, AS SPECIFIED Not required under 42 CFR 430.12(b)(2)(i)

12, OFFICIAL |

13. TYPED NAME Marylou Sudders

14, TITLE Secretary

15. DATE SUBMITTED 9/22/2020

16. RETURN TO

The Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid

One Ashburton Place, Room 1109

Boston, MA 02108

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED September 23, 2020

18. DATE APPROVED April 8, 2021

PLAN APPROVED - ONE COPY ATTACHED

“Digtany stored Dy Alissa 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAIIOSAIGVAL M. Deboy -S March 1, 2020 Deboy -S Date: 2021 4.08 21. TYPED NAME 22. TITLE Acting Deputy Director issa Mooney DeBoy On Behalf of Anne Center for Medicaid and CHIP Services Marie Costello 23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

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State/Territory: _Massachusetts _________ TN: _020-019_____________ Approval Date: __________ Supersedes TN: NEW

Effective Date: 03/01/2020 This SPA is in addition to Disaster Relief SPA 20-0008 approved on July 16, 2020, Disaster Relief SPA 20-0007 approved on July 20, 2020, Disaster Relief SPA 20-0006 approved on August 18, 2020, Disaster Relief SPA 20-0018 approved on October 27, 2020, Disaster Relief SPA 20-0020 approved on December 10, 2020, Disaster Relief SPA 20-0025 approved January 19, 2021, Disaster Relief SPA 20-0017 approved February 12, 2021 and Disaster Relief SPA 21-0002 approved on March 25, 2021 and does not supersede anything approved in those SPAs. Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency 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 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 waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. N/A NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 ___X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X___ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X___ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These ϬϰͬϬϴͬϮϬϮϭ

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State/Territory: _Massachusetts _________ TN: _020-019_____________ Approval Date: __________ Supersedes TN: NEW

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: ϬϰͬϬϴͬϮϬϮϭ

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State/Territory: _Massachusetts _________ TN: _020-019_____________ Approval Date: __________ Supersedes TN: NEW

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State/Territory: _Massachusetts _________ TN: _020-019_____________ Approval Date: __________ Supersedes TN: NEW

Effective Date: 03/01/2020 This SPA is in addition to Disaster Relief SPA 20-0008 approved on July 16, 2020, Disaster Relief SPA 20-0007 approved on July 20, 2020, Disaster Relief SPA 20-0006 approved on August 18, 2020, Disaster Relief SPA 20-0018 approved on October 27, 2020, Disaster Relief SPA 20-0020 approved on December 10, 2020, Disaster Relief SPA 20-0025 approved January 19, 2021, Disaster Relief SPA 20-0017 approved February 12, 2021 and Disaster Relief SPA 21-0002 approved on March 25, 2021 and does not supersede anything approved in those SPAs. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. ϬϰͬϬϴͬϮϬϮϭ

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State/Territory: _Massachusetts _________ TN: _020-019_____________ Approval Date: __________ Supersedes TN: NEW

Effective Date: 03/01/2020 This SPA is in addition to Disaster Relief SPA 20-0008 approved on July 16, 2020, Disaster Relief SPA 20-0007 approved on July 20, 2020, Disaster Relief SPA 20-0006 approved on August 18, 2020, Disaster Relief SPA 20-0018 approved on October 27, 2020, Disaster Relief SPA 20-0020 approved on December 10, 2020, Disaster Relief SPA 20-0025 approved January 19, 2021, Disaster Relief SPA 20-0017 approved February 12, 2021 and Disaster Relief SPA 21-0002 approved on March 25, 2021 and does not supersede anything approved in those SPAs. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). Eliminate copays on acute inpatient hospital stays for all members (effective 3/18/20 per approved Disaster SPA 20-006). The State does not require cost-sharing for COVID testing and treatment services (including in vitro diagnostic products), testing-related services, and treatments for COVID-19, including vaccines, specialized equipment and therapies (including drugs), in any quarter in which the temporary increased FMAP is claimed (effective 3/18/20 per approved Disaster SPA 20-006). The following changes in this section are effective 7/1/20 and remain in effect during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak or any renewals thereof. The state will tier the remaining drug copay amounts. For members whose income is at or below 50% of the FPL copays will be $0 per drug. Eliminate copays on the following services: • Detoxification and maintenance treatment of an individual for substance use disorders using FDA approved medications (including methadone, buprenorphine, buprenorphine/naloxone, and naltrexone); • Preventive services assigned a grade of ‘A’ or ‘B’ by the United States Preventive Services Task Force (USPSTF), or such broader exclusion as specified by MassHealth; • All approved vaccines and their administration, recommended by the Advisory Committee on Immunization Practices (ACIP); and • Smoking cessation products and drugs. 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: ϬϰͬϬϴͬϮϬϮϭ

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State/Territory: _Massachusetts _________ TN: _020-019_____________ Approval Date: __________ Supersedes TN: NEW

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State/Territory: _Massachusetts _________ TN: _020-019_____________ Approval Date: __________ Supersedes TN: NEW

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Attachment 4.19-A (1) Page 1 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 I. Introduction Overview This attachment describes methods used to determine rates of payment for acute inpatient hospital services for RY21. 1. Except as provided in subsection 2, and in subsection 6, below, the payment methodologies specified in this Attachment 4.19-A(1) apply to: • RY21 admissions at in-state Acute Hospitals beginning on or after October 1, 2020 through September 30, 2021, and • inpatient payments made to in-state Acute Hospitals on an administrative day, psychiatric or rehabilitation per diem basis for RY21 dates of service on or after October 1, 2020 through September 30, 2021. 2. In-state Critical Access Hospitals will be paid in accordance with the methods set forth in Exhibit 1, which is attached hereto and incorporated by reference into this Attachment, for inpatient admissions occurring in RY21 on or after October 1, 2020 through September 30, 2021. 3. The supplemental payment methodologies specified in Section III.J are effective in RY21 beginning October 1, 2020 through September 30, 2021. 4. The Pay-for-Performance payment methodologies specified in Section III.K are effective in RY21 beginning October 1, 2020 through September 30, 2021. 5. In-state Acute Hospitals are defined in Section II. 6. This Section I.A.6 describes the payment methods to out-of-state acute hospitals for inpatient hospital services. Components of the out-of-state payment methods that are based on the in-state methods will simultaneously adjust effective with the 2nd RY21 Period (as defined in Section II) to reflect updates implemented effective with the 2nd RY21 Period to the in-state method, as applicable. Except if subsection 6(e) applies, below, payment for out-of-state acute inpatient hospital services is as follows: (a) Payment Amount Per Discharge. (i) Out-of-State APAD: Out-of-state acute hospitals are paid an adjudicated payment amount per discharge (“Out-of-State APAD”) for inpatient services; provided that the out-of-state APAD is not paid for inpatient services that are paid on a per diem basis under subsections 6(b) or (c) and that payment for certain APAD carve-out services (as described in subsection 6(d), below) is governed by subsection 6(d), and not this subsection 6(a). The discharge-specific Out-of-State APAD is equal to the sum of the statewide operating standard per discharge and the statewide capital standard per discharge both as in effect for in-state 3/24/21

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Attachment 4.19-A (1) Page 2 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 acute hospitals, multiplied by the MassHealth DRG Weight assigned to the discharge using information on the claim. (ii) Out-of-State Outlier Payment: If the calculated cost of the discharge exceeds the discharge- specific outlier threshold, the out-of-state acute hospital is also paid an outlier payment for that discharge (“Out-of-State Outlier Payment”). The Out-of-State Outlier Payment is equal to the Marginal Cost Factor in effect for in-state acute hospitals multiplied by the difference between the calculated cost of the discharge and the discharge-specific outlier threshold. a. The “calculated cost of the discharge” equals the out-of-state acute hospital’s allowed charges for the discharge, multiplied by the applicable inpatient cost-to-charge ratio. For High MassHealth Volume Hospitals, the inpatient cost-to-charge ratio is hospital- specific. For all other out-of-state acute hospitals, the median in-state acute hospital inpatient cost-to-charge ratio in effect, based on MassHealth discharge volume, is used. An out-of-state acute hospital’s charges for any APAD carve-out services (as described in subsection 6(d), below) will not be included in this calculation. b. The “discharge-specific outlier threshold” equals the sum of the hospital’s Out-of- State APAD corresponding to the discharge, and the Fixed Outlier Threshold in effect for in-state acute hospitals. (b) Out-of-State Transfer Per Diem: (i) Out-of-state acute hospitals are paid the out-of-state transfer per diem for inpatient services as calculated and capped as set forth in subsection 6(b)(ii) (“Out-of-State Transfer Per Diem”) in the following circumstances. a. If an out-of-state acute hospital transfers a MassHealth inpatient to another acute hospital, the transferring out-of-state acute hospital is paid the Out-of-State Transfer Per Diem for the period during which the Member was an inpatient at the transferring hospital. b. MassHealth will pay the Out-of-State Transfer Per Diem in such other additional circumstances as MassHealth determines in-state acute hospitals would be paid the in- state Transfer Per Diem, as applicable. (ii) The out-of-state transfer per diem equals the sum of the hospital’s Out-of-State APAD plus, if applicable, any Out-of-State Outlier Payment, that would have otherwise applied for the period during which the transfer per diem is payable, as calculated by EOHHS, divided by the mean in-state acute hospital all payer length of stay for the applicable APR-DRG that is assigned. Total out-of-state transfer per diem payments for a given hospital stay are capped at the sum of the hospital’s Out-of-State APAD plus, if applicable, any Out-of-State Outlier Payment that would have otherwise applied for the transfer per diem period. (c) Out-of-State Psychiatric Per Diem: If an out-of-state acute hospital admits a MassHealth patient primarily for Behavioral Health Services, the out-of-state acute hospital will be paid an all-inclusive psychiatric per diem equal to the psychiatric per diem most recently in effect for in-state acute hospitals (“Out-of-State Psychiatric Per Diem”), and no other payment methods apply. 3/24/21

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Attachment 4.19-A (1) Page 3 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 (d) Payment for APAD Carve-Outs. (i) Long-Acting Reversible Contraception (LARC) devices: Out-of-state acute hospitals will be paid for LARC Devices (as defined in Section II) in accordance with Section 8.d. of Attachment 4.19-B of the State Plan if the LARC procedure occurs immediately post-labor and delivery during the same inpatient hospital labor and delivery stay for clinically appropriate members. No other payment methods apply to such devices. (ii) APAD Carve-Out Drugs: Out-of-state acute hospitals will be paid for APAD Carve-Out Drugs (as defined in Section II) in accordance with the payment method applicable to such drugs as in effect for in-state acute hospitals on the date of service. (e) For medical services payable by MassHealth that are not available in-state, an out-of-state acute hospital that is not a High MassHealth Volume Hospital will be paid the rate of payment established for the medical service under the other state’s Medicaid program (or equivalent) or such other rate as MassHealth determines necessary to ensure member access to services. (f) For purposes of this Section I.A.6, a “High MassHealth Volume Hospital” is any out-of-state acute hospital provider that had at least 100 MassHealth discharges during the most recent federal fiscal year for which complete data is available. (g) The payment methods in this Section I.A.6 are the same for private and governmental providers. Non-Covered Services The payment methods specified in this Attachment do not apply to the following Inpatient Hospital Services: 1. Behavioral Health Services for Members Enrolled with the Behavioral Health Contractor MassHealth contracts with a Behavioral Health (BH) Contractor to provide Behavioral Health Services to Members enrolled with the BH Contractor. Hospitals are not entitled to, and may not claim for, any payment from EOHHS for any services that are BH Contractor-covered services or are otherwise payable by the BH Contractor. 2. MCO Services MassHealth contracts with Managed Care Organizations (MCOs) to provide medical services, including Behavioral Health Services, to Members enrolled with the MCO. Hospitals are not entitled to any payment from EOHHS, and may not claim such reimbursement for any services provided to Members enrolled with an MCO that are MCO-covered services or are otherwise reimbursable by the MCO. 3/24/21

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Attachment 4.19-A (1) Page 9

State Plan Under Title XIX of the Social Security Act

State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term

Definition Applicable During 1 RY21 Period

Community-based Physician

Any physician or physician group practice, excluding interns, residents, fellows, and house officers, who is not a Hospital-Based Physician. For purposes of this definition and related provisions, the term physician includes dentists, podiatrists, and osteopaths.

Definition Applicable During 2™4 RY21 Period

No change to definition.

Contract

See RFA and Contract.

No change to definition.

Critical Access Hospital (CAH)

An acute hospital that, prior to October 1, 2019, was designated by CMS as a Critical Access Hospital. and that continues to maintain that status.

An acute hospital that, prior to October 1, 2020, was designated by CMS as a Critical Access Hospital, and that continues to maintain that status.

DMH-Licensed Bed

A bed in a Hospital that is located in a unit licensed by the Massachusetts Department of Mental Health (DMB).

No change to definition.

Discharge-Specific Case Cost

The product of the Hospital’s MassHealth allowed charges for a specific discharge and the Hospital’s inpatient cost to charge ratio as calculated by EOHHS using the Hospital’s FY18 Massachusetts Hospital cost report. For applicable discharges, a Hospital’s charges corresponding to LARC Devices or APAD Carve-Out Drugs are excluded in calculating the Discharge-Specific Case Cost.

The product of the Hospital’s MassHealth allowed charges for a specific discharge and the Hospital’s inpatient cost to charge ratio as calculated by EOHHS using the Hospital’s FY18 Massachusetts Hospital Cost Report. For applicable discharges, a Hospital’s charges corresponding to LARC Devices or APAD Carve-Out Drugs are excluded in calculating the Discharge-Specific Case Cost.

Discharge-Specific Outlier Threshold

The sum of the APAD for a specific discharge (utilizing the methodology applicable to the 1st RY21 Period),

The sum of the APAD for a specific discharge (utilizing the methodology applicable to the 2" RY21 Period),

and the Fixed Outlier Threshold. and the Fixed Outlier Threshold. Drugs Drugs and biologics (including. e.g., No change to definition. cell and gene therapies), or any other similar substance containing one or TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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State: Massachusetts

Attachment 4.19-A (1) Page 12

State Plan Under Title XIX of the Social Security Act

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term

Definition Applicable During 1 RY21 Period

Hospital-Based Physician

Any physician, or physician group practice, excluding interns, residents, fellows, and house officers, who contracts with a Hospital to provide Inpatient Services to Members at a site for which the Hospital is otherwise eligible to receive payment under the RFA. For purposes of this definition and related provisions, the term physician includes dentists, podiatrists and osteopaths. Nurse practitioners, nurse midwives, physician assistants, and other allied health professionals are not

Definition Applicable During 2™4 RY21 Period

No change to definition.

Hospital-Based Physicians. Hospital Discharge Data Hospital discharge filings for FY17 | Hospital discharge filings for FY17 (HDD) provided and verified by each provided and verified by each hospital, submitted to CHIA, and hospital, submitted to CHIA, and screened and updated by CHIA. screened and updated by CHIA. HDD is used for determining HDD is used for determining casemix as part of the APAD rate casemix as part of the APAD rate development for purposes of Section | development for purposes of TIL.B, as applicable to the 1 RY21 | Section III-B, as applicable to the Period. 2°4 RY21 Period. Inflation Factors for An inflation factor that is a blend of Administrative Days the Centers for Medicare and Medicaid Services (CMS) market Not applicable basket and the Massachusetts Consumer Price Index (CPI). Specifically, the CPI replaces the labor-related component of the CMS market basket to reflect conditions in the Massachusetts economy. The Inflation Factor for Administrative Days is as follows: e 1.937% reflects the price changes between RY16 and RY17. TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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State: Massachusetts

Attachment 4.19-A (1) Page 13

State Plan Under Title XIX of the Social Security Act

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term Definition Applicable During Definition Applicable During 1 RY21 Period 2™4 RY21 Period © 2.26% reflects the price changes between RY17 and RY18. © 2.183% reflects the price changes between RY18 and RY19. © 2.236% reflects the price changes between RY19 and RY20 Inflation Factors for For price changes between RY04 | For price changes between RY04 Capital Costs and RY18 and between RY19 and | and RY18 and between RY19 and RY20, the inflation factors for RY21, the inflation factors for capital costs are the factors used | capital costs are the factors used by CMS to update capital by CMS to update capital payments made by Medicare, and | payments made by Medicare, and are based on the CMS Capital are based on the CMS Capital Input Price Index. For price Input Price Index. For price changes between RY18 and changes between RY18 and RY19, the inflation factors for RY19, the inflation factors for capital costs are the factors used | capital costs are the factors used by CMS to update capital by CMS to update capital payments made by Medicare and | payments made by Medicare and are based on the CMS Capital are based on the CMS Capital Input Price Index, plus a RY19 Input Price Index, plus a RY19 capital enhancement factor of capital enhancement factor of 0.9%. The Inflation Factors for | 0.9%. The Inflation Factors for Capital Costs between RY04 and | Capital Costs between RY04 and RY19 are as follows: RY21 are as follows:

e 0.7% reflects the price e 0.7% reflects the price changes between RY04 changes between RY04 and RY05 and RY0S

e 0.7% reflects the price e 0.7% reflects the price changes between RY05S changes between RYOS and RY06 and RY06

e 0.8% reflects the price e 0.8% reflects the price changes between RY06 changes between RY06 and RY07 and RY07

e 0.9% reflects the price e 0.9% reflects the price changes between RY07 changes between RY07 and RY08 and RY08

TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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State: Massachusetts

Attachment 4.19-A (1) Page 15

State Plan Under Title XIX of the Social Security Act

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term Definition Applicable During Definition Applicable During 1 RY21 Period 2™4 RY21 Period ¢ 1.5% reflects the price changes between RY20 and RY21 Inflation Factors for For price changes between RY04 For price changes between RY04 Operating Costs and RY07, and between RY09 and RY07, and between RY09 (starting with admissions beginning | (starting with admissions beginning December 7, 2008) and RY20, the December 7, 2008) and RY21, the inflation factor for operating costs is | inflation factor for operating costs is a blend of the CMS market basket a blend of the CMS market basket and the Massachusetts Consumer and the Massachusetts Consumer Price Index (CPI) in which the CPI | Price Index (CPI) in which the CPI replaces the labor-related component | replaces the labor-related component of the CMS market basket to reflect | of the CMS market basket to reflect conditions in the Massachusetts conditions in the Massachusetts economy. For price changes economy. For price changes between RY07 and RY09 (for between RY07 and RY09 (for admissions through December 6, admissions through December 6, 2008), the inflation factor for 2008), the inflation factor for operating costs is the CMS market operating costs is the CMS market basket. The Inflation Factors for basket. The Inflation Factors for Operating Costs between RY04 and | Operating Costs between RY04 and RY20 are as follows: RY21 are as follows: © 1.186% reflects price changes between © 1.186% reflects price changes between RY04 and RY05 RY04 and RY05 © 1.846% reflects price changes between e 1.846% reflects price changes between RY05 and RY06 RY05 and RY06 © 1.637% reflects price changes between © 1.637% reflects price changes between RY06 and RY07 RY06 and RYO7 © 3.300% reflects price changes between © 3.300% reflects price changes between RY07 and RY08 RY07 and RY08 © 3.000% reflects price changes between © 3.000% reflects price changes between RY08 and RY09 for admissions beginning RY08 and RY09 for admissions beginning from October 1, 2008 through December from October 1, 2008 through December 6, 2008 6, 2008 e 1.424% reflects price changes between e 1.424% reflects price changes between RY08 and RY09 for admissions beginning RY08 and RY09 for admissions beginning from December 7, 2008 through from December 7, 2008 through September 30, 2009 September 30, 2009 © 0.719% reflects the price changes © 0.719% reflects the price changes between RY09 and RY10* between RY09 and RY10* TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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State: Massachusetts

Attachment 4.19-A (1) Page 16

State Plan Under Title XIX of the Social Security Act

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term Definition Applicable During Definition Applicable During 1 RY21 Period 2™4 RY21 Period © 1.820% reflects the price changes © 1.820% reflects the price changes between RY10 and RY11 between RY10 and RY11 © 1.665% reflects the price changes © 1.665% reflects the price changes between RY11 and RY12 between RY11 and RY12 ¢ 1.775% reflects the price changes e 1.775% reflects the price changes between RY12 and RY13 between RY12 and RY13 e 1.405% reflects the price changes e 1.405% reflects the price changes between RY13 and RY14 between RY13 and RY14 © 1.611% reflects the price changes ¢ 1.611% reflects the price changes between RY14 and RY15 between RY14 and RY15 © 1.573% reflects the price changes © 1.573% reflects the price changes between RY15 and RY16 between RY15 and RY16 ¢ 1.937% reflects the price changes © 1.937% reflects the price changes between RY16 and RY17 between RY16 and RY17 © 2.26% reflects the price changes between | © 2.26% reflects the price changes between RY17 and RY18. RY17 and RY18. © 2.183% reflects the price changes © 2.183% reflects the price changes between RY18 and RY19. between RY18 and RY19. © 2.236% reflects the price changes © 2.236% reflects the price changes between RY19 and RY20 between RY19 and RY20 e 1.854 % reflects the price changes * The Inflation Factor for Operating Costs between RY20 and RY21 reflecting price changes between RY09 and December 7, 2008 through September 30, | rv19 was calculated based on the RY09 rate in effect for admissions beginning from December 7, 2008 through September 30, 2009. Inpatient Services (also Medical services, including Inpatient Hospital Behavioral Health Services, so: Services) provided to a Member admitted to a No change to definition. Hospital. Long-Acting Reversible Long-acting reversible contraception Contraception (LARC) (LARC) device refers to intrauterine device (LARC Device) devices and contraceptive implants. No change to definition. LARC Device does not refer to the procedure, itself. Managed Care Any entity with which EOHHS Organization (MCO) contracts to provide primary care No change to definition. and certain other medical services, including Behavioral Health Services, to Members on a capitated TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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State: Massachusetts

Attachment 4.19-A (1) Page 17

State Plan Under Title XIX of the Social Security Act

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term Definition Applicable During Definition Applicable During 1 RY21 Period 2™4 RY21 Period basis, and which meets the definition of an MCO at 42 CFR §438.2. For clarity purposes, MCO also includes Accountable Care Partnership Plans (ACPPs).

Marginal Cost Factor As used in the calculation of an As used in the calculation of an Outlier Payment, the percentage of | Outlier Payment, the percentage of payment made for the difference payment made for the difference between the Discharge-Specific between the Discharge-Specific Case Cost and the Discharge- Case Cost and the Discharge- Specific Outlier Threshold (utilizing | Specific Outlier Threshold (utilizing the 1‘ RY21 Period methodology). the 2% RY21 Period methodology). For the 1' RY21 Period, the For the 2% RY21 Period, the Marginal Cost Factor is 60%. Marginal Cost Factor is 60%.

Massachusetts-specific Each wage area’s Wage Index is the | Each wage area’s Wage Index is the

Wage Area Index average hourly wage divided by the | average hourly wage divided by the statewide average hourly wage. statewide average hourly wage. Massachusetts Hospitals’ wages and | Massachusetts Hospitals’ wages and hours were determined based on hours were determined based on CMS’s FY2020-April-27-2019- CMS’s FY2021-April-30-2020- Wage-Index-PUF zip file, Wage-Index-PUF zip file, downloaded May 1, 2019 from the downloaded May 1, 2020 from the CMS web site at www.cms.hhs.gov | CMS web site at www.cms.hhs.gov (the “CMS File”). Wage areas were | (the “CMS File”). Each Hospital assigned according to the same CMS | was assigned to a wage area File, except that Baystate Franklin according to the same CMS File, Medical Center was assigned to (and | except that: its wages and hours included in) the e Brigham and Women's Springfield wage area, Brigham and Hospital and Massachusetts Women's Hospital was assigned to General Hospital were the Boston wage area and its wages assigned to the Boston wage and hours included in the Boston area and their wages and area, and PPS-exempt hospitals were hours included in the Boston assigned to the wage area in which area; their main campus is located, as e = The following four hospitals determined from their hospital’s were redesignated as follows: license. The area’s Wage Index is o Baystate Medical Center the Massachusetts-specific Wage from Springfield to Area Index for each Hospital Worcester, assigned to the area, except for (1) o Lahey Hospital and any Hospital that was redesignated Medical Center from

TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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State: Massachusetts

Attachment 4.19-A (1) Page 18

State Plan Under Title XIX of the Social Security Act

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term Definition Applicable During Definition Applicable During 1 RY21 Period 2™4 RY21 Period to a different wage area in a written Cambridge-Newton- decision from CMS to the Hospital Framingham to Boston, provided to EOHHS by April 30, o Saint Vincent Hospital 2019, and (2) Southcoast Hospitals from Worcester to Group, which is redesignated to the Boston, and Boston area. For any such o The University of redesignated Hospital, its Massachusetts Memorial Massachusetts-specific Wage Area Medical Center from Index was calculated based on the Worcester to Boston: and wages and hours, determined from o PPS-exempt hospitals the CMS File, of (i) the redesignated were assigned to the wage Hospital, (ii) all other Hospitals area in which their main redesignated to that same area, and campus is located, as (ii) all Hospitals assigned to that determined by EOHHS area, combined. from the hospital's license (PPS-exempt hospitals are not included in the CMS File). The area's wage index is the Massachusetts-specific wage area index for each Hospital assigned to the area, except for any Hospital that was redesignated to a different wage area in a written decision from CMS to the Hospital provided to EOHHS by June 17, 2020. For any such redesignated Hospital, its Massachusetts-specific wage area index was calculated based on the wages and hours, determined from the CMS File, of (i) the redesignated hospital, (ii) all other hospitals redesignated to that same area, and (iii) all hospitals assigned to that area, combined. MassHealth (also The Medical Assistance Program Medicaid) administered by EOHHS: to furnish No change to definition. and pay for medical services pursuant to M.G.L. c. 118E and Titles XIX and XXI of the Social TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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Attachment 4.19-A (1) Page 19

State Plan Under Title XIX of the Social Security Act

State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term Definition Applicable During Definition Applicable During 1 RY21 Period 2™4 RY21 Period Security Act, and any approved waivers of such provisions.

MassHealth DRG Weight | The MassHealth relative weight The MassHealth relative weight developed by EOHHS for each developed by EOHHS for each unique combination of APR-DRG unique combination of APR-DRG and severity of illness (SOD, and severity of illness (SOD), applicable to the 1st RY21 Period. applicable to the 2 RY21 Period.

Medicaid Management The state-operated system of data

Information System processes, certified by CMS that so:

(MMIS) meets federal guidelines in Part 11 No change to definition. of the State Medicaid Manual.

Member A person determined by EOHHS to be eligible for medical assistance No change to definition. under the MassHealth program.

Non-Acute Unit A chronic care, Rehabilitation, or skilled nursing facility unit within a No change to definition. Hospital.

Outlier Payment

A hospital-specific, discharge- specific inpatient Hospital payment made in addition to the APAD for qualifying discharges in accordance with Section III.C, utilizing the methodology applicable to the 1 RY21 Period.

Pediatric Specialty Unit

A designated pediatric unit, pediatric intensive care unit, or neonatal intensive care unit in an Acute Hospital other than a Freestanding Pediatric Acute Hospital, in which the ratio of licensed pediatric beds to total licensed Hospital beds as of July 1, 1994, exceeded 0.20.

No change to definition.

Primary Care ACO

A type of ACO with which the MassHealth agency contracts under its ACO program.

No change to definition.

TN: 020-027 Supersedes: 019-027

Approval Date: 3/24/21

Effective Date: 10/01/20

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State: Massachusetts

Attachment 4.19-A (1) Page 22

State Plan Under Title XIX of the Social Security Act

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Defined Term

Definition Applicable During 1 RY21 Period

Standard Payment Amount Per Discharge (SPAD)

A payment methodology that was utilized in prior Rate Years. The SPAD was a Hospital-specific all- inclusive payment for the first twenty cumulative acute days of an inpatient hospitalization, which was the complete fee-for-service payment for an acute episode of illness, excluding additional fee-for- service payment for services as described in prior acute inpatient hospital SPAs, including TN-013- 020. Calculation of the SPAD was discussed in Section III-B of TN-013- 020. This payment methodology was replaced by the APAD payment

Definition Applicable During 2™4 RY21 Period

No change to definition.

methodology in RY15.

Total Case Payment The sum, as determined by EOHHS, | The sum, as determined by EOHHS. of the APAD and, if applicable, any | of the APAD and, if applicable, any Outlier Payment (applying the 1* Outlier Payment (applying the 2" RY21 Period methodology(ies)). RY21 Period methodology(ies)).

Total Transfer Payment The Total Case Payment amount The Total Case Payment amount

Cap calculated by EOHHS utilizing the | calculated by EOHHS utilizing the APAD and, if applicable, Outlier APAD and, if applicable, Outlier Payment methodology(ies) set forth | Payment methodology(ies) set forth in Section IIIB and III.C, in Section III.B and IIL.C, respectively, for the period for respectively, for the period for which the Transferring Hospital is which the Transferring Hospital is being paid on a Transfer Per Diem _| being paid on a Transfer Per Diem basis under Section III.D (applying | basis under Section III.D (applying the 1* RY21 Period the 2% RY21 Period methodology(ies)). methodology(ies)).

Transferring Hospital An Acute Hospital that is being paid on a Transfer Per Diem basis, No change to definition. pursuant to Section III.D.

TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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Attachment 4.19-A (1) Page 24 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 III. Payment for Inpatient Services Overview 1. Except as otherwise provided in subsections C through I below, and in Exhibit 1, fee-for-service payments for Inpatient Services provided to MassHealth Members not enrolled in an MCO will be a Hospital-specific, DRG-specific Adjudicated Payment Amount per Discharge (APAD) (see subsection B below). For qualifying discharges, Hospitals may also be paid an Outlier Payment in addition to the APAD, under the conditions set forth in, and calculated as described in, subsection C, below. Payment separate from the APAD may also be made to Hospitals for LARC Devices and APAD Carve-Out Drugs, respectively, as described in subsection I.1 and I.2, respectively. 2. Subsections C through I describe non-APAD fee-for-service payments, including, as applicable, Outlier Payments, and payment for Behavioral Health Services, transfer patients, Hospital-Based Physician services, Administrative Days, Rehabilitation Unit services in Acute Hospitals, LARC Devices and APAD Carve-Out Drugs. Payment for other unique circumstances is described in subsection J, and Exhibit 1. Pay-for-Performance payments are described in subsection K. 3. For Inpatient Services paid on a per diem basis, MassHealth pays the lesser of (i) the per diem rate, or (ii) 100% of the Hospital’s actual charge submitted. Calculation of the Adjudicated Payment Amount Per Discharge (APAD) RY21 is bifurcated into the 1st RY21 Period and the 2nd RY21 Period for purposes of applying the APAD payment methodology. The APAD methodology is set forth in Section III.B below. The “1st RY21 Period” column applies to admissions occurring in the 1st RY21 Period, and incorporates applicable definitions in Section II that apply to the 1st RY21 Period. The “2nd RY21 Period” column applies to admissions occurring in the 2nd RY21 Period, and incorporates applicable definitions in Section II that apply to the 2nd RY21 Period. 3/24/21

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Attachment 4.19-A (1) Page 25

State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

1st RY21 Period (for admissions occurring in the Ist RY21 Period)

2nd RY21 Period (for admissions occurring in the 2nd RY21 Period)

1. APAD Overview

The Adjudicated Payment Amount per Discharge (APAD) is a Hospital-specific, DRG-specific all- inclusive facility payment for an acute inpatient hospitalization from admission through discharge (exclusive of any separate payment for LARC Devices or APAD Carve-Out Drugs, if applicable, as described in Section IILD).

The components that make up the APAD include (1) the Statewide Operating Standard per Discharge, adjusted for the Hospital’s Massachusetts-specific Wage Area Index; (2) the Statewide Capital Standard per Discharge; and (3) the discharge-specific MassHealth DRG Weight. Each of these components, and the calculation of the APAD, is described more fully below.

The APAD Base Year is FY17.

1. APAD Overview

The APAD Base Year is FY17.

2. Statewide Operating Standard per Discharge

The Statewide Operating Standard per Discharge is determined by multiplying:

e the weighted average of the APAD Base Year standardized cost per discharge, where any Hospital's standardized cost per discharge that exceeds the efficiency standard is limited by the efficiency standard; by

e an outlier adjustment factor of 92.7% and by

e the Inflation Factors for Operating Costs to trend APAD Base Year costs forward to the

2. Statewide Operating Standard per Discharge

The Statewide Operating Standard per Discharge is determined by multiplying:

e an outlier adjustment factor of 90.78%: and by

e the Inflation Factors for Operating Costs to

current Rate Year. trend APAD Base Year costs forward to the current Rate Year. TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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Attachment 4.19-A (1) Page 26

State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

1st RY21 Period (for admissions occurring in the Ist RY21 Period)

2nd RY21 Period (for admissions occurring in the 2nd RY21 Period)

These elements are described in greater detail below. The Statewide Operating Standard per Discharge is $11,391.79.

These elements are described in greater detail below. The Statewide Operating Standard per Discharge is $11,411.23.

a. APAD Base Year Standardized Cost per Discharge

The APAD Base Year standardized cost per discharge is based on the average all-payer cost per discharge for each Hospital, adjusted as described below.

The average cost per discharge for each Hospital is derived by dividing total inpatient Hospital costs by total inpatient Hospital discharges. APAD Base Year costs and discharges are determined using the Hospital’s APAD Base Year Massachusetts Hospital cost report as screened and updated as of July 24, 2018. Specific costs and discharges are included and excluded as follows:

a. APAD Base Year Standardized Cost per Discharge

The APAD Base Year standardized cost per discharge is based on the average all-payer cost per discharge for each Hospital, adjusted as described below.

Average Cost per Discharge: treatment of costs and discharges

Included Excluded Total non-excluded Costs and costs of providing discharges from

Inpatient Services Excluded Units.

Routine outpatient Professional costs associated with services admissions from the

Emergency Capital costs and Department direct medical

education costs. Routine and ancillary

outpatient costs Costs associated resulting from with postpartum admissions from LARC Devices

Observation status

Included Excluded

Total non-excluded Costs and

costs of providing discharges from Inpatient Services Excluded Units. Routine outpatient Professional costs associated with services admissions from the

Emergency Capital costs and Department direct medical

education costs. Routine and ancillary

outpatient costs Costs associated resulting from with postpartum admissions from LARC Devices Observation status

TN: 020-027 Supersedes: 019-027

Approval Date: 3/24/21

Effective Date: 10/01/20

(ma-20-0027)(approval-document)(page-31)Page 31#

Attachment 4.19-A (1) Page 28

State Plan Under Title XIX of the Social Security Act

State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

1st RY21 Period 2nd RY21 Period (for admissions occurring (for admissions occurring in the 1st RY21 Period) in the 2nd RY21 Period) Efficiency Standard Efficiency Standard

All Hospitals are ranked with respect to their APAD Base Year standardized costs per discharge, and the efficiency standard is set at the 60" percentile of the cumulative frequency of FY18 discharges where MassHealth is the primary payer in MMIS. The efficiency standard is $13,305.69.

All Hospitals are ranked with respect to their APAD Base Year standardized costs per discharge, and the efficiency standard is set at the 60" percentile of the cumulative frequency of FY19 discharges where MassHealth is the primary payer in MMIS. The efficiency standard is $13,336.17.

Outlier Adjustment Factor and Inflation Factors for Operating Costs

The weighted average of the APAD Base Year standardized cost per discharge, as limited by the efficiency standard, is multiplied by the outlier adjustment factor referenced above, and by the Inflation Factors for Operating Costs reflecting price changes between RY17 and RY20, to result in the Statewide Operating Standard per Discharge.

Outlier Adjustment Factor and Inflation Factors for Operating Costs

The weighted average of the APAD Base Year standardized cost per discharge, as limited by the efficiency standard, is multiplied by the outlier adjustment factor referenced above, and by the Inflation Factors for Operating Costs reflecting price changes between RY17 and RY21, to result in the Statewide Operating Standard per Discharge.

3. Statewide Capital Standard per Discharge

The Statewide Capital Standard per Discharge is

calculated based on the APAD Base Year statewide capital cost per discharge, updated by the Inflation Factors for Capital Costs between the APAD Base Year and the current Rate Year. The calculation is

summarized in the following chart:

The Statewide Capital Standard per Discharge is

calculated based on the APAD Base Year statewide

capital cost per discharge, updated by the Inflation Factors for Capital Costs between the APAD Base Year and the current Rate Year. The calculation is summarized in the following chart:

Statewide Capital Standard per Discharge Statewide Capital Standard per Discharge APAD Base Year | a. the APAD Base $736.41 APAD Base Year | a. the APAD Base $727.58 statewide capital Year all-payer statewide capital Year all-payer cost per capital cost per cost per capital cost per discharge discharge discharge discharge (subsection a), |» adjusted by the (subsection a), |» adjusted by the

APAD Base Year APAD Base Year all payer casemix all payer casemix index index TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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Attachment 4.19-A (1)

Page 29 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services 1st RY21 Period 2nd RY21 Period (for admissions occurring (for admissions occurring in the 1st RY21 Period) in the 2nd RY21 Period) c. capped at the c. capped at the capital efficiency capital efficiency standard standard d. multiplied by the d. multiplied by the FY18 Hospital- FY18 Hospital- specific specific MassHealth MassHealth discharges discharges e. summed and e. summed and divided by the divided by the total FY18 total FY18 statewide statewide MassHealth MassHealth discharges discharges trended to the $773.16 trended to the $775.34 current rate year current rate year using the using the Inflation Factors Inflation Factors for Capital Costs for Capital Costs (subsection b), (subsection b),

a. APAD Base Year statewide capital cost per

discharge

The APAD Base Year statewide capital cost per discharge is the discharge-weighted average over all Hospitals of the all payer casemix-adjusted capital cost per discharge capped at the capital efficiency standard.

For each Hospital, the total inpatient capital costs include the Buildings and Fixtures and Movable Equipment categories reported on the APAD Base Year Massachusetts Hospital cost report. Total capital costs for Buildings and Fixtures are allocated to inpatient services through the square-footage-based allocation formula, and total capital costs for Movable Equipment are allocated to inpatient services through the dollar-value-based allocation formula, of the APAD Base Year Massachusetts Hospital cost report. Capital costs for Excluded Units are omitted to derive

discharge

TN: 020-027 Supersedes: 019-027

Approval Date: 3/24/21

Effective Date: 10/01/20

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Attachment 4.19-A (1) Page 30

State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

1st RY21 Period (for admissions occurring in the Ist RY21 Period)

2nd RY21 Period (for admissions occurring in the 2nd RY21 Period)

net inpatient capital costs. Each Hospital's capital cost per discharge is calculated using APAD Base Year Massachusetts Hospital cost reports by dividing total net inpatient capital costs by the Hospital’s total all-payer discharges, net of Excluded Unit discharges.

Each Hospital's capital cost per discharge is then adjusted by the APAD Base Year all- payer Casemix Index.

All Hospitals are then ranked with respect to their casemix-adjusted capital cost per discharge, and the capital efficiency standard is set at the 60th percentile of the cumulative frequency of FY18 discharges where MassHealth is the primary payer in MMIS. Each Hospital's capital cost per discharge that exceeds the capital efficiency standard is then limited by the capital efficiency standard.

The APAD Base Year statewide capital cost per discharge is the statewide average of these adjusted costs per discharge, weighted based on each Hospital’s number of FY18 MassHealth discharges.

Each Hospital's capital cost per discharge is then adjusted by the APAD Base Year all- payer Casemix Index.

All Hospitals are then ranked with respect to their casemix-adjusted capital cost per discharge, and the capital efficiency standard is set at the 60th percentile of the cumulative frequency of FY19 discharges where MassHealth is the primary payer in MMIS. Each Hospital's capital cost per discharge that exceeds the capital efficiency standard is then limited by the capital efficiency standard.

The APAD Base Year statewide capital cost per discharge is the statewide average of these adjusted costs per discharge, weighted based on each Hospital’s number of FY 18 MassHealth discharges.

TN: 020-027 Supersedes: 019-027

Approval Date: 3/24/21 Effective Date: 10/01/20

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Attachment 4.19-A (1) Page 32

State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

1st RY21 Period (for admissions occurring in the Ist RY21 Period)

2nd RY21 Period (for admissions occurring in the 2nd RY21 Period)

6. Calculation of the APAD

Each APAD is determined by the following

steps: (1) multiplying the labor portion of

the Statewide Operating Standard per Discharge by the Hospital’s Massachusetts-specific Wage Area Index, (2) adding this amount to the non-labor portion of the Statewide Operating Standard per Discharge to result in the Hospital’s Wage Adjusted Operating Standard per Discharge, (3) adding the Wage Adjusted Operating Standard per Discharge to the Statewide Capital Standard per Discharge (which result is referred to as the “APAD Base Payment”), and (4) multiplying the APAD Base Payment by the discharge-specific MassHealth DRG Weight. For purposes of step (1) in this subsection 6, above, the Hospital’s Massachusetts-specific Wage Area Index which is multiplied by the labor portion of the Statewide Operating Standard per Discharge, is determined as specified in the definition of “Massachusetts- specific Wage Area Index” in Section II as applicable to the Ist RY21 Period.

For qualifying discharges from Freestanding Pediatric Acute Hospitals and the Hospital with a Pediatric Specialty Unit for which the MassHealth DRG Weight assigned to the discharge is 3.5 or greater, the APAD Base Payment will be adjusted to include an additional 57% for purposes of step (4), above, in this subsection 6, in the calculation of the APAD. A qualifying discharge for this purpose is one that (i) meets this minimum MassHealth DRG Weight requirement, and (ii) in the case of the Hospital with a Pediatric Specialty Unit, is for a Member who is under the age of 21 at the time of admission.

6. Calculation of the APAD

Each APAD is determined by the following

steps: (1) multiplying the labor portion of

TN: 020-027 Supersedes: 019-027

Approval Date: 3/24/21

Effective Date: 10/01/20

(ma-20-0027)(approval-document)(page-36)Page 36#

Attachment 4.19-A (1) Page 33 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 The following is an illustrative example of the calculation of the Total Case Payment for a standard APAD claim that does not also qualify for an Outlier Payment under Section III.C, below. The example assumes the 2nd RY21Period applies. Outlier Payment RY21 is bifurcated into the 1st RY21 Period and the 2nd RY21 Period for purposes of applying the Outlier Payment methodology. The Outlier Payment methodology is set forth in this Section III.C; provided that, (i) the “1st RY21 Period” column applies to admissions occurring in the 1st RY21 Period, and incorporates applicable definitions from Section II that apply to the 1st RY21 Period; (ii) the “2nd RY21 Period” column applies to admissions occurring in the 2nd RY21 Period, and incorporates applicable definitions from Section II that apply to the 2nd RY21 Period; and (iii) all references in this Section III.C to the APAD method (or any component of the APAD) shall refer to the APAD (or APAD component) as calculated utilizing the methodology that applies to the specific admission (1st Table 1: Standard APAD claim - 2nd RY21 Period (Values are for demonstration purposes only) Hospital: Sample Hospital DRG: 203, Chest Pain. Severity of Illness (SOI) = 2. Line Description Value Calculation or Source 1 Statewide Operating Standard per Discharge $11,411.23 Section III.B.2 (2nd RY21 Period) 2 Hospital's Masschusetts-specific wage area index 1.0704 Varies by hospital, determined annually 3 Labor Factor 0.68257 Determined annually 4 Hospital's Wage Adjusted Operating Standard per Discharge $11,959.57 (Line 1 * Line 2 * Line 3) + (Line 1 * (1.0-Line 3)) 5 Statewide Capital Standard per Discharge $775.34 Section III.B.3 (2nd RY21 Period) 6 APAD Base Payment $12,734.91 Line 4 + Line 5 7 MassHealth DRG Weight 0.3547

Determined based on claim information 8 Total Case Payment = Adjudicated Payment Amount per Discharge (APAD) $4,517.07 Line 6 * Line 7 3/24/21

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Attachment 4.19-A (1) Page 34

State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

RY21 Period method for admissions in the 1 RY21 Period, or 2% RY21 Period method for admissions in the 2 RY21 Period).

1% RY21 Period (for admissions occurring in the 1 RY21 Period)

24 RY21 Period (for admissions occurring in the 2"? RY21 Period)

A Hospital will be paid a discharge-specific Outlier Payment for a discharge in addition to the APAD (see Section III.B., above) if all of the following conditions are met:

1. the amount of the APAD for the discharge exceeds $0.

2. the Hospital’s Discharge-Specific Case Cost exceeds the Discharge-Specific Outlier Threshold for that discharge:

3. the patient is not ina DMH-licensed bed for any part of the discharge, or the patient is a patient in a DMH-Licensed Bed during the Governor’s March 10, 2020, Declaration of a State of Emergency within the Commonwealth due to COVID-19, with a primary diagnosis that is not BH-related: and

4. the patient is not a patient in an Excluded Unit within the Hospital.

In cases where an Outlier Payment applies, the Outlier Payment will equal the product of the Marginal Cost Factor and the amount by which the Discharge-Specific Case Cost exceeds the Discharge-Specific Outlier Threshold.

A Hospital will be paid a discharge-specific Outlier Payment for a discharge in addition to the APAD (see Section III.B., above) if all of the following conditions are met:

1. the amount of the APAD for the discharge exceeds $0.

2. the Hospital’s Discharge-Specific Case Cost exceeds the Discharge-Specific Outlier Threshold for that discharge:

4. the patient is not a patient in an Excluded Unit within the Hospital.

The following is an illustrative example of the calculation of the Total Case Payment for a claim that also involves an Outlier Payment. The example assumes the 2% RY21 Period applies.

TN: 020-027 Supersedes: 019-027

Approval Date: 3/24/21 Effective Date: 10/01/20

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Attachment 4.19-A (1) Page 35 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 Transfer Per Diem Payments RY21 is bifurcated into the 1st RY21 Period and the 2nd RY21 Period for purposes of applying the Transfer Per Diem payment methodology. The Transfer Per Diem payment methodology is set forth in this Section III.D; provided that, (i) for admissions in the 1st RY21 Period, applicable definitions from Section II that apply to the 1st RY21 Period are incorporated; (ii) for admissions in the 2nd RY21 Period, applicable definitions from Section II that apply to the 2nd RY21 Period are incorporated; (iii) all references in this Section III.D to the APAD and Outlier Payment methodologies in Sections III.B and III.C shall refer to the methodology that applies to the specific admission (1st RY21 Period method for admissions in the 1st RY21 Period or 2nd RY21 Period method for admissions in the 2nd RY21 Period); and (iv) any other differences in the Transfer Per Diem methodology as between the 1st RY21 Period and the 2nd RY21 Period are as specified below. Hospitals will be paid a Transfer Per Diem under the circumstances specified in this section. In general, total payments made on a Transfer Per Diem basis are capped at the Hospital’s Total Transfer Payment Cap. The Transfer Per Diem rate is case-specific and is calculated as set forth in Section III.D.1, below. 1. Transfer between Hospitals In general, a Hospital that transfers a patient to another Acute Hospital will be paid at the Transfer Per Diem rate, up to the Transferring Hospital’s Total Transfer Payment Cap. In general, the Hospital that is receiving the patient will be paid (a) on a per discharge basis in accordance with the APAD, and, if applicable, Outlier Payment methodology(ies) specified in Sections III.B and III.C, above, if the patient is actually discharged from that Table 2: Claim with Outlier Payment - 2nd RY21 Period (Values are for demonstration purposes only) Hospital: Sample Hospital DRG: 203, Chest Pain. Severity of Illness (SOI) = 2. Line Description Value Calculation or Source 1 APAD (must be > $0) $4,517.07 Table 1, Line 8, above 2 Allowed charges $75,000.00 Determined from claim 3 Hospital's Inpatient Cost-to-Charge Ratio 72.00% FY18 Massachusetts Hospital Cost Report 4 Discharge-Specific Case Cost $54,000.00 Line 2 * Line 3 5 Fixed Outlier Threshold $38,400 Section II Definition (2nd RY21 Period) 6 Discharge-Specific Outlier Threshold $42,917.07 Line 1 + Line 5 7 Does Discharge-Specific Case Cost exceed Discharge-Specific Outlier Threshold? TRUE Is Line 4 > Line 6? If TRUE, then Outlier Payment is due 8 Marginal Cost Factor 60% Determined annually 9 Outlier Payment $6,649.76 (Line 4 - Line 6) * Line 8 10 Total Case Payment = APAD plus Outlier Payment $11,166.83 Line 1 + Line 9 3/24/21

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Attachment 4.19-A (1) Page 36

State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

Hospital; or (b) on a Transfer Per Diem basis, capped at the Hospital’s Total Transfer Payment Cap, if the Hospital transfers the patient to another Acute Hospital or back to the Acute Hospital from which it received the patient.

The Transfer Per diem rate will equal the following. For admissions in the 1* RY21 Period, the “1 RY21 Period” column applies. For admissions in the 2% RY21 Period, the “2% RY21

Period” column applies. 1* RY21 Period 24 RY21 Period (for admissions occurring (for admissions occurring in the 1* RY21 Period) in the 2" RY21 Period)

The Transfer Per Diem rate equals the Transferring Hospital’s Total Case Payment amount, divided by the applicable DRG- specific mean all-payer length of stay from the APR-DRG Massachusetts-specific weight file applicable to the 1" RY21 Period. For purposes of this calculation, the Total Case Payment amount is calculated utilizing the APAD, and if applicable, Outlier Payment methodology(ies) set forth in Section II-B. and III.C., above, for the period for which the Transferring Hospital is being paid on a Transfer Per Diem basis pursuant to this Section II.D. Payment on a Transfer Per Diem basis will be capped at the Transferring Hospital’s Total Transfer Payment Cap.

The Transfer Per Diem rate equals the Transferring Hospital’s Total Case Payment amount, divided by the applicable DRG- specific mean all-payer length of stay from the APR-DRG Massachusetts-specific weight file applicable to the 2 RY21 Period. For purposes of this calculation, the Total Case Payment amount is calculated utilizing the APAD, and if applicable, Outlier Payment methodology(ies) set forth in Section II-B. and III.C., above, for the period for which the Transferring Hospital is being paid on a Transfer Per Diem basis pursuant to this Section II.D. Payment on a Transfer Per Diem basis will be capped at the Transferring Hospital’s Total Transfer Payment Cap.

See Table 3: Claim with Transfer (APAD only) and Table 4: Claim with Transfer (APAD and Outlier), respectively, below, for illustrative examples of the calculation of the Transfer Per Diem, Total Transfer Payment Cap, and corresponding Total Transfer Case Payment, that would apply to the case. These illustrative examples apply to all subsections of Section III.D, and assume that the 2** RY21 Period applies.

TN: 020-027

Approval Date: 3/24/21

Supersedes: 019-027

Effective Date: 10/01/20

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Attachment 4.19-A (1) Page 37 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 2. Transfers within a Hospital Except as described below, a transfer within a Hospital is not considered a discharge. Consequently, in most cases a transfer between units within a Hospital will be paid on a Transfer Per Diem basis, capped at the Hospital’s Total Transfer Payment Cap. This section outlines payment under some specific transfer circumstances. a. Transfer to/from a Non-Acute, Skilled Nursing, or other Separately Licensed Unit within the Same Hospital If a patient is transferred from an acute bed to a Non-Acute bed (except for a DMH- licensed bed or any separately licensed unit in the same Hospital), the transfer is considered a discharge. EOHHS will pay the Hospital’s discharge-specific APAD for the portion of the stay that preceded the patient’s discharge to any such unit. Table 3: Claim with Transfer (APAD only) - 2nd RY21 Period (Values are for demonstration purposes only) Hospital: Sample Hospital DRG: 203, Chest Pain. Severity of Illness (SOI) = 2. Line Description Value Calculation or Source 1 APAD (Total Case Payment Amount) $4,517.07 Table 1, line 8, above 2 Patient length of stay (# of days) 2

Determined from claim 3 Mean all-payer length of stay for DRG 203 2.06

Determined from Mass. weight file (2nd RY21 Period) 4 Transfer per diem $2,187.97 Line 1 / Line 3 5 Transfer per diem x Patient length of stay (# of days) $4,375.95 Line 4 * Line 2 6 Total Transfer Payment Cap $4,517.07 Table 3, Line 1 7 Total Transfer Case Payment $4,375.95 Lower of Line 5 or Line 6 Table 4: Claim with Transfer (APAD and Outlier) - 2nd RY21 Period (Values are for demonstration purposes only) Hospital: Sample Hospital DRG: 203, Chest Pain. Severity of Illness (SOI) = 2. Line Description Value Calculation or Source 1 Total Case Payment amount (Claim with Outlier Payment) $11,166.83 Table 2, Line 10 above 2 Patient length of stay (# of days) 2 Determined from claim 3 Mean all-payer length of stay for DRG 203 2.06

Determined from Mass. weight file (2nd RFY21 Period) 4 Transfer per diem $5,408.98 Line 1 / Line 3 5 Transfer per diem x Patient length of stay (# of days) $10,817.95 Line 4 * Line 2 6 Total Transfer Payment Cap $11,166.83 Table 4, Line 1 7 Total Transfer Case Payment $10,817.95 Lower of Line 5 or Line 6 3/24/21

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Attachment 4.19-A (1) Page 38 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 b. MassHealth Payments for Newly Eligible Members, Members Who Change Enrollment from the PCC Plan, Primary Care ACO, or Fee-for-Service to an MCO (or vice versa) during a Hospital Stay, or in the Event of Exhaustion of (or eligibility for) Other Insurance When a patient becomes MassHealth-eligible (or loses MassHealth eligibility), after the date of admission and prior to the date of discharge, changes enrollment from the PCC Plan, a Primary Care ACO, or Fee-for-Service to an MCO (or vice versa) during the course of a Hospital stay, or exhausts other insurance benefits (or becomes eligible for other insurance benefits) after the date of admission and prior to the date of discharge, the MassHealth-covered portion of the acute stay will be paid at the Transfer Per Diem rate, capped at the Hospital’s Total Transfer Payment Cap, or if the patient is at the Administrative Day level of care, at the applicable AD per diem rate, in accordance with Section III.G. c. Admissions Following Outpatient Surgery or Procedure If a patient who requires Inpatient Hospital Services is admitted following an outpatient surgery or procedure at the Hospital, the Hospital shall be paid at the Transfer Per Diem rate, capped at the Hospital’s Total Transfer Payment Cap. d. Transfer between a DMH-licensed Bed and Any Other Bed within the Same Hospital Payment for a transfer between a DMH-licensed Bed and any other bed within a Hospital will vary depending on the circumstances involved, such as managed care status, whether the Hospital is part of the BH network, and the type of service provided. See also subsection e, below. When a Member who is not enrolled with the BH Contractor transfers between a DMH- licensed Bed and a non-DMH-licensed Bed in the same Hospital during a single admission, except in the circumstances described in the last sentence of this paragraph, EOHHS will pay the Hospital at the Transfer Per Diem rate, capped at the Hospital’s Total Transfer Payment Cap for the non-DMH-licensed bed portion of the stay, and on a Psychiatric Per Diem basis (see Section III.E, below) for the DMH-licensed bed portion of the stay. For the duration of the Governor’s March 10, 2020, Declaration of a State of Emergency within the Commonwealth due to COVID-19, a Member transferred between a DMH-Licensed Bed and a non-DMH-Licensed Bed whose primary diagnosis while in the DMH-Licensed bed is not BH-related will not be considered a Transfer Patient. If the Member is enrolled with the BH Contractor and the Hospital is in the BH Contractor's network, EOHHS will pay only for the non-DMH-licensed bed portion of the stay, and such payment will be at the Transfer Per Diem rate, capped at the Hospital’s Total Transfer Payment Cap. 3/24/21

(ma-20-0027)(approval-document)(page-42)Page 42#

Attachment 4.19-A (1) Page 39 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 e. Change of BH Managed Care Status during a Behavioral Health Hospitalization When a Member is enrolled with the BH Contractor during a Behavioral Health admission and the Hospital is in the BH Contractor's network, the portion of the Hospital stay during which the Member is enrolled with the BH Contractor is payable by the BH Contractor. The portion of the Hospital stay during which the Member was not enrolled with the BH Contractor will be paid by EOHHS on a Psychiatric Per Diem basis (see Section III.E, below) for Behavioral Health Services in a DMH-licensed Bed, or at the Transfer Per Diem rate, capped at the Hospital’s Total Transfer Payment Cap, for Behavioral Health Services in a non-DMH-licensed Bed. Payments for Behavioral Health Services (Psychiatric Per Diem) 1. Overview a. Services provided to MassHealth Members in DMH-licensed Beds who are not enrolled with the BH Contractor or an MCO shall be paid on an all-inclusive Psychiatric Per Diem basis. b. The statewide standard Psychiatric Per Diem rate is the sum of the three Psychiatric Per Diem Base Year Operating Standards (see subsection 2) and the Psychiatric Per Diem Base Year Capital Standard (see subsection 3), adjusted for the current Rate Year (see subsection 4). c. The Psychiatric Per Diem Base Year is RY04. MassHealth utilizes the costs, statistics, and revenue reported in the 2004 -403 cost reports as screened and updated as of March 10, 2006. d. RY21 is bifurcated into the 1st RY21 Period and the 2nd RY21 Period for purposes of applying this Psychiatric Per Diem payment methodology. Differences in the methodology and the final per diem rate that applies to dates of services in the 1st RY21 Period and the 2nd RY21 Period, respectively, are identified in Section III.E.4, below. The methodology is otherwise the same for both periods. 2. Determination of the Psychiatric Per Diem Base Year Operating Standards a. Standard for Inpatient Psychiatric Overhead Costs The Standard for Inpatient Psychiatric Overhead Costs is the median of the inpatient psychiatric overhead costs per day for the array of Acute Hospitals providing mental health services in DMH-licensed beds. The median is determined based upon inpatient psychiatric days. The base year Standard for Inpatient Psychiatric Overhead Costs is $363.28. 3/24/21

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Attachment 4.19-A (1) Page 40 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 b. Standard for Inpatient Psychiatric Direct Routine Costs The Standard for Inpatient Psychiatric Direct Routine Costs is the median of the inpatient psychiatric direct routine costs per day (minus direct routine physician costs) for the array of Acute Hospitals providing mental health services in DMH-licensed beds. The median is determined based upon inpatient psychiatric days. The base year Standard for Inpatient Psychiatric Direct Routine Costs is $325.13. c. Standard for Inpatient Psychiatric Direct Ancillary Costs The Standard for Inpatient Psychiatric Direct Ancillary Costs is the median of the inpatient psychiatric direct ancillary costs per day for the array of Acute Hospitals providing mental health services in DMH-licensed beds. The median is determined based upon inpatient psychiatric days. The base year Standard for Inpatient Psychiatric Direct Ancillary Costs is $56.83. 3. Determination of the Psychiatric Per Diem Base Year Capital Standard The Standard for Inpatient Psychiatric Capital Costs is the median of the inpatient psychiatric capital costs per day for the array of Acute Hospitals providing mental health services in DMH-licensed beds. The median is determined based upon inpatient psychiatric days. The base year Standard for Inpatient Psychiatric Capital Costs is $30.73. a. Each Hospital’s base year psychiatric capital cost per day equals the base year psychiatric capital cost divided by the greater of: the actual base year psychiatric days or eighty-five percent (85%) of the base year maximum licensed psychiatric bed capacity, measured in days. b. Each Hospital’s base year capital costs consist of the Hospital’s actual Psychiatric Per Diem Base Year patient care capital requirement for historical depreciation for building and fixed equipment, reasonable interest expenses, amortization, leases, and rental of facilities. Any gains from the sale of property will be offset against the Hospital’s capital expenses. 4. Adjustment to Base Year Standard In calculating the final statewide standard Psychiatric Per Diem rate applicable to dates of service in RY21, the three Psychiatric Per Diem Base Year Operating Standards are updated between the Base Year and RY2007 using the Inflation Factors for Operating Costs (see Section II above). The Psychiatric Per Diem Base Year Capital Standard is updated between the Base Year and RY2007 using the Inflation Factors for Capital Costs (see Section II above). The Inflation Factors for Operating Costs (see Section II above) between RY08 and RY10 and between RY12 and RY20 were then applied to the rate calculated above to determine the statewide standard Psychiatric Per Diem rate applicable to dates of service in RY21. 3/24/21

(ma-20-0027)(approval-document)(page-44)Page 44#

Attachment 4.19-A (1) Page 41 State Plan Under Title XIX of the Social Security Act State: Massachusetts

Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services

The total adjustment to Base Year Costs from the Psychiatric Per Diem Base Year costs for the RY21 Period Psychiatric Per Diem is $165.13. The statewide standard Psychiatric Per Diem rate applicable to dates of service in RY21 is $941.10.

F. Physician Payment

For physician services provided by Hospital-Based Physicians to MassHealth patients, the Hospital will be paid for the professional component of Hospital-Based Physician services in accordance with Section 8.d. of Attachment 4.19-B of the State Plan.

Hospitals will be paid for Hospital-Based Physician services only if the Hospital-Based Physician took an active patient care role, as opposed to a supervisory role, in providing the Inpatient Service(s) on the billed date(s) of service.

Physician services provided by residents and interns are not reimbursable separately. The Hospital-Based Physician may not bill for any professional component of the service that is billed by the Hospital. Hospitals will only be reimbursed separately for professional fees for practitioners who are Hospital-Based Physicians as defined in Section II.

Hospitals shall not be paid for inpatient physician services provided by Community-Based Physicians.

G. Payments for Administrative Days

RY21

is bifurcated into the 1* RY21 Period and the 2% RY21 Period for purposes of applying the

payment methodology for Administrative Days. The methodology in the “1 RY21 Period” column of this Section III.G, below, applies to dates of service in the 1‘ RY21 Period and incorporates applicable definitions in Section II that apply to the 1 RY21 Period. The methodology in the “2 RY21 Period” column applies to dates of service in the 2" RY21 Period and incorporates applicable definitions in Section II that apply to the 2% RY21 Period.

1* RY21 Period 2™4 RY21 Period (for dates of service occurring (for dates of service occurring in the 1 RY 21 Period) in the 2" RY 21 Period)

1. Payments for Administrative Days will be 1. Payments for Administrative Days will be made on a per diem basis as described made on a per diem basis as described below. These per diem rates are all- below. These per diem rates are all- inclusive and represent payment in full for inclusive and represent payment in full for all Administrative Days in all Acute all Administrative Days in all Acute Hospitals. Hospitals.

2. The AD rate is a base per diem payment 2. The AD rate is a base per diem payment and an ancillary add-on. and an ancillary add-on.

3. The base per diem payment is $201.63, 3. The base per diem payment is $219.14, which represents the median nursing which represents the median nursing

TN: 020-027 Approval Date: 3/24/21 Effective Date: 10/01/20

Supersedes: 019-027

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Attachment 4.19-A (1)

Page 42 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services 1* RY21 Period 2™4 RY21 Period (for dates of service occurring (for dates of service occurring in the 1 RY 21 Period) in the 2! RY 21 Period)

facility rate that was effective October 1, facility rate that was effective July 1, 2020

2015 for all nursing home rate categories, for all nursing home rate categories, as

as determined by EOHHS. determined by EOHHS.

4. The ancillary add-on is based on the ratio The ancillary add-on is based on the ratio of ancillary charges to routine charges, of ancillary charges to routine charges, calculated separately for calculated separately for Medicaid/Medicare Part B eligible patients Medicaid/Medicare Part B eligible patients and Medicaid-only eligible patients on AD and Medicaid-only eligible patients on AD status, using MassHealth paid claims for status, using MassHealth paid claims for the period October 1, 1997 to September the period October 1, 1997 to September 30, 1998. 30, 1998.

5. These ratios are 0.278 and 0.382, These ratios are 0.278 and 0.382, respectively. respectively.

The resulting AD rates were then updated The resulting AD rates for the 2" RY21

by the Inflation Factor for Administrative Period are $280.06 for Medicaid/Medicare

Days between RY16 and RY20. The Part B eligible patients and $302.85 for

resulting AD rates for the 1*RY21 Period Medicaid-only eligible patients.

are $280.61 for Medicaid/Medicare Part B

eligible patients and $303.45 for Medicaid- The Hospital may not bill for more than

only eligible patients. one APAD even if the patient fluctuates between acute status and AD status.

6. The Hospital may not bill for more than one APAD even if the patient fluctuates between acute status and AD status.

H. Rehabilitation Unit Services in Acute Hospitals

RY21 is bifurcated into the 1 RY21 Period and the 2 RY21 Period for purposes of applying the Rehabilitation Unit per diem payment. The methodology in the “1 RY21 Period” column of this Section III.H, below, applies to dates of service in the 1 RY21 Period and incorporates applicable definitions in Section II that apply to the 1*RY21 Period. The methodology in the “2% RY21 Period” column applies to dates of service in the 2% RY21 Period and incorporates applicable definitions in Section II that apply to the 2" RY21 Period.

TN: 020-027

Approval Date: 3/24/21

Supersedes: 019-027

Effective Date: 10/01/20

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Attachment 4.19-A (1)

Page 43 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services 1% RY21 Period 2™4 RY21 Period (for dates of service occurring (for dates of service occurring in the 1t RY21 Period) in the 2"! RY21 Period)

A DPH-licensed Acute Hospital with a Rehabilitation Unit may bill a per diem rate for Rehabilitation Services provided in the Rehabilitation Unit.

For dates of service in the 1t RY21 Period, the per diem rate for such Rehabilitation Services will equal the median MassHealth RY20 Rehabilitation Hospital group per diem rate for Chronic Disease and Rehabilitation hospitals. Acute Hospital Administrative Day rates (see Section III.G above) will be paid for all days that a patient remains in the Rehabilitation Unit while not at hospital level of care.

A DPH-licensed Acute Hospital with a Rehabilitation Unit may bill a per diem rate for Rehabilitation Services provided in the Rehabilitation Unit.

For dates of service in the 2 RY21 Period, the per diem rate for such Rehabilitation Services will equal the median MassHealth RY20 Rehabilitation Hospital group per diem rate for Chronic Disease and Rehabilitation hospitals. Acute Hospital Administrative Day rates (see Section III.G above) will be paid for all days that a patient remains in the Rehabilitation Unit while not at hospital level of care.

I. APAD Carve-Outs

A Hospital may be paid separate from the APAD for a LARC Device if the LARC procedure is performed immediately after labor and delivery during same inpatient hospital labor and delivery stay for clinically appropriate members. For qualifying discharge, Hospitals will be reimbursed for LARC Devices in accordance with Section 8.d. of Attachment 4.19-B of the

RY21 is bifurcated into the 1 RY21 Period and the 2% RY21 Period for purposes of determining payment for APAD Carve-Out Drugs. The methodology in the “1‘t RY21 Period” column of this Section III.1.2, below, applies to dates of service in the 1 RY21 Period and incorporates applicable definitions in Section II that apply to the 1% RY21 Period. The

1. Payment for LARC Device State Plan. 2. Payment for APAD Carve-Out Drugs TN: 020-027

Supersedes: 019-027

Approval Date: 3/24/21

Effective Date: 10/01/20

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Attachment 4.19-A (1) Page 45 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 J. Payment for Unique Circumstances 1. High Public Payer Hospital Supplemental Payment a. Eligibility In order to qualify for the High Public Payer Hospital Supplemental Payment, a Hospital’s FY19 public payer percentage, which is the ratio of the Hospital’s FY19 Gross Patient Service Revenue from government payers and free care to the Hospital’s FY19 Gross Patient Service Revenue (“FY19 Public Payer Percentage”), must exceed 63% (“High Public Payer Threshold”), as determined by EOHHS based on the Hospital’s FY19 Massachusetts Hospital Cost Report. b. Supplemental Payment Methodology Subject to compliance with all applicable federal rules and payment limits, EOHHS will make a supplemental payment to each Hospital satisfying the eligibility criteria set forth in Section III.J.1.a (each an “Eligible Hospital” for purposes of this Section III.J.1). “MCO” for purposes of this Section III.J.1 includes only “traditional” MCOs, and excludes ACPPs, Senior Care Organizations (SCOs), and One Care plans. The inpatient portion of the supplemental payment amount for each Qualifying Hospital will be determined by apportioning a total of $6.5 million to such Qualifying Hospitals on a pro-rata basis, as follows: • First, EOHHS will calculate each Eligible Hospital’s Weighted Discharge Volume by summing 60% of the Hospital’s FY21 Accountable Care Partnership Plan (ACPP) and Primary Care ACO discharge volume, 20% of the Hospital’s FY21 MCO discharge volume, and 20% of the Hospital’s FY21 PCC Plan discharge volume; • Second, EOHHS will calculate each Eligible Hospital’s Pro-Rata Discharge Volume by dividing its Weighted Discharge Volume by the sum of all Eligible Hospitals’ Weighted Discharge Volumes; • Third, EOHHS will calculate each Eligible Hospital’s HPP Ratio by: o Subtracting the 63% High Public Payer Threshold from that Hospital’s FY19 Public Payer Percentage; o Multiplying that difference by 12%; and o Adding 2% to that product; • Fourth, EOHHS will calculate each Eligible Hospital’s Inpatient HPP Distribution Percentage by multiplying its Pro-Rata Discharge Volume by its HPP Ratio; 3/24/21

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Attachment 4.19-A (1) Page 46 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 • Fifth, EOHHS will calculate each Eligible Hospital’s Inpatient HPP Payment Factor by dividing its Inpatient HPP Distribution Percentage by the sum of all Inpatient HPP Distribution Percentages for all Eligible Hospitals; and • Sixth, EOHHS will calculate the inpatient portion of each Eligible Hospital’s supplemental payment by multiplying its Inpatient HPP Payment Factor by $6.5 million. For purposes of this calculation, FY21 ACPP, Primary Care ACO, MCO, and PCC Plan discharge volume refers to paid inpatient discharges from the Qualifying Hospital for MassHealth Members enrolled in an ACPP, a Primary Care ACO, an MCO, or the PCC Plan, as determined by EOHHS utilizing, for the ACPP and MCO discharges, ACPP and MCO encounter data submitted by each ACPP or MCO for FY21, respectively, and residing in the MassHealth Data Warehouse as of March 31, 2022, and for the PCC Plan and Primary Care ACO discharges, Medicaid paid claims data for FY21 residing in MMIS as of March 31, 2022 for which MassHealth is primary payer. Only MCO and ACPP encounter data and MMIS paid claims data pertaining to qualifying High Public Payer Hospitals (as specified in Section III.J.1.a) is considered in determining the pro rata share. 2. Essential MassHealth Hospitals a. Eligibility In order to qualify for payment as an Essential MassHealth Hospital, a Hospital must itself meet, or be within a system of Hospitals, any one of which meets, at least four of the following criteria, as determined by EOHHS, provided that all Hospitals within such system are owned or controlled, directly or indirectly, by a single entity that (i) was created by state legislation prior to 1999; and (ii) is mandated to pursue or further a public mission: (1) The Hospital is a non-state-owned public Acute Hospital. (2) The Hospital meets the current MassHealth definition of a non-profit teaching Hospital affiliated with a Commonwealth-owned medical school. (3) The Hospital has at least 7% of its total patient days as Medicaid days. (4) The Hospital is an acute care general Hospital located in Massachusetts which provides medical, surgical, emergency and obstetrical services. (5) The Hospital enters into a separate contract with EOHHS relating to payment as an Essential MassHealth Hospital. Based on these criteria, Cambridge Health Alliance (CHA) and the UMass Memorial Health Care, Inc. Hospitals (UMass Hospitals) are the only Hospitals eligible for this payment. 3/24/21

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Attachment 4.19-A (1) Page 47 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 b. Supplemental Payment Methodology Subject to compliance with all applicable federal rules and payment limits, including 42 CFR 447.271, EOHHS will make a supplemental payment to Essential MassHealth Hospitals. This payment is based on approval by EOHHS of the Hospital’s accurately submitted and certified EOHHS Office of Medicaid Uniform Medicaid and Low Income Uncompensated Care Cost & Charge Report (UCCR) for the hospital fiscal year corresponding with the payment. For the UMass Hospitals, the Federal Fiscal Year 2021 (FFY21) inpatient payment amount will be up to $6,000 times the total number of inpatient days for admissions beginning during FFY21, not to exceed $8.0 million. For CHA, the Federal Fiscal Year inpatient payment amount will be the difference between the non-state-owned public hospital Upper Payment Limit (calculated on an annual basis) and other payments made under this Attachment, not to exceed $7.5 million. Notwithstanding such maximum inpatient amount, EOHHS may make inpatient payments to CHA of up to an additional 10% of the CHA Total Maximum Essential Amount (as defined in this paragraph, below), subject to compliance with all applicable federal rules and payment limits, including 42 CFR 447.271, and satisfying all other conditions of this Section III.J.2.b as it applies to CHA, so long as the total inpatient and outpatient Essential MassHealth Hospital supplemental payment amounts to CHA for the Federal Fiscal Year under this paragraph and under Section III.F.2 of Attachment 4.19-B(1) (TN-020-028) do not, in the aggregate, exceed the CHA Total Maximum Essential Amount. The CHA Total Maximum Essential Amount is $25.0 million. The 10% provisions referenced above in this section may be invoked if, upon reconciliation, an applicable outpatient hospital limit would be exceeded if CHA was paid its maximum FFY21 outpatient Essential MassHealth Hospital Supplemental Payment amount under Section III.F.2 of Attachment 4.19-B(1) (TN-020-028), or if CHA has insufficient outpatient utilization or otherwise to support the payment of such maximum outpatient payment amount. Essential MassHealth Hospital payments will be made after EOHHS’ receipt of the hospital's certified UCCR, finalization of payment data and applicable payment amounts, and receipt of any necessary approvals, but no later than 1 year after receipt of the hospital's final reconciliation UCCR (which must be submitted by 45 days after the Hospital's Medicare 2552 Report for the payment year has been finalized by Medicare’s Fiscal Intermediary). 3/24/21

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Attachment 4.19-A (1) Page 48 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 3. High Medicaid Volume Freestanding Pediatric Acute Hospitals a. Eligibility Based on the definition of High Medicaid Volume Freestanding Pediatric Acute Hospital as defined in Section II, Boston Children's Hospital is the only Hospital eligible for this payment. b. Supplemental Payment Methodology Subject to compliance with all applicable federal rules and payment limits, EOHHS will make a supplemental payment to High Medicaid Volume Freestanding Pediatric Acute Hospitals to account for high Medicaid volume. The supplemental payment amount is determined by EOHHS based on data filed by each qualifying Hospital in its financial and cost reports, and projected Medicaid volume for the hospital Federal Fiscal Year. The Federal Fiscal Year payment is based on Medicaid payment and cost data. The payment equals the variance between the Hospital’s inpatient Medicaid payments and inpatient Medicaid costs, not to exceed $3,850,000. High Medicaid Volume Freestanding Pediatric Acute Hospital payments will be made after finalization of payment data, applicable payment amounts, and obtaining any necessary approvals. 4. Acute Hospitals with High Medicaid Discharges a. Eligibility In order to qualify for payment as an Acute Hospital with High Medicaid Discharges, a Hospital must be an Acute Hospital that has more than 2.7% of the statewide share of Medicaid discharges, determined by dividing each Hospital’s total Medicaid discharges as reported on the Hospital’s Massachusetts Hospital Cost Report by the total statewide Medicaid discharges for all Hospitals. b. Supplemental Payment Methodology Subject to compliance with all applicable federal rules and payment limits, EOHHS will make a supplemental payment to Acute Hospitals that have higher Medicaid discharges when compared with other participating MassHealth Hospitals. The payment amount is based on Medicaid payment, cost and charge data for the federal fiscal year. The payment equals the variance between the Hospital’s inpatient Medicaid payment and inpatient Medicaid costs, not to exceed the Hospital’s Health Safety Net Trust Fund-funded payment amount for the federal fiscal year. Interim payments to Acute Hospitals with High Medicaid Discharges will be reconciled within 12 months after final settlement of the applicable Health Safety Net year. 3/24/21

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Attachment 4.19-A (1) Page 49 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 5. High Public Payer Behavioral Health Service Supplemental Payment a. Eligibility In order to qualify for the High Public Payer Hospital Behavioral Health Supplemental Payment, an Acute Care Hospital must (1) qualify for a RY21 High Public Payer Supplemental Payment pursuant to Section III.J.1; (2) operate at least one DMH- Licensed Bed throughout RY21, and (3) have provided Inpatient Behavioral Health Services to MassHealth members in FY19. b. Payment Methodology (1) Subject to compliance with all applicable federal rules and payment limits, EOHHS will make a supplemental payment to Hospitals that meet the qualifications described in Section III.J.5.a, in the aggregate amount of $9.0 million, to support access to Inpatient Behavioral Health Services for MassHealth Members, with particular emphasis on supporting access to such services for child and adolescent Members, using the APAD payment methodology to develop a proxy that takes into account the various acuity levels such Members present. EOHHS will pay qualifying hospitals in accordance with the formula set forth in Section III.J.5.b.(2), below. (2) Each qualifying Hospital receives an amount as calculated by the following methodology: Step A. Calculate Hospital Specific Payment Amount based on Share of IP BH Days, weighted toward pediatric/adolescent days. ൥൥ቈቂ Hospital Specific IP Pedi Adol BH Days Total IP Pedi Adol BH Days for all Hospitals ∗0.6ቃ+ ቂ Hospital Specific IP Adult BH Days Total IP Adult BH Days for all Hospitals ∗0.4ቃ቉൩∗$9,000,000 ൩= 𝐴𝐴 Step B. Calculate Hospital Specific Relative Acuity Adjusted Proxy Payment Amount, determined by APAD grouper methodology. ൥൤Hospital specific relative acuity adjusted payment proxy Total relative acuity adjusted proxy payments ൨∗$9,000,000൩= 𝐵𝐵 Step C. Blend Hospital Specific Payment Amount based on Share of IP BH Days and Hospital Specific Payment Amount based on Relative Acuity Complexity ൤ቂ A $9,000,000 ∗0.5ቃ+ ቂ B $9,000,000 ∗0.5ቃ൨∗$9,000,000 =Hospital Specific Supplemental Payment 3/24/21

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Attachment 4.19-A (1) Page 50 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 Glossary: As used in this Section III.J.5, the following terms shall have the meanings that follow: “BH days” refers to the total number of days in which MassHealth Members (whether fee for service or enrolled in managed care or MBHP) received Inpatient Behavioral Health Services in FY19, using data residing in MMIS and/or the Data Warehouse as of March 31, 2020. “Hospitals” refers to qualifying Hospitals that meet the requirements of Section III.J.5.a, above. “Pedi Adol” is short for “pediatric and adolescent” and refers to MassHealth members under age 18. “Adult” refers to MassHealth members age 18 and older. “Relative Acuity Adjusted Proxy Payment” refers to a relative acuity adjusted proxy payment calculated as follows. To develop a relative acuity adjusted proxy payment, EOHHS processed all Hospital IP BH claims (whether for fee for service members or members enrolled in managed care or MBHP) residing in MMIS and/or the Data Warehouse as of March 31, 2020, using the APAD methodology (used to price medical IP claims). The APAD methodology assigns relative acuity to each discharge and then multiplies the acuity by a base rate to establish an acuity adjusted proxy payment. EOHHS will then take the ratio of each qualifying hospital’s total average relative acuity adjusted proxy payment to the sum of all qualifying hospitals’ acuity adjusted proxy payments to establish each hospital’s pro rata share of such total payments. “IP” refers to inpatient. 6. Specialized Pediatric Service Hospital Supplemental Payment a. Eligibility In order to qualify for the Specialized Pediatric Service Hospital Supplemental Payment, a Hospital must be a Specialized Pediatric Service Hospital, as defined in Section II. Based on these criteria, Boston Children's Hospital, Tufts Medical Center, and Massachusetts General Hospital are the only hospitals eligible for this payment. b. Payment Methodology Subject to compliance with all applicable federal rules and payment limits, EOHHS will make $5.5 million in total aggregate supplemental payments to Specialized Pediatric Service Hospitals, with payment to each hospital based on its pro rata share of all Specialized Pediatric Service Hospitals’ acute inpatient discharges of Members meeting certain criteria, according to the methodology that follows. EOHHS will first calculate each Specialized Pediatric Service Hospital’s pro rata share of all Specialized Pediatric Service Hospitals’ acute inpatient discharges of members under the age of 21 and enrolled in either an ACPP or a Primary Care ACO during the period from October 1, 3/24/21

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Attachment 4.19-A (1) Page 51 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 2019 through September 30, 2020. EOHHS will then multiply that ratio by $5.5 million to determine that Specialized Pediatric Service Hospital’s supplemental payment. 7. High Medicaid Volume Safety Net Hospital Supplemental Payment a. Eligibility In order to qualify for this payment, a Hospital must be a High Medicaid Volume Safety Net Hospital as defined in Section II, and must enter into a separate payment agreement with EOHHS relating to payment as a High Medicaid Volume Safety Net Hospital. Based on these criteria, Boston Medical Center is the only hospital eligible for this payment. b. Payment Methodology Subject to compliance with all applicable federal rules and payment limits, including 42 CFR 447.271, EOHHS will make a supplemental payment to High Medicaid Volume Safety Net Hospitals to account for high Medicaid volume. The payment amount will be based on Medicaid payment and charge data for the federal fiscal year. The payment will be an amount up to the variance between the Hospital’s FY21 MMIS-based inpatient hospital charges and its other inpatient hospital payments made under this Attachment for the applicable federal fiscal year, not to exceed $15.0 million. 8. Infant and Pediatric Outlier Payment Adjustments a. Infant Outlier Payment Adjustment In accordance with 42 U.S.C. § 1396a(s), EOHHS will make an annual infant outlier payment adjustment to Acute Hospitals for inpatient services furnished to infants under one year of age involving exceptionally high costs or exceptionally long lengths of stay based on the prior year's claims data from the Medicaid Management Information System (MMIS). i. Eligibility In order to qualify for an infant outlier payment, a Hospital must provide services to infants less than one year of age, and must have one of the following during the Rate Year for individuals less than one year of age: • An average Medicaid inpatient length of stay that equals or exceeds the statewide weighted average plus two standard deviations; or • An average cost per inpatient Medicaid discharge that equals or exceeds the Hospital's average cost per Medicaid inpatient discharge plus two standard deviations for individuals of all ages. 3/24/21

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Attachment 4.19-A (1) Page 52 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 ii. Payment to Hospitals Annually, each Hospital that qualifies for an infant outlier adjustment receives an equal portion of $50,000. For example, if two Hospitals qualify for an outlier adjustment, then each Hospital receives $25,000. b. Pediatric Outlier Payment Adjustment In accordance with 42 U.S.C. § 1396a(s), EOHHS will make an annual pediatric outlier payment adjustment to Acute Hospitals for inpatient services furnished to children greater than one year of age and less than six years of age involving exceptionally high costs or exceptionally long lengths of stay based on the prior year's discharge data from MMIS. i. Eligibility In order to qualify for a pediatric outlier payment, a Hospital must provide services to children greater than one year of age and less than six years of age, and must have one of the following during the Rate Year for individuals within this age range: • An average Medicaid inpatient length of stay that equals or exceeds the statewide weighted average plus two standard deviations; or • An average cost per inpatient Medicaid discharge that equals or exceeds the Hospital's average cost per Medicaid inpatient discharge plus two standard deviations for individuals of all ages. ii. Payment to Hospitals Annually, each Acute Hospital qualifying for a pediatric outlier adjustment will receive $1,000. 9. Adult Inpatient BH Per Diem Supplemental Payment a. Definitions For purposes of this Section III.J.9, the following terms shall have the following meanings: 1. Adult – a Member aged 18 years or older 2. Adult Inpatient BH Bed-Days Baseline - the adjusted total CY19 Adult Inpatient BH Bed-Days, calculated in accordance with Section III.J.9. b.2.c. 3. Adult Inpatient BH Bed-Days Volume - the calculated number of the Hospital’s Adult Inpatient BH Bed-Days for a particular period. 3/24/21

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Attachment 4.19-A (1) Page 53 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 4. Adult Inpatient BH Bed-Day – a day on which a Hospital provided Inpatient Behavioral Health Services to an Adult for which payment was made by MassHealth or a Managed Care Entity, as determined by EOHHS, provided, however, that days on which the Hospital provided Inpatient Behavioral Health Services to an Adult enrolled in SCO, One Care, or the Program of All-Inclusive Care for the Elderly (PACE) shall not constitute Adult Inpatient BH Bed-Days. Adult Inpatient BH Bed-Days shall include each day of utilization for each Adult to whom Inpatient Behavioral Health Services were rendered. 5. Managed Care Entity (MCE) – An MCO or the BH Contractor. 6. First RY21 Performance Period – the period beginning on November 1, 2020 and ending on April 30, 2021. 7. Second RY21 Performance Period – the period beginning on May 1, 2021 and ending on October 31, 2021. 8. RY21 Performance Period – either the First RY21 Performance Period or the Second RY21 Performance Period. b. Eligibility Criteria 1. A Hospital is eligible for an Adult Inpatient BH Per Diem Supplemental Payment or Payments if its Adult Inpatient BH Bed-Days Volume for an RY21 Performance Period, calculated in accordance with Section III.J.9.b.3, exceeds its Adult Inpatient BH Bed- Days Baseline for that RY21 Performance Period, calculated in accordance with Section III.J.9.b.2. EOHHS shall determine a Hospital’s eligibility to receive payment pursuant to this Section. 2. EOHHS shall calculate a Hospital’s Adult Inpatient BH Bed-Days Baseline for an RY21 Performance Period as follows: a. If the Hospital had at least one Adult Inpatient BH Bed-Day during each calendar month in CY2019, EOHHS will determine the Hospital’s Adult Inpatient BH Bed- Days Volume during Calendar Year 2019 (“CY19 Adult Inpatient BH Bed-Days”) by summing all of the Hospital’s Adult Inpatient BH Bed-Days during CY19, determined based on CY2019 fee-for-service MMIS paid claims and encounter data submitted to EOHHS by Managed Care Entities as of September 11, 2020. b. If the Hospital had zero Adult Inpatient BH Bed-Days during at least one calendar month in CY2019, EOHHS will calculate the Hospital’s CY19 Adult Inpatient BH Bed-Days as follows: i. If the Hospital had zero Adult Inpatient BH Bed-Days during at least one calendar month in the second half of CY19 (July to December), EOHHS will determine the Hospital’s CY19 Adult Inpatient BH Bed-Days by summing all of the Hospital’s Adult Inpatient BH Bed-Days during CY19, determined 3/24/21

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Attachment 4.19-A (1) Page 54 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 based on CY2019 fee-for-service MMIS paid claims and encounter data submitted to EOHHS by Managed Care Entities as of September 11, 2020. ii. If a Hospital not described in section III.J.9.b.2.b.i had zero Adult Inpatient BH Bed-Days during at least one calendar month in the first half of CY19 (January to June), EOHHS will determine the Hospital’s Adult Inpatient BH Bed-Days Volume during the second half of Calendar Year 2019 by summing all of the Hospital’s Adult Inpatient BH Bed-Days during the second half of CY19, determined based on CY2019 fee-for-service MMIS paid claims and encounter data submitted to EOHHS by Managed Care Entities as of September 11, 2020. The Hospital’s CY19 Adult Inpatient BH Bed-Days shall equal 200% of the Hospital’s Adult Inpatient BH Bed-Days Volume during the second half of CY19. c. EOHHS will multiply the Hospital’s CY19 Adult Inpatient BH Bed-Days (as calculated pursuant to Section III.J.9.b.2.a, III.J.9.b.2.b.i, or III.J.9.b.2.b.ii) by 90%, resulting in the Hospital’s Adult Inpatient BH Bed-Days Baseline. d. The Hospital’s Adult Inpatient BH Bed-Days Baseline for an RY21 Performance Period shall equal 50% of the amount calculated in Section III.J.9.b.2.c. 3. A Hospital’s Adult Inpatient BH Bed-Days Volume during an RY21 Performance Period shall be calculated as follows: a. The Hospital’s Adult Inpatient BH Bed-Days Volume for an RY21 Performance Period shall equal the sum of the Hospital’s Inpatient BH Bed-Days during that RY21 Performance Period. b. EOHHS will determine the Hospital’s Adult Inpatient BH Bed-Days Volume for the First RY21 Performance Period utilizing RY21 fee-for-service MMIS paid claims and encounter data submitted to EOHHS by Managed Care Entities by October 31, 2021. c. EOHHS will determine the Hospital’s Adult Inpatient BH Bed-Days Volume for the Second RY21 Performance Period utilizing RY21 fee-for-service MMIS paid claims and encounter data submitted to EOHHS by Managed Care Entities by April 30, 2022. c. Payment Methodology Subject to compliance with all applicable federal rules and payment limits, for each Hospital eligible for an Adult Inpatient BH Per Diem Supplemental Payment for an RY21 Performance Period in accordance with Section III.J.9.b, the Hospital’s payment shall equal $250 multiplied by the number of days by which the Hospital’s Adult Inpatient BH Bed-Days Volume for the RY21 Performance Period, calculated in accordance with Section III.J.9.b.3, exceeds the Hospital’s Adult Inpatient BH Bed-Days Baseline for that RY21 Performance Period, calculated in accordance with Section III.J.9.b.2. 3/24/21

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Attachment 4.19-A (1) Page 55 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 10. Pediatric Inpatient BH Per Diem Supplemental Payment a. Definitions For purposes of this Section III.J.10, the following terms shall have the following meanings: 1. Pediatric – a Member under 18 years of age. 2. Pediatric Inpatient BH Bed-Days Baseline - the adjusted CY19 Pediatric Inpatient BH Bed- Days for a given performance period, calculated in accordance with Section III.J.10.b.2. 3. Pediatric Inpatient BH Bed-Days Volume - Pediatric inpatient BH bed-days utilization equal to the Hospital’s Pediatric Inpatient BH Bed-Days for a particular period. 4. Pediatric Inpatient BH Bed-Day – a day on which a Hospital provided Inpatient Behavioral Health Services to a Pediatric Member for which payment was made by MassHealth or a Managed Care Entity, as determined by EOHHS. Pediatric Inpatient BH Bed-Days shall include each day of utilization for each Pediatric Member to whom Inpatient Behavioral Health Services were rendered. 5. Managed Care Entity (MCE) – An MCO or the BH Contractor. 6. First RY21 Performance Period – the period beginning on November 1, 2020 and ending on April 30, 2021. 7. Second RY21 Performance Period – the period beginning on May 1, 2021 and ending on October 31, 2021. 8. RY21 Performance Period – either the First RY21 Performance Period or the Second RY21 Performance Period. b. Eligibility Criteria 1. A Hospital is eligible for a Pediatric Inpatient BH Per Diem Supplemental Payment or Payments if its Pediatric Inpatient BH Bed-Days Volume for an RY21 Performance Period, calculated in accordance with Section III.J.10.b.3, exceeds its Pediatric Inpatient BH Bed- Days Baseline for that RY21 Performance Period, calculated in accordance with Section III.J.10.b.2. EOHHS shall determine a Hospital’s eligibility to receive payment pursuant to this Section III.J.10.b. 2. EOHHS shall calculate a Hospital’s Pediatric Inpatient BH Bed-Days Baseline for an RY21 Performance Period as follows: a. If the Hospital had at least one Pediatric Inpatient BH Bed-Day during each calendar month in CY2019, EOHHS will determine the Hospital’s Pediatric Inpatient BH Bed- Days Volume during Calendar Year 2019 (“CY19 Pediatric Inpatient BH Bed-Days”) 3/24/21

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Attachment 4.19-A (1) Page 56 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 by summing all of the Hospital’s Pediatric Inpatient BH Bed-Days during CY19, determined based on CY2019 fee-for-service MMIS paid claims and encounter data submitted to EOHHS by Managed Care Entities as of September 11, 2020. b. If the Hospital had zero Pediatric Inpatient BH Bed-Days during at least one calendar month in CY2019, EOHHS will calculate the Hospital’s CY19 Pediatric Inpatient BH Bed-Days Volume as follows: i. If the Hospital had zero Pediatric Inpatient BH Bed-Days during at least one calendar month in the second half of CY19 (July to December), EOHHS will determine the Hospital’s Pediatric Inpatient BH Bed-Days Volume during Calendar Year 2019 (“CY19 Pediatric Inpatient BH Bed-Days”), by summing all of the Hospital’s Pediatric Inpatient BH Bed-Days during CY19, determined based on CY2019 fee-for-service MMIS paid claims and encounter data submitted to EOHHS by Managed Care Entities as of September 11, 2020. ii. If a Hospital not described in section III.J.10.b.2.b.i had zero Pediatric Inpatient BH Bed-Days during at least one calendar month in the first half of CY19 (January to June), EOHHS will determine the Hospital’s Pediatric Inpatient BH Bed-Days Volume during the second half of Calendar Year 2019, by summing all of the Hospital’s Pediatric Inpatient BH Bed-Days during the second half of CY19, determined based on CY2019 fee-for-service MMIS paid claims and encounter data submitted to EOHHS by Managed Care Entities as of September 11, 2020. The Hospital’s CY19 Pediatric Inpatient BH Bed-Days shall equal 200% of the Hospital’s Pediatric Inpatient BH Bed- Days Volume during the second half of CY19. c. EOHHS will multiply the Hospital’s CY19 Pediatric Inpatient BH Bed-Days (as calculated pursuant to Section III.J.10.b.2.a, III.J.10.b.2.b.i, or III.J.10.b.2.b.ii) by 80%, resulting in the Hospital’s Pediatric Inpatient BH Bed-Days Baseline. d. The Hospital’s Pediatric Inpatient BH Bed-Days Baseline for the First RY21 Performance Period shall equal 52.5% of the amount calculated in Section III.J.10.b.2.c. e. The Hospital’s Pediatric Inpatient BH Bed-Days Baseline for the Second RY21 Performance Period shall equal 47.5% of the amount calculated in Section III.J.10.b.2.c. 3. A Hospital’s Pediatric Inpatient BH Bed-Days Volume during an RY21 Performance Period shall be calculated as follows: a. The Hospital’s Pediatric Inpatient BH Bed-Days Volume for an RY21 Performance Period shall equal the sum of the Hospital’s Pediatric Inpatient BH Bed-Days during that RY21 Performance Period. 3/24/21

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Attachment 4.19-A (1) Page 57 State Plan Under Title XIX of the Social Security Act State: Massachusetts Methods Used to Determine Rates of Payment for Acute Inpatient Hospital Services TN: 020-027 Approval Date: Effective Date: 10/01/20 Supersedes: 019-027 b. EOHHS will determine the Hospital’s Pediatric Inpatient BH Bed-Days Volume for the first RY21 Performance Period utilizing RY21 fee-for-service MMIS paid claims and managed care encounter data submitted to EOHHS by Managed Care Entities by October 31, 2021. c. EOHHS will determine the Hospital’s Pediatric Inpatient BH Bed-Days Volume for the Second RY21 Performance Period utilizing RY21 fee-for-service MMIS paid claims and managed care encounter data submitted to EOHHS by Managed Care Entities by April 30, 2022. c. Methodology Subject to compliance with all applicable federal rules and payment limits, for each Hospital eligible for a Pediatric Inpatient BH Per Diem Supplemental Payment for an RY21 Performance Period in accordance with Section III.J.10.b, the Hospital’s payment shall equal $300 multiplied by the number of days by which the Hospital’s Pediatric Inpatient BH Bed-Days Volume for an RY21 Performance Period, calculated in accordance with Section III.J.10.b.3, exceeds the Hospital’s Pediatric Inpatient BH Bed-Days Baseline for that RY21 Performance Period, calculated in accordance with Section III.J.10.b.2. K. Pay-for-Performance (P4P) Payment Pay-for-Performance (P4P) is MassHealth’s method for quality scoring and converting quality scores to P4P payments contingent upon Hospital adherence to quality standards and achievement of performance thresholds and benchmarks. P4P incentive payments will be based on pay-for- performance (see Sections III.K.1.c and III.K.2.c, below). A Hospital will qualify to earn P4P payments if it meets data accuracy and completeness requirements, including data validation requirements where applicable, and achieves performance thresholds for the P4P measures listed below. Each measure is evaluated using the methods outlined below to produce measure rates or values which result in performance scores that are converted into incentive payments. The P4P program applies to inpatient services for MassHealth Members where Medicaid is the primary payer. In general, payment calculations are based on a combination of performance scores, which utilize all-Medicaid payer data for certain measures and all payer data for other measures, and the number of eligible discharges, which includes only individuals enrolled in the Primary Care Clinician (PCC) Plan or a Primary Care ACO, and members with fee-for-service coverage. RY21 is bifurcated into the 1st RY21 Period and the 2nd RY21 Period for purposes of applying the P4P payment methodology. The methodology in Section III.K.1 applies to dates of service in the 1st RY21 Period and incorporates applicable definitions in Section II that apply to the 1st RY21 Period. The methodology in Section III.K.2 applies to dates of service in the 2nd RY21 Period and incorporates applicable definitions in Section II that apply to the 2nd RY21 Period. The 1st RY20 Period methodology is the same methodology that applied during the 2nd RY20 Period (effective November 1, 2019) under approved SPA TN-019-027, as modified by approved SPA TN 020-013. 3/24/21

(ma-09-009)(approval-document)Massachusetts Medicaid SPA MA-09-009: Approval Document (approved December 22, 2009, effective August 29, 2009)#

(ma-09-009)(approval-document)Massachusetts Medicaid SPA MA-09-009: Approval Document (approved December 22, 2009, effective August 29, 2009)#

(ma-10-001)(approval-document)Massachusetts Medicaid SPA MA-10-001: Approval Document (approved June 28, 2010, effective January 1, 2010)#

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(ma-10-002)(approval-document)Massachusetts Medicaid SPA MA-10-002: Approval Document (approved September 20, 2010, effective April 1, 2010)#

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(ma-11-006)(approval-document)Massachusetts Medicaid SPA MA-11-006: Approval Document (approved February 3, 2012, effective April 1, 2011)#

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(ma-11-012)(approval-document)Massachusetts Medicaid SPA MA-11-012: Approval Document (approved June 12, 2012, effective July 1, 2012)#

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(ma-13-009)(approval-document)Massachusetts Medicaid SPA MA-13-009: Approval Document (approved March 27, 2014, effective December 31, 2013)#

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(ma-13-0018-mm5)(approval-document)Massachusetts Medicaid SPA MA-13-0018-MM5: Approval Document (approved May 30, 2014, effective January 1, 2014)#

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(ma-13-0027-mm2)(approval-document)Massachusetts Medicaid SPA MA-13-0027-MM2: Approval Document (approved March 26, 2014, effective October 1, 2013)#

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